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L  E  C  T  U  II  E  S 


ON  THE 


PRINCIPLES  AND   PRACTICE 


OF 


MEDICINE. 


DELIVERED  IN 


CHICAGO  MEDICAL  COLLEGE,  MEDICAL  DEPARTMENT  OF  THE 
NORTHWESTERN  UNIVERSITY, 


BY 


NATHAN  SMITH  DAVIS,  A.M.,  M.D.,  LL.D., 

DEAN  OF  THE  FACULTIE  AND  PROFESSOR  OF  PBINCIPIES  AND  PRACTICE  OF  MEDICINE  AND    CLINICAL   MEDH.INF..  IN  CHICAGO 

MEDICAL   COLLEGE;    SENIOR   PHTSICIAy    TO    THE    MERCY    HOSPITAL,    CmCAGO ;    MEMBER    AND    EX-PRESIDENT    OF 

THE  AMERICAN  MEDICAL  ASSOCIATION,  OF  THE  ILLINOIS  STATE  MEDICAL  SOCIETY  AND  OF  THE  CHICAGO  JIEDI- 

CAL  SOCIETY  :  MEMBER  OF  THE  ILLINOIS  STATE   3nCR0SC0PICAl    SOCIETY,    CHICAGO    ACADEMY  OF 

SCIENCES,  AMERICAN  PUBLIC  HEALTH  ASSOCIATION;  HONORARY  MEMBER  OP  THE  NEW 

YORK.    ACADEMY    OF   MEDICINE,    AND    OF    THE   COLLEGE    OF  PHYSICIANS, 

PHILADELPHIA,   ETC. 


^,>/ 


2-^  O  ^ 


,     CHICAGO: 

JANSEN,    McCLUEG   &   CO. 
1884. 


COPYRIGHT, 

BY    JANSEN,  MCCLUKG,   &  CO., 

A.  D.  1884. 


*r«»torr6ci  rrom  the  I^ihrarr 
•f  Conpreas  under  Sec   59 
0.pyrt«rht  Act  Of  Mch.  4.  l^ 


stereotyped  and  Printed 

by  the 

Chicago  Legal  News  Company. 


PREFACE. 


The  lectures  comprised  in  this  volume,  embrace  substantially  the  course 
of  instruction  on  the  principles  and  practice  of  medicine  given  by  me 
in  the  Medical  Department  of  the  Northwestern  University,  better  known 
as  the  Chicago  Medical  College.  My  method  of  lecturing  being  entirely 
extempore,  the  lectures  comprising  the  first  half  of  the  volume,  under  the 
heads  of  Pi  inciples  of  Medicine  and  Acute  General  Diseases,  were  origi- 
nally reported  by  Leander  Stone,  stenographer;  and  those  comprising  the 
rest  of  the  volume,  by  James  E.  Henderson,  M.  D.  All  the  manuscript 
has  been  fully  revised,  and  not  a  small  portion  re-written  by  me  in  the 
midst  of  so  great  an  amount  of  other  professional  and  literary  work,  that 
it  has  been  impossible  to  bestow  upon  it  sufficient  minuteness  of  attention 
to  avoid  all  errors  in  typography  and  modes  of  expression. 

Three  motives  have  combined  to  induce  me  to  endure  the  labor  of  pre- 
paring these  lectures,  and  superintending  their  publication  at  the  present 
time.  One  was  to  comply  with  the  expressed  wish  of  a  large  number  of 
practitioners  who  have  hoiiored  me  with  their  presence  in  the  lecture  room 
of  the  college  and  the  clinical  wards  of  the  hospital,  during  some  part  of 
the  thirty-five  years  that  I  have  been  engaged  uninterruptedly  in  the 
work  of  teaching  medicine.  Another  was  the  desire  to  place  within  the 
reach  of  medical  students,  a  work  on  practice  which  embodies  in  its 
text  the  metric  system  of  weights  and  measures,  and  thereby  greatly 
facilitate  the  change  which  has  been  declared  by  nearly  all  our  social  pro- 
fessional organizations  to  be  desirable.  This  change  from  the  apotheca- 
ries' system  to  the  metric,  has  progressed  just  far  enough  to  give  us 
throughout  our  current  medical  literature  a  most  undesirable  mixture  of 
both  systems.  To  render  the  transition  complete  in  a  brief  period  of  time, 
it  is  only  necessary  that  the  authors  of  practical  works  should  incorporate 
the  metric  system  into  the  text  of  their  volumes.  To  prevent  embarrass- 
ment on  the  part  of  the  great  body  of  practitioners  who  have  already  been 
educated  exclusively  in  the  apothecaries'  system,  the  latter  might  be  given 
as  equivalents  in  brackets,  as  has  been  done  throughout  all  the  lectures 
embraced  in  this  volume. 

The  third  motive  was  a  desire  to  place  on  record,  accessible  to  the 
profession  generally,  those  views  and  modes  of  practice  developed  in 
my  own  mind,  as  a  result  of  fifty  years  of  constant  devotion  to  the  study 
and  practice  of  the  healing  art,  on  a  field  amply  sufficient  for  both  scientific 
study  and  direct  clinical  observation. 

N.  S.  DAVIS. 

65  Randoloh  St.,  Chicago,  Sept.  8,  1884. 

(i) 


% 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/lecturesonprinciOOdavi 


CONTENTS. 


PAET  I. 

ELEMENTARY  COXSIDERATIONS  OR  PRINCIPLES  OF   MEDICINE. 

LECTURE  L 

PAGE 

Health.  Definition  of  Disease.  A  Knowledge  of  what  Constitutes  Health  necessaiy 
to  a  clear  conception  of  Disease.  Analysis  of  Health.  The  Fluids.  The 
Solids.  Their  Properties  and  Relations.  Elementary  Properties.  Ele- 
mentary Functions,     Tabular  Statement 11 

LECTURE   II. 

Disease.  Analysis  of  Disease.  Its  Elementary  Forms.  Changes  in  the  Blood. 
Changes  in  the  Organized  Tissues.  Functional  and  Structural  Disease.  Tab- 
ular Statement.  Why  all  Attempts  to  Build  up  Systems  or  Theories  of 
Medicine,  Founded  on  some  supposed  Universal  Principle  of  Morbid  Action, 
have  failed 19 

LECTURE  in. 

General  Processes  and  Complex  Functions.  Their  Relations  to  Each  Other  in 
Health  and  Disease.  What  Constitutes  Nature.  The  Efforts  of  Nature. — 
**  Vis  Medicatrix  Naturae. " 25 

LECTURE  IV. 

Medicines.     What    are   Medicines  ?    What  the  Distinctions  Between  Food  and 

Medicines.     Their  Classification  for  Therapeutic  Purposes.     Etiology.    .        .     33 

LECTURE  V. 

Examination  of  the  Sick.  By  Inspection,  Oral  Questions,  Palpation  or  Touch, 
Instrumental  Aid.  The  Principles  of  Diagnosis.  Therapeutic  Methods, 
etc " 40 


PART  II. 


CONSIDERATION    OF    INDIVIDUAL    DISEASES    OR    PRACTICE    OF 

MEDICINE. 


LECTURE  VI. 

Classification  of  Disease.     Objects  to  be  attained.     Extended  Nosological  Ai-range- 
ments  of  Little  Practical  Value.     The  Simplest  Classification  the  Best.  .     48 

(iii) 


IV  CONTENTS. 


GENERAL   DISEASES. 


LECTURE  VII. 


General  Pathology  of  Fevers.  Ancient  and  Modern  Views  Compared.  The 
Unity  or  Oneness  of  All  Fevers,  and  Their  Diversity.  Pathological  Conditions 
Common  to  them  all .52 

LECTURE  VIII. 

Continued  Fevers :  Their  General  Characteristics — Individual  Members  of  the  class 
— Divisible  into  Three  groups  with  Distinct  Etiological  Characteristics — 
First  Group — Simple  Continued,  Irritative  or  Transient  Fever  or  Febricula.    .     61 

LECTURE  IX. 

Influenza  and  Dengue :  Influenza— Its  History,  Symptoms,  Prognosis,  Pathological 
Anatomy,  Etiology,  Diagnosis  and  Treatment.  Dengue — Its  History,  Sytap- 
toms,  Prognosis,  Etiology,  Diagnosis  and  Treatment 69 

LECTURE  X. 
Typhoid  Fever:     Its  History  and  Etiology 77 

LECTURE  XI. 
Typhoid  Fever:    Its  Symptoms,  Diagnosis,  and  Prognosis 86 

LECTURE  XII. 
Typhoid  I'ever:    Its  Pathology  and  Pathological  Anatomy 94 

LECTURE  XIIL 
Typhoid  Fever:     Its  Treatment 102 

LECTURE  XIV. 

Typhoid  Fever:  Its  Treatment,  Complications,  Intestinfd  Hemorrhage,  Per- 
foration of  the  Intestines,  Sequelae. Ill 

LECTURE  XV. 

Typhus  Fever  and  Plague:  Their  History,  Causes,  Symptoms,  Diagnosis,  Prog- 
nosis, Special  Pathology,  Pathological  Anatomy,  Treatment  and  Prophylaxis.  122 

LECTURE  XVL 

Relapsing  Fever:  Its  History,  Causes,  Symptoms,  Diagnosis,  Prognosis,  Special 
Pathology,  Pathological  Anatomy,  Treatment  and  Prophylaxis.  .  .  131 

LECTURE  XVII. 

Yellow  Fever:  Its  History,  Causes,  Symptoms,  Diagnosis,  Prognosis,  Patholog- 
ical Anatomy,  Special  Pathology,  Treatment  and  Prophylaxis.         .        .        .  I'jd 

LECTURE  XVIII. 

Erysipelas:     Its  History,  Causes,  Symptoms,  Diagnosis,  Prognosis,   Pathological 

Anatomy,  Special  Pathology,  Treatment  and  Prophylaxis 154 


CONTENTS.  V 


LECTURE  XIX. 

PAGE 

Diphtheria:  Its  History,  Causes,  Symptoms,  Diag-nosis,  Prognosis,  Pathology, 
Treatment,  Convalescence,  Prophylaxis  and  Sequelae 16B 

LECTURE  XX. 
Periodical  Fevers:  History,  Causes,  Varieties 178 

LECTURE  XXL 

Intermittent  and  Remittent  Fever:  Symptoms,  Pathological  Anatomy,  Diagnosis, 
Prognosis,  Treatment 186 

LECTURE  XXII. 

Pernicious  Fever;   Hemorrhagic  Malarial  Fever;   Typho -Malarial:     Symptoms, 

Pathology  and  Treatment •        .        .        .        .  196 

LECTURE  XXTII. 

Eruptive  Fevers:  History,  Causes,  Pathology,  Anatomical  Characteristics,  Gen- 
eral Principles  of  Treatment 204 

LECTURE  XXIV. 

Variola,  Varioloid  and  Vaccinia:  Symptoms,  Diagnosis,  Prognosis,  Special  Treat- 
ment and  Prophylaxis 213 

LECTURE  XXV. 

Varicella,  Sudamina  and  Scarlatina:  History,  Symptoms,  Diagnosis,  Prognosis, 
Pathological  Changes,  Complications  and  Sequelte,  Treatment  and  Prophy- 
laxis  225 

LECTURE  XXVI. 

Rubeola,  Rotheln,  Roseola,  Pertussis,  Muraps:  History,  Causes,  Symptoms, 
Diagnosis,  Prognosis,  Pathological  Anatomy,  Treatment  and  Sequelae.  .  226 

LECTURE  XXVII. 

Chronic  General  Diseases:  Diseases  Included  Under  this  Head— Circumstances 
Common  to  Them  All — General  Etiological  and  Pathological  Considerations 
Concerning  Them — General  Treatment. 249 

LECTURE  XXVIII. 

Scrofula:  Adenitis — Symptoms,  Pathology,  Treatment.  ScroWous  Inflamma- 
tion of  Mucous  Membranes,  etc 253 

LECTURE  XXIX. 

Leucocythsemia,  Pseudo-leucocythaemia,  Pernicious  Anaemia,  Addison's  Disease: 
History,  Causes,  Symptoms,  Pathology,  Diagnosis,  Prognosis,  Treatment.     .  267 

LECTURE  XXX. 

Carcinoma,  Constitutional  Syphilis:  Varieties,  Development,  Diagnosis,  Prognosis 
and  Treatment 278 


VI  CONTENTS. 


LECTURE  XXXI. 

PAGE 

Rheumatism:      Etiology,    Symptoms,  Acute,    Sub-acute,     Chronic;    Diagnosis, 
Prognosis,  Pathology,  Treatment 291 

LECTURE  XXXIL 

Gout,  Arthritis  Deformans:    History,  Causes,  Symptom',  Morbid  Anatomy,  Di- 
agnosis, Prognosis,  Treatment 302 


LOCAL  DISEASES. 


LECTURE  XXXIII. 
Inflammation:  Pathology,  Results  or  Terminations  of  Inflammation,  Treatment.     313 

LECTURE  XXXIV. 

Pachymeningitis,  Meningitis,  Cerebritis:  Pachymeningitis — Symptoms,  Diagno- 
sis, Pathology,  Prognosis,  Treatment.  Meningitis — Tubercular  Meningitis. 
Cerebritis — Cerebral  Sclerosis,  Symptoms 321 

LECTURE  XXXV. 

Meningitis,  Cerebritis  and  Sclerosis:  Pathology,  Diagnosis,  Prognosis,  Treat- 
ment and  Convalescence 331 

LECTURE  XXXVI. 

Cerebro-Spinal  Meningitis — Sporadic  and  Epidemic:  Sporadic — Symptoms,  Di- 
agnosis, Prognosis,  Treatment.  Epidemic — History,  Causes,  Symptoms, 
Morbid  Anatomy,  Diagnosis,  Prognosis 339 

LECTURE  XXXVII. 

Epidemic  Cerebro-Spinal  Meningitis,  Spinal  Meningitis,  Myelitis:  Epidemic 
Cerebro-Spinal — Treatment  and  Sequelse.  Spinal  Meningitis  and  Myelitis — 
Etiology,  Symptoms,  Morbid  Anatomy,  Diagnosis,  Prognosis,  Treatment.     350 

LECTURE  XXXVIII. 

Chronic  Spinal  Meningitis,  Myelitis  or  Spinal   Sclerosis:    Symptoms,  Morbid 

Anatomy,  Diagnosis,  Prognosis,  Treatment.        .  ....    361 

LECTURE  XXXIX. 

Inflammation  of  Respiratory  Organs — Several  Structures  included  under  this 
Head — Historical  and  Etiological  Considerations — Acute  and  Chronic  In- 
flammation of  the  Naso-Pharyngeal  Membrane:  Symptoms,  Diagnosis, 
Prognosis,  and  Treatment.  369 

LECTURE  XL. 

Laryngo-Tracheitis:  Varieties,  Causes,  Pathology,  Symptoms,  Diagnosis,  Treat- 
ment  381 


CONTENTS.  Vll 

V 

LECTURE  XLI. 

PA  OB 

Bronchitis — Acute  and  Chronic:   History,  Etiology,  Symptoms,  Pathology.        .    3y3 

LECTURE  XLIL 
Bronchitis,  and  Asthmatic  Bronchitis:   Prognosis,  Treatment,  Prophylaxis.  403 

LECTURE  XLIIL 

Pneumonia:     History,  Etiology,  Symptoms,  Varieties,    Pathology,  Diagnosis, 

Prognosis 416 

LECTURE  XLIY. 

Pneumonia:      Treatment.     Chronic  Pneumonia:     History,    Symptoms,    Treat- 
ment  426 

LECTURE  XLV. 

Pleuritis — Acute  and  Chronic:     Symptoms,  Morbid  Anatomy,  Prognosis,  Diag- 
nosis, Treatment. 437 

LECTURE  XLYL 

Phthisis  Pulmonalis:     Varieties,  Symptoms,  Anatomical  Changes.    .        .        .    450 

LECTURE  XLVII. 

Phthisis  Pulmonalis:     Diagnosis,  Prognosis.  Treatment 461 

LECTURE  XLVIII. 

Pericarditis:     Symptoms,  Pathology,  Diagnosis,  Prognosis,  Treatment.  .     471 

LECTURE  XLIX. 

Myo-  and  Endocarditis:     Symptoms,  Diagnosis,  Prognosis,  Treatment.    Inflam- 
mation of  the  Aorta.    Acute  Ulcerative  Endocarditis 478 

LECTURE  L. 
Stomatitis:     Varieties,  Symptoms,  Diagnosis,  Treatment.  ....    489 

/                                                         LECTURE  LI. 
/ 
Glossitis,  Tonsilitis,  Oesophagitis,  Gastritis:     Symptoms,  Diagnosis  and  Treat- 
ment  505 

LECTURE  LIT. 

Gastritis,    Duodenitis,    Duodeno- Hepatitis:    Symptoms,    Diagnosis,   Prognosis 

and  Treatment 516 

LECTURE  LIII. 

Enteritis,    Typhlitis,    Perityphlitis:     Causes,  Symptoms,  Pathology,  Diagnosis, 

Prognosis  and  Treatment .     584 


Vlll  COJ!?TENTS. 

LECTURE  LIV. 

PAGE 

Bilious  Colie  and  Dysentery:     Causes,  Symptoms,  Patholoay,  Diagnosis,  Prog- 
nosis, Treatment 547 

LECTURE  LV. 

Peritonitis — Acute  and   Chroni::     Causes,     Symptoms,    Pathology,    Diagnosis, 

Prognosis  and  Treatment 572 

LECTURE  LVL 
Hepatitis:    Varieties,  Symptoms,  Pathology,  Diagnosis,  Pro:gnosig,  Treatment.      589 

LECTURE  LYIL 

Spleenitis,  Acute  Nephritis:     Causes,  Symptoms,  Pathology,  Diagnosis,  Prog- 
nosis and  Treatment 603 

LECTURE  LVin. 

Uhronic Nephritis:     Causes,  Symptoms,    Pathology,    Diagnosis,  Prognosis  and 

Treatment 619 

LECTURE   LIX. 

:Suppnrative   Nephritis:     Causes,  Symptoms,  Pathology,  Diagnosis,  Prognosis, 

Treatment. 630 

LECTURE  LX. 
"Fluxes:    DiaDhoresis — Causes,  Pathology  and  Treatment 638 

LECTURE  liXI. 

Serous  Diarrhoea,  Cholera  Morbus  and  Epidemic    Cholera:     General  History, 

Etiology. 644 

LECTURE  LXII. 
Serous  Diarrhoea  and  Cholelra  Morbus:    Pathology  and  Treatment.        .        .     654 

lECTURE  LXin. 
Epidemic  Cholera:    History,  Causes,  Symptoms,  Anatomical  Changes.     .        .     661 

LECTURE  LXIV. 

Epidemic  Cholera:    Treatment  and  Prophylaxis 671 

LECl'URE  LXV. 
Dropsies:    Varieties,  Causes,  Prognosis,  Treatment.  678 

LECTURE  LXVI. 
Hemorrhages:    Varieties,  Causes,  Consequences,  Treatment,    '.        .        .        .    G85 


CONTENTS.  IX 


LECTURE  LXVir. 

TAQE 

Neurosis:     General  Physiologj-  and  Pathology 694 

LECTURE  LXVIIT. 
Apoplexy:     Varieties,  Causes,  Clinical  History,  Anatomical  Changes,  Diagnosis,  .    700 

LECTURE  LXIX. 
Apoplexy:     Prognosis  and  Treatment. 707 

LECTURE  LXX. 
Hemiplegia:     Symptoms,  Pathology 71-1 

LECTURE  LXXL 

Hemiplegia,  Paraplegia,  Locomotor  Ataxia.  Hemiplegia:  Diagnosis,  Prog- 
nosis, Treatment.  Paraplegia,  Locomotor  Ataxia:  Symptoms,  Prognosis, 
Treatment 719 

LECTURE  LXXIL 
Epilepsy:     Varieties,  Causes,  Clinical  History 724 

LECTURE  LXXIIL 
Epilepsy;    Anatomical  Changes,  Diagnosis,  Prognosis,  Treatment.     .        .        .    731 

LECTURE  LXX  IV. 
Chorea:     Causes,  Clinical  History,  Pathology,  Diagnosis,  Prognosis,  Treatment.      738 

LECTURE   LXXV. 

Catalepsy  and  Convulsions:  Symptoms,  Pathology,  Diagnosis,  Prognosis,  Treat- 
ment  746 

LECTURE  LXXVL 

Hysteria:  Varieties,  Causes,  Symptoms,  Pathology,  Diagnosis,  Piognosis,  Treat- 
ment  755 

LECTURE  LXXVII. 

Insomnia  and  Neuralgia:  Varieties,  Causes,  Symptoms,   Pathology,  Diagnosis, 
Prognosis,  Treatment 762 

LECTURE  LXXVIIL 
Tetanus:  Causes,  Symptoms,  Pathology,  Diagnosis,  Prognosis  and  Treatment.     .  770 

LECTURE  LXX  IX. 

Hydrophobia:    Causes,   Symptoms,    Pathology,    Diagnosis,    Prognosis,    Treat- 
ment  "^^6 


X  002f,TENTS. 


LECTURE  LXXX, 

PACK 

Sun  Slroke:  Varieties,  Causes,  Symptoms,  Patholoary,  Pro^osig,  Diagnosis, 
Treatment ' "       ...  783 

LECTURE  LXXXr. 

Delirium  Tremens:  Causes,  Symptoms,  Pathology,  Diagnosis,  Prognosis,  Treat- 
ment  790 

LECTURE  LXXXIL 
Mental  Derangements:  Varieties,  Causes,  Pathology,  Symptoms.        .        .        .  796 

LECTURE  LXXXIII. 
Mental  Derangements:  Clinical  History,  Diagnosis,  Prognosis,  Treatment.  .  802 

LECTURE  LXXXIV. 
Miscellaneous  Diseases:  Variety,  Causes  and  Tendencies 810 

LECTURE  LXXXV. 

Spasmodic  Astlima,  Laryngismus  Stridulus,  Aphonia:  Causes,  Symptoms,  Diag- 
nosis, Prognosis,  Treatment 815 

LECTURE  LXXXVL 

Cardiac  In-itability,  Angina  Pectoris:   Causes,  Symptoms,  Diagnosis,  Prognosis, 

Treatment 822 

LECTURE  LXXXVII. 

Exophthalmic  Goitre,  Fatty  Degeneration  of  Heart,  Aneurism:  Symptoms,  Pathol- 
ogy, Treatment 829 

LECTURE  LXXXVin. 
Functional  Derangements  of  Digestive  Organs:    Their  Nature  and  Treatment.  835 

LECTURE  LXXXIX. 
Parasites:    Varieties,  Symptoms  and  Treatment. 843 

LECTURE  XC. 

Diabetes:  Diabetes  Insipidus — Symptoms,  Anatomical  Changes,  Prognosis, 
Treatment.    Diabetes  Mellitus — Symptoms,  Pathology 850 

LECTURE  XCl. 

Diabetes  Mellitus,  continued:  Diagnosis,  Prognosis,  Treatment.  Enuresis: 
Treatment 856 

LECTURE  XCIL  . 

Alcoholic  Liquids  as  Therapeutic  Agents.  What  Indications  are  They  Actually 
Capable  of  Fulfilling  in  the  Treatment  of  Disease?  What  Substitutes  may 
be  Employed  v?ith  Advantage  to  the  Patients? 862 


PART   I. 

ELEMENTARY  CONSIDERATIONS,  OR  PRINCIPLES 

OF  MEDICINE. 


LECTUKE    I. 

Definitions  of  Disease— A  knowledge  of  what  constitutes  health  necessary  to  a  clear  conception  of 
Disease— Analysis  of  Health— The  Fluids— The  Solids— Their  properties  and  relations—  Elemen- 
tary Properties— Elementary  Functions— Tabular  Statement. 

GENTLEMEN:  In  investigating  the  principles  and  practice  of  medi- 
cine, whether  in  the  lecture-room  or  in  the  hospital- wards,  morl)id 
action  and  disease  in  its  various  forms,  tendencies  and  results,  will  consti- 
tute the  primary  theme  of  discussion  and  observation. 

To  determine  the  exact  pathological  condition  of  the  patient,  is  the  first 
object  of  every  enlightened  practitioner  when  called  to  the  bed-side  of  the 
sick.  Having  done  this,  he  sees  clearly,  both  the  tendencies  of  the  case, 
and  the  indications  to  be  fulfilled  by  the  employment  of  remedial  agents. 
If  the  practitioner  comprehends  fully  the  nature,  extent  and  tendencies  of 
the  disease  before  him,  and  sees  distinctly  the  objects  to  be  accomplished 
by  treatment,  he  will  find  it  comparatively  an  easy  task  to  select  and  apply 
the  appropriate  remedies.  Hence,  while  standing  here  upon  the  thresh- 
old of  the  present  course  of  instruction  we  are  confronted  with  the  ques- 
tion: What  is  morbid  action  or  disease?  Most  of  the  modern  writers 
and  teachers  in  this  department,  simply  reply,  that  disease  is  a  deviation 
from  health  in  some  one  of  the  structures  or  functions  of  the  human 
system. 

This,  instead  of  explaining  anything  however,  simply  necessitates  an- 
other question,  namely:  "What  is  health  ?  And  if  the  answer  is  made  in 
the  usual  manner,  that  health  is  the  natural  condition  of  the  structures 
and  functions  of  the  human  body,  it  simply  changes  the  phraseology  with- 
out advancing  our  knowledge  of  the  subject.  If  disease  is  merely  a  de- 
parture from  a  healthy  or  natural  condition  of  some  structure  or  function, 
it  is  evident  that  a  clear  and  accurate  knowledge  of  what  constitutes  the 
proper  standard  of  health,  both  in  regard  to  structural  organization  and 
functional  action,  affords  the  only  basis  on  which  we  can  ap})reciate  such 
deviations  from  that  standard  as  constitute  morbid  action  or  disease.  To 
gain  a  full  and  accurate  idea  of  health  as  a  base-line  or  point  of  departure 
for  studying  the  elementary  forms  of  disease,  it  is  necessary  to  subject  the 
animal  economy  to  a  proximate  analysis  sufficient  to  display  the  several 
elementary  structures,  their  properties,  their  mutual  relations,  and  their 
special  functions.  By  such  analysis  we  may  resolve  all  the  materials  of 
the  body,  first,  mio  fluids  and  solids.     The  first  consists  of  the  blood  and 

(11) 


12  ELEMENTARY    CONSIDERATIONS, 

the  various  products  of  secretory  action;  and  the  second,  of  the  organized 
living  structures  and  the  solid  inorganic  materials  deposited  in  them.  The 
blood  is  a  very  complex  fluid,  containing  all  the  products  of  digestion  and 
assimilation  on  the  one  hand,  and  the  primary  products  of  disintegration 
or  waste  of  structures  on  the  other,  together  with  certain  elementary  forms 
of  organization  known  as  red  and  white  corpuscles.  Hence  its  constit- 
uents   or  proximate  elements  may  be  arranged  under  three  heads,  viz: 

1st.  Such  elements  as  are  nutritive,  that  is,  designed  to  supply  the 
waste  of  tissues,  as  albumen,  white  corpuscles,  fatty  matter,  certain  salts, 
and  oxygen. 

2d.  Such  as  are  derived  from  the  disintegration  of  tissues  and  are  con- 
sequently effete,  as  fibrin,  extractive  matter,  certain  salts,  and  carbonic 
acid  gas. 

3d.  Such  as  possess,  at  least,  a  partial  organization  and  vitality,  and 
serve  their  purpose  in  the  blood,  as  the  red  corpuscles. 

The  secretions  of  the  animal  economy  may  be  divided  into  three  class- 
es, viz  : 

1st.  Such  as  are  wholly  effete  or  excrementitious,  and  consequently 
cannot  be  retained  without  producing  a  disturbing  or  injurious  influence. 
To  this  class  belong  the  eliminations  from  the  skin,  lungs,  kidneys,  and 
mucous  membrane  of  the  intestines. 

2d.  Such  as  are  retained  for  the  accomplishment  of  some  specific  pur- 
pose in  the  system,  and  are  either  reabsorbed  or  disappear  by  entering 
into  new  combinations  of  a  harmless  character.  To  this  class  belong  the 
salivary,  gastric,  and  pancreatic  secretions,  all  of  which  enter  into  com- 
bination with  the  elements  of  food  and  disappear  in  the  processes  of  di- 
gestion and  assimilation.  To  the  same  class  also  belong  the  secretions 
from  the  serous,  mucous,  and  synovial  membranes  that  serve  to  moisten  or 
lubricate  their  surfaces. 

3d.  Such  as  are  partly  excrementitious  and  partly  retained  to  aid  in 
the  processes  of  digestion  and  assimilation.  The  bile  is  the  most  promi- 
nent sample  of  this  class,  the  alkaline  constituents  of  which  undoubtedly 
enter  into  combination  with  the  oily  ingredients  of  chyme  in  the  duode- 
num, while  its  coloring  matter  and  cholesterin  are  as  certainly  efi'ete  and 
are  discharged  with  the  foeces. 

For  a  detailed  statement  of  the  composition,  properties,  and  uses  of  the 
blood  and  secretions,  I  must  refer  you  to  the  departments  of  physiology 
and  organic  chemistry.  But  those  of  you,  gentlemen,  who  have  confined 
your  reading  principally  to  the  works  of  English  and  American  writers  on 
physiology,  may  be  surprised  to  hear  me  mention  the  fibrin  of  the  blood  in 
the  class  of  wholly  effete  substances.  For,  until  a  very  recent  period,  it  was 
almost  universally  regarded  as  a  product  of  assimilation,  at  least  partially 
endowed  with  vitality,  and  designed  to  enter  largely  into  the  nutrition  of 
the  tissues.  Such  was  the  view  taken  of  this  substance  by  Carpenter, 
Williams,  Paget,   Dunglison,  and  many  other  writers  of  an    earlier    date. 

Zimmerman  was  perhaps  the  first  to  seriously  call  in  question  the  cor- 
rectness of  this  doctrine,  and  to  suggest  that  the  fibrin  of  the  blood  was 
an  effete  constituent,  derived  from  the  disintegration  of  tissues,  and  de- 
signed for  excretion.  It  was  shown  by  Nasse  and  Miilier  that  there  is  no 
fibrin  in  chyme,  and  but  a  very  small  quantity  in  the  chyle  of  the  lac- 
teals,  while  it  is  abundant  in  the  lymph  of  the  lymphatics  It  is  univer- 
sally acknowledged  to  be  more  abundant  in  the  blood  during  the  progress 
of  the  active  phlegmasia,  than  in  health.  It  has  also  been  found  in  excess 
in  the  blood  of  persons  anemic  either  from  loss  of  blood,  want  of  food,  or 
the  suppression  of  some  important  secretion,  as  well  as  in  the   advanced 


OK    PEINCIPLES    OF   MEDICINE.  13 

stages  of  tubercular  phthisis.  Indeed,  a  careful  and  extended  series  of 
clinical  observations,  long  since,  led  me  to  believe  that  whenever  the 
processes  of  disintegration  or  waste  of  tissues  continued  active,  while  the 
secretory  action  of  the  kidneys  was  diminished,  fibrin  accumulated  in  the 
blood  in  quantity  above  the  natural  proportion.  As  these  conditions, 
whether  arising  from  the  influence  of  an  active  local  inflammation,  or  from 
anemic  and  debilitated  states  of  the  system  are  almost  always  associated 
with  loss  of  appetite  and  impaired  or  suspended  dio^estion,  it  is  extremely 
difficult  to  account  for  the  increase  of  fibrin  on  the  supposition  that  it  is  a 
product  of  digestion  and  assimilation.  But  its  accumulation  under  such 
circumstances  is  in  perfect  harmony  with  the  theory  that  it  is  one  of  the 
primary  products  of  disintegration.  While  investigating  this  subject  in 
the  autumn  of  1850,  it  occurred  to  me  that  a  careful  comparison  of  the  rel- 
ative proportion  of  fibrin  in  the  blood  of  the  renal  vein  returning  from  an  ac- 
tive excretory  organ,  with  that  in  the  iliac  vein  returning  from  non-secre- 
ting structures,  together  with  that  in  the  arteries,  would  go  far  towards 
demonstrating  fully  the  question  whether  fibrin  was  a  nutritive  or  effete 
constituent  of  the  blood.  The  only  attempt  of  this  kind,  which  I  could 
then  find  on  record,  was  made  by  Simon,*  who  procured  the  blood  from  the 
renal  vein,  the  hepatic  vein,  and  the  aorta  of  a  horse,  and  subjected  each 
specimen  to  an  analysis  with  special  reference  to  the  relative  proportions 
of  water,  albumen  and  fibrin.  These  results  showed  of  fibrin  in  the  blood 
from  the  aorta,  8.3  parts  in  the  1,000;  in  that  from  the  hepatic  vein,  2.5 
parts  in  the  1,000;  in  that  from  the  renal  vein,  wo^e.  These  results  ob- 
tained by  Simon,  though  strongly  corroborating  the  view  that  fibrin  is 
effete,  were  diminished  in  value  by  the  fact  that  the  horse  from  which  the 
blood  had  been  obtained  was  not  healthy  and  well  fed,  and  the  quantity 
of  blood  obtained  from  the  renal  vein  (only  50  grains  ),  was  insufficient  to 
determine  accurately  the  proportion  of  fibrin. 

To  obviate  these  objections,  and  at  the  same  time  to  add  another  im- 
portant element  to  the  comparison,  I  selected  a  good  sized,  healthy  dog,  and 
while  stunned  by  a  blow  on  the  head  quickly  opened  the  abdom.en,  passed 
a  ligature  around  the  renal  vein  near  its  junction  with  the  ascending  vena 
cava,  and  from  a  puncture  in  it  received  into  a  cupping  glass  590  grains 
of  blood  for  analysis. 

A  ligature  was  next  passed  around  the  iliac  vein,  and  through  a  suit- 
able puncture  771  grains  of  blood  flowed  readily  into  another  cup.  A 
third  specimen,  amounting  to  425  grains,  was  then  obtained  from  the  left 
ventricle  of  the  heart.  On  subjecting  these  several  specimens  of  blood  to 
a  careful  quantative  analysis,  that  from  the  renal  vein  was  found  to  con- 
tain twenty  per  cent,  less  fibrin  than  that  from  the  left  ventricle,  while 
that  from  the  iliac  vein  contained  about  ten  per  cent  more.j  Robin, 
Bernard,  and  others  have  since  shown  that  the  blood  from  the  hepAtic 
vein  also  contains  less  fibrin  than  that  from  the  jugular  vein  or  from  the 
vena  cava  The  fact  thus  clearly  established,  that  the  quantity  of  fibrin 
diminishes  while  the  blood  is  passing  through  the  principal  excretory  or- 

*  See  Simons'  Chemistry  of  Man,  pa^e  139. 

tSee  an  experimental  inquiry  concerning  some  points  in  the  vital  processes  of  assimilation  and 
nutrition,  published  in  the  North  Western  Medical  and  Surgical  Journal,  p.  169,  vol.  4,  1851.  The 
analytical  results  reierred  to  are  as  follows : 

Blood  from  Blood  from 

Arterial  Blood.  Iliac  Vein.  Eenal  Vein. 

Water _ 812.2  «11.9        803.4. 

Rod  c-orpuseles 82.5  92  7        92.2. 

Fibrin 2.2  -     2.5        1.7. 

Albumen  (fat  and  extract  mat- 
ter not  separated 98.1  89.5        98.5. 

Salts 5.9  -     3.9        4.2. 


14  ELEMENTARY    CONSIDERATIONS, 

gans,  and  increases  while  passing  through  muscular  and  non-secreting 
structures,  shows  conclusively  its  effete  character,  and  leaves  no  reason  for 
hesitation  in  classing  it  as  one  of  the  primary  products  of  disintegration, 
or  waste  of  the  tissues.  This  brief  review,  and  classification  of  the  more 
important  natural  constituents  of  the  fluids  of  the  body,  will  be  sufficient 
for  our  present  purpose,  with  the  additional  remark  that  when  all  these 
constituents  exist  in  their  natural  relative  proportions  and  natural  quali- 
ties, without  the  intermixture  of  deleterious  foreign  ingredients,  the 
fluids  present  the  proper  standard  of  health. 

The  solids,  or  organized  structures,  that  enter  into  the  formation  of  the 
living  animal  body,  may,  for  our  present  purpose,  be  resolved  into  five 
proximately  elementary  forms  of  organization,  namely  :  the  nervous,  the 
muscular,  the  capillary  vascular,  the  secretory,  and  the  fibrous.  I  do  not 
mean  that  these  are  the  elementary  or  primary  forms  of  organic  matter, 
but  the  elementary  forms  of  organized  structure,  each  of  which  is  capable 
of  performing  a  distinct  function.  Of  these  five  elementary  struct- 
ures, with  the  addition  of  certain  inorganic  materials,  all  the  complex  tis- 
sues and  organs  of  the  human  body  are  composed. 

Whether  these  several  distinct  structures  or  primary  tissues  are  each 
composed  of  elementary  cells  united  in  a  definite  manner,  as  claimed  by 
a  laro-e  majority  of  the  histologists  of  the  present  day,  or  non-cellular  or- 
ganic atoms,  we  leave  for  our  distinguished  colleague  in  the  chair  of 
histology,  to  demonstrate  to  you.  For  whatever  may  be  the  prima- 
ry form  of  organization,  whether  a  cell,  a  nucleus,  a  granule,  or  an 
atom;  a  little  reflection  will  make  it  apparent  to  each  one  of  you,  that  the 
same  properties  or  forces  would  be  required  to  effect  their  union  in  such 
definite  modes  as  to  form  in  one  case  a  muscular  fibre,  in  another  a  nerve 
fibre,  in  a  third  a  white  or  yellow  elastic  fibre,  in  a  fourth  a  secreting  cell,  and 
in  a  fifth  a  capillary  tube.  Hence  it  is  not  so  much  the  form  of  the  pri- 
mary organic  atom  that  interests  us,  as  it  is  the  properties  or  forces  with 
which  it  is  endowed,  and  which  control  its  movements,  its  combinations, 
and  its  ultimate  destiny.  An  investigation  of  the  former  could  do  but 
little  more  than  gratify  a  laudable  ciu'iosity,  while  on  the  correctness  of 
our  appreciation  ot  the  latter  depends  the  clearness  of  our  conceptions  in 
regard  to  the  essential  phenomena  of  of  life  and  organic  changes,  both  in 
health  and  disease. 

What,  then,  are  the  properties,  if  any,  with  which  living  organized  mat- 
ter is  endowed  ? 

Perhaps  no  subject  in  the  whole  range  of  medical  sciences  has  been  left 
involved  in  greater  obscurity  than  this.  That  living  organized  matter  is 
possessed  of  certain  properties  which  give  to  its  changes  and  developments 
certain  determinate  directions,  and  enable  it  to  resist  the  action  of  such 
agencies  as  control  the  changes  in  inorganic  or  dead  matter,  has  been 
plainly  acknowledged  from  the  most  ancient  records  of  medical  opin- 
ions to  the  present  time. 

The  ancients  regard  id  these  properties  as  purely  chemical  or  phj^sic- 
al,  as  developed  in  the  various  modifications  of  the  humoral  theories  of 
concoction,  fermentation,  etc.  ;  or  as  some  superadded  essence,  spirit, 
or  controlling  anima  as  represented  in  the  earlier  theories  of  solid- 
ism,  and  more  fully  developed  by  Stahl  and  his  disciples.  It  was  not 
until  Haller  had  clearly  demonstrated  the  existence  of  an  inherent  proper- 
ty in  the  muscular  structure,  which  he  styled  '■'■  irritability^''''  that  we  find 
a  distinct  recognition  of  a  property  or  force  in  organized  matter  neither 
dependent  on,  nor  necessarily  connected  with,  the  immaterial  spirit  or 
soul.     He,  however,  restricted  the  existence  of  this   property  to  muscular 


OE    PRINCIPLES    OF    MEDICINE.  15 

fibres  alone;  and  failed  to  make  any  clear  distinction  between  the  elemen- 
tary property  inherent  in  the  living  fibre  and  the  function  or  office  per- 
formed by  such  fibre.  The  latter  error  has  prevailed  to  a  greater  or  less 
extent  in  the  -writings  and  teachings  of  all  the  advocates  of  solidism  or 
vitalism  even  to  the  present  time.  Thus  Dr.  Williams,  in  his  Principles 
of  Medicine,  speaks  of  irritability  and  tonicity,  as  elementary  p7'opet'ties 
of  muscular  structures,  while  he  calls  sensibility  and  transmisibility/wnc- 
tio?is  of  nerve  structures.  Dr.  Martyn  Paine,  in  his  Institutes  of  Medi- 
cine, claims  one  vital  principle,  which  he  considers  as  synonymous  with  vi- 
tality or  life,  and  which  pervades  all  living  matter.  This  vital  principle  he 
endows  with  six  properties,  namely,  irritability^  mobility^  vital  affinity, 
vii'ification,  sensibility,  Jiervous  power.  Now,  gentlemen,  tonicity  as  ex- 
plained by  Dr.  "SYilliams  means  simply  a  certain  degree  of  muscular  con- 
traction, and  consequently  is  as  purely  a  function  of  the  muscular  structure 
as  sensibility  is  of  the  nervous.  So,  the  mobility,  sensibility  and  nervous 
power  of  Dr.  Paine,  are  -phdinly  functions  of  the  muscular  and  nervous 
tissues;  and  yet  he  classes  them  in  the  same  catgeory  with  irritability  and 
vital  affinity,  which  are  really  properties  common  to  all  tissues.  Dr. 
Samuel  Jackson,  of  Philadelpha,  in  his  work  on  the  Principles  of  Medi- 
cine, exhibits  a  much  more  correct  appreciation  of  the  distinction  between 
elementary  properties  common  to  all  the  tissues,  and  elementary  func- 
tions of  particular  parts.  But  since  the  more  complete  development  of 
the  physiology  of  the  nervous  tissues,  the  great  majority  of  medical  writ- 
ers have  completely  confounded  all  elementary  properties  with  nerve  sen- 
sibility, or,  as  they  term  it,  nerve  force;  and  have  consequently  recognized 
no  capacity  for  receiving  impressions  or  modifications  of  actions  in  the 
several  elementary  structures,  except  through  the  medium  of  nerve  mat- 
ter. Hence  you  will  find  most  of  the  writers  on  pathology  and  practical 
medicine,  endeavoring  to  trace  the  primary  actions  of  all  morbific  causes, 
to  an  impression,  either  directly  on  the  constituents  of  the  blood  or  upon 
some  part  of  the  nervous  system.  This  error  has  not  only  caused  many 
important  questions  in  pathology  to  remain  involved  in  obscurity,  but  has 
also  equally  retarded  the  progress  of  our  knowledge  concerning  the  mo- 
dus operandi  of  our  remedial  agents.  That  tliere  are  certain  properties 
inherent  in  all  organized  matter,  so  long  as  it  retains  the  capacity  to  ex- 
hibit the  phenomena  of  life,  is  evident  from  facts  familiar  to  all  of  you. 
Take,  for  example,  the  simplest  form  of  organization — the  germinal  cell 
of  the  ovum  or  the  chit  or  germinal  part  of  the  vegetable  seed.  Each  is 
destitute  of  all  trace  of  either  capillary  vessels  or  nerves,  yet  each  is  sus- 
ceptible to  the  impressions  of  certain  exterior  agents  or  influences;  and 
whenever  these  are  applied,  a  series  of  regular  and  determinate  changes 
commence,  constituting  the  active  phenomena  of  life. 

It  requires  but  a  moment  of  careful,  logical  thought  to  recognize  here 
the  existence  of  two  inherent  elementary  properties  :  one  imparts  to  the 
cell  or  germ  the  capacity  to  receive  impressions,  and  hence,  I  have  called 
it,  susceptibility.  The  other  causes  the  atomic  changes  which  result  from 
the  impressions  received,  to  follow  certain  laws,  both  in  the  addition  of 
new  atoms  and  the  liberation  of  old  ones  ;  and  I  have  therefore  called  it 
vital  affinity.  Susceptibility  and  vital  affinity  are  the  elementary  prop- 
erties of  all  organized  living  matter.  It  is  the  possession  of  these  prop- 
erties that  gives  to  the  protoplasm  of  Mr.  Huxley  and  the  bioplasm  of  Mr. 
Beale,  all  their  peculiarities  and  capabilities  of  development.  It  would 
be  a  waste  of  your  time  to  speculate  as  to  the  nature  of  these  properties. 
They  constitute  the  peculiar  and  elementary  forces  of  the  organic  world, 
and  can  be  recognized  and  studied  only  by  their  effects,  in  the   same 


16  ELEMENTAEY  CONSIDERATIONS, 

manner  that  we  recognize  and  study  the  imponderable  or  elementary 
forces  of  the  inorganic  world,  as  heat,  electricity,  attraction,  etc.  You 
suspend  two  inorganic  substances  in  the  same  cup  of  water,  and  if  they 
unite,  forming  a  new  material,  you  say  the  union  was  the  result  of  a 
property  or  force  in  the  combining  bodies,  which  you  call  chemical  affin- 
ity. You  do  not  see  this  property  or  force,  yet  for  that  reason  you  do  not 
doubt  its  existence.  So  if  we  place  the  germinal  cell  of  the  animal  or 
vegetable  in  certain  relations,  we  find  it  uniting  with  other  atoms  of  mat- 
ter, and  forming — not  a  new  and  homogenious  compound,  as  in  the  dis- 
play of  chemical  affinity — but  a  complex  and  progressive  series  of  addi- 
tions constituting  growth  or  development,  and  I  call  the  property  or 
force  in  the  germinal  cell  by  which  these  changes  are  effected,  vital 
affinity.  These  properties — susceptibility  and  vital  affinity — are  elemen- 
tary, and  inherent  in  all  organized  living  atoms  of  matter,  however  dor- 
mant such  atoms  may  appear  to  be.  Deprive  the  germ,  whether  animal 
or  vegetable,  of  these  properties,  and  it  immediately  becomes  subject  to 
the  same  laws  and  forces  that  govern  inorganic  matter.  Expose  it  to 
warmth  and  moisture  ever  so  sedulously,  and  instead  of  the  phenomena 
of  life,  you  have  only  those  of  disintegration  and  decay.  To  recognize 
the  existence  of  these  properties  and  learn  how  far  they  are  capable  of 
being  acted  upon  and  modified  by  exterior  forces  and  influences,  is  a  very 
important  part  of  the  study  of  physiology  and  pathology. 

In  another  part  of  this  lecture  it  was  stated  to  you  that  all  the  organ- 
ized parts  of  the  body  can  be  resolved  anatomically  into  five  primary 
structures,  namely — nervous,  muscular,  secretory,  vascular,  and  fibrous. 
The  elementary  properties,  susceptibility  and  vital  affinity,  are  general, 
and  belong  equally  to  all  the  primary  structures.  And  each  of  these 
structures  thus  endowed  with  the  elementary  properties,  is  capable  of  per- 
forming certain  acts  or  serving  certain  purposes  which  constitute  the  spe- 
cial or  primary  function  of  such  structure.  For  example,  the  nervous 
tissue  receives  and  transmits  impressions  ;  the  muscular  contracts  ;  the 
secretory  elaborates  some  special  fluid  called  a  secretion. ;  the  capillary 
vascular  allows  the  active  passage  of  fluids,  and  at  the  same  time  perme- 
ation and  imbibition,  exosmose  and  endosmose,  through  its  walls  ;  while 
the  fibrous  tissue  simply  affords  both  a  support  and  a  bond  of  union  to 
all  the  other  structures.  Hence,  we  may  conveniently  designate  the  pri- 
mary functions  as  follows ; 

N-estactu« fSSbility. 

Muscular  structure Contractility. 

Secretory  structure, Secretion. 

Capillary  vascular  structure,     ....    Movement  of  fluids. 
Fibrous  structure, Elasticity. 

You  have  already  learned  in  your  course  on  histology  that  these  sev- 
eral primary  structures  are  formed  by  the  union  of  cells  or  organic  atoms, 
varying  from  each  other  both  in  their  form  and  the  manner  of  their  union; 
such  variations  constituting  the  apparent  differences  between  one  struc- 
ture and  another.  You  have  also  learned  that  the  same  primary  structure 
is  not  homogenious  throughout,  but  presents  diversities  in  the  union  of  its 
primary  atoms  or  cells.  The  nerve  structure,  for  instance,  presents  in 
some  places  its  cells  aggregated  in  masses,  as  in  the  ganglia  of  the  sym- 
pathetic and  spinal  nerves,  and  in  the  gray  matter  of  the  brain  and  spinal 
cord,  and  in  other  parts  they  are  united  in  linear  form,  constituting  fibres, 
as  in  the  white  portion  of  the  brain,  spinal  cord  and  nerves.     The  former 


OR    PEINCIPLES    OF    MEDICIKE. 


17 


indicates  the  function  of  sensibility  and  the  active  generation  of  the 
nerve  force,  while  the  latter  appears  simply  conducting  or  transmitting  in 
its  function.  Still  more  strikingly  you  see  the  elementary  cells  of  the 
secretory  structure,  in  one  place  united  in  such  form  as  to  present  a  sin- 
o-le  follicle  ;  in  another  a  tubule,  and  in  another  a  lobule  of  a  conglom- 
erate o-land.  And  every  variation  thus  in  the  minute  anatomy  or  histol- 
oo-y  ot^  any  primary  structure,  indicates  a  corresponding  modification  of 
its  function. 

To  make  the   foregoing    brief  analysis  more  easily  understood,  we  will 
place  it  in  tabular  form  on  the  blackboard  before  you,  as  follows  : 


COMPOSITION 

OF 

THE  BODY. 


f  Albumen. 

r  Nuti-itive  Constituents.  \  J^^^Stter.''^^'' 
[Salts  and  Oxygen. 

Blood -j  Formative -j  Red  Coi-puscles. 

(  Fibrin. 
,  -j  Extractive  Matter. 
(  Salts  and  Carbonic  Acid. 


Flotds. 


Excrementitious 


(  Saliva. 
Used  in  the  Sys-  -I  Gastric  Juice. 

tern.  (  Pancreatic  Fluid,   etc. 

Secretions.  <j  Partly  Eetained  and  Excretory  j  Bile 

{Cutaneous. 
Pulmonary. 
Renal  Secretions,  &c. 


f  Nervous. 

o„^^„     1  Resolvable  into  Five!  Qj^^„f„    ' 
So^-s. .  ^  Elementary     Struc-     ^S^^y^^, 
^         tures.  [Fibrous. 


Elementary  Properties  and  Functions. 

Properties  Common  to  aU  Organized  Living  Matter,  j  Susceptibility. 
Therefore  Elementaiy i  Vital  Affinity. 

Sensibmty   .  .  .    j  j^ervous  Structure. 
Transmissibility  .  ( 


Functions   Peculiar  to  Each 

Structure  ; 

Therefore  Elementary. 


Contractihty  .    .    -j  Muscular. 
Secretion  .  .  .  .   ]  Secretory. 

Movement  of  Fluids  with  [  CapiUary  Vasculax. 
Exudation  and  Imbibition  )      *^       •' 


Elasticity  . 


Fibrous. 


In  these  two  tables  you  are  enabled  to   see    at   a  glance  the  primary 
composition,  properties  and  functions  of  the  human  body.     Reflect  upon 

2 


18  ELEMENTAKY    CONSIDERATIONS, 

them,  gentlemen,  until  each  of  them  is  clearly  appreciated  and  fully  im- 
pressed upon  the  mind. 

That  which  will  be  most  difficult  for  you  to  appreciate,  and  trace  accu- 
rately in  the  study  of  the  more  complex  structures  and  functions,  is  the 
dift'erence  between  the  susceptibility  as  an  elementary  property  of  all  liv- 
ing matter  and  the  elementary  function  peculiar  to  nerve  matter  called 
sensibility.  If  you  remember,  however,  that  the  first  is  a  passive  quality 
or  endowment  of  each  and  every  atom  of  living  matter,  imparting  the  ca- 
pacity to  be  acted  upon  by  various  agents;  while  the  other  involves  both 
a  special  structure  and  a  positive  local  action,  you  will  not  be  likely  to 
confound  them  with  each  other.  For  instance,  a  muscular  fibre  made  up 
of  a  peculiar  arrangement  of  atoms  or  cells  and  endowed  with  the  prop- 
erty siisceptibility,  receiving  a  current  of  electricity  or  a  nervous  impres- 
sion from  either  a  mental  or  organic  nervous  centre,  performs  its  pe- 
culiar function  by  contracting.  But  if  the  muscular  fibre  be  first  washed 
with  a  solution  of  carbonic  or  hydrocyanic  acid  by  which  its  susceptibility 
is  destroyed,  neither  electricity  nor  nervous  force  will  elicit  from  it  the  slight- 
est action.  The  same  is  illustrated  in  the  processes  of  secretion,  nutrition, 
etc.  If  the  secreting  cell  is  endowed  with  its  proper  susceptibility  and 
the  blood  containing  the  proper  elements  is  brought  in  contact  with  it,  an 
sctive  process  takes  place  by  which  a  new  fluid  is  evolved,  called  a  secre- 
tion. The  vaso-motor  nervous  force,  by  altering  the  action  of  the  blood- 
vessels and  consequently  the  supply  of  blood,  may  modify  secretion,  but 
does  not  either  produce  or  suppress  it.  The  exhibition  of  nervous  force 
requires  a  special  apparatus  or  anatomical  structure;  while  the  results  of 
susceptibility  and  vital  affinity  are  seen  wherever  there  is  a  cell  or  atom  of 
living  matter  whether  animal  or  vegetable. 

It  is  the  possession  of  these  properties  that  distinguishes  living  organic 
inatter  from  dead  matter.  If  you  ask,  from  whence  are  they  derived,  I 
answer  that  so  far  as  reliable  observation  has  yet  reached,  they  are  derived 
with  the  germ  from  the  parent,  and  in  no  other  way.  They  are  neither 
material  agents,  nor  active  organic  forces,  but  simply  properties  of  living 
matter,  by  which  such  matter  becomes  susceptible  to  the  influence  of  ex- 
ternal agents,  on  the  one  hand;  and  specific  direction  is  given  to  whatever 
molecular  changes  take  place,  on  the  other. 

If  you  now  fix  your  attention  upon  the  tabular  statements  on  the  black- 
board, and  get  clearly  delineated  in  the  mind  the  human  body,  composed 
of  the  several  elementary  structures,  each  with  its  own  peculiar  arrange- 
ment of  organic  atoms,  possessed  of  its  elementary  properties,  and  per- 
vaded by  the  fluids  in  their  normal  proportion  and  composition,  you  will 
have  an  adequate  idea  of  health  as  applied  to  the  animal  organization  in  a 
passive  condition.  But  to  make  the  picture  complete  and  capable  of  prac- 
tical application  another  element  must  be  considered,  namely,  the  action  of 
exterior  agents.  Organized  bodies,  like  all  other  ponderable  matter,  are 
inert  or  passive  until  acted  vipon  or  broughtin  contact  with  certain  exterior 
agents  or  influences.  The  vegetable  germ  may  be  complete  in  its  organi- 
zation and  its  germinal  cell  endowed  with  the  necessary  properties,  but 
until  it  receives  the  ext(?rior  impression  of  heat  and  moisture,  it  will  ex- 
hibit no  sign  of  activity  or  life.  So  the  human  body  may  have  6very 
structure  complete  in  the  arrangement  of  its  atoms;  the  fluids  may  be 
perfect  in  their  quantity  and  quality,  and  the  whole  may  be  possessed  of 
the  required  susceptibility  and  vital  affinity,  yet  no  action  or  sign  of  life 
will  be  seen  until  the  application  of  an  external  force  or  influence,  such 
as  atmospheric  air  containing  oxygen,  heat  and  electricity.  Three  things, 
then,  are  essential  to  constitute  what  we  terra  health;   namely,  an  exact 


OE-    PEINCIPLES    OF    MEDICINE.  19 

formation  and  arrangement  of  atoms  or  cells  constituting  the  several 
structures  of  the  human  body,  the  proper  quantity  and  composition  of  the 
fluids,  and  the  presence  in  due  quantity  and  quality  of  the  external  agents 
just  alluded  to.  When  all  these  exist  in  their  normal  relations  to  each 
other,  the  phenomena  of  life  are  manifested  in  a  strictly  normal  or  healthy 
manner. 

By  these  remarks,  gentlemen,  you  will  perceive  that  to  gain  the  first 
or  preliminary  step  necessary  to  the  philosophical  study  of  disease,  you 
need  to  be  perfectly  familiar  with  the  departmentsof  anatomy,  physio  log;y , 
chemistry  and  physics,  in  their  most  complete  development. 


LECTURE    11. 

Analysis  of  Disease— Tts  Elementnrv  Forms— Changes  in  the  Blood--  Changes  in  the  Organized 
Tissues— Functional  and  Structural  Disease— Tabular  Statement— Why  all  Attempts  to  Build 
up  Systems  or  Theories  of  Mediciue  Founded  on  Some  Supposed  Universal  Principle  of  Morbid 
Action,  have  Failed. 

GENTLEMEN:  Having  in  the  preceding  lecture  subjected  the  human 
body  to  an  analytical  examination,  and  pointed  out  the  elementary 
items  which,  aggregated,  constitute  what  we  term  healthy  you  are  pre- 
pared, by  following  out  the  analysis,  to  appreciate  the  elementary  forms 
and  conditions  of  morbid  action  constituting  disease.  If  disease  is  simply 
a  deviation  from  the  natural  or  healthy  condition  of  some  part  of  the 
human  system,  we  inquire  first  as  to  the  directions  in  which  such  deviations 
are  possible.  Reflection  and  clinical  observation  alike  show  us  that  devia- 
tions from  the  normal  standard  may  take  place  in  three  directions,  namely: 
increase,  diminution,  and  perversion.  If  we  give  our  attention,  first,  to 
the  fluids  of  the  body,  we  find  the  blood  capable  of  being  increased  in 
quantity  so  as  to  cause  over-fullness  of  the  vascular  system,  constituting 
what  pathologists  term  plethora.  In  other  cases  it  is  diminished  in 
quantity  so  far  below  the  natural  standard  as  to  leave  the  vascular  appar- 
atus without  the  proper  distension,  which  constitutes  anaemia.  In  still 
another  class  of  cases  the  blood  may  be  neither  increased  nor  diminished 
in  quantity,  but  its  proximate  elements  may  be  altered  in  their  relative 
proportion,  or  in  their  quality,  or  by  the  intermixture  of  some  foreign  sub- 
stance, which  several  conditions  may  be  included  under  the  general  term 
perverted.  If  we  turn  our  attention  from  the  blood  as  a  whole,  to  its  sev- 
eral constituents,  we  find  each  capable  of  undergoing  the  same  deviations 
from  the  standard  of  health.  Either  one  or  all  of  the  nutritive  and  form- 
ative constituents  may  be  increased,  constituting  a  hyperremic  or  hyper- 
plastic condition;  or  they  may  be  diminished,  constituting  spanfemia,  or 
poor  blood;  or  their  properties  may  be  so  altered  as  to  constitute  septicae- 
mia, or  blood  degeneration.  The  latter,  however,  is  much  more  frequently 
induced  by  either  excess  or  alteration  of  the  effete  constituents  of  the 
blood.  When  some  deleterious  agent  is  introduced  into  the  blood,  capa- 
ble of  altering  its  properties,  the  condition  is  called  toxaemia. 

If  we  pass  to  an  examination  of  the  secretions,  we  shall  find  them  all  ca- 
pable  of  undergoing  the  same  primary   deviations  from   the  normal  or 


20 


ANALYSIS   OF    DISEASE. 


healthy  standard.  That  is,  each  is  capable  of  being'  simply  increased  above 
the  normal  quantity,  or  diminished  below  it,  or  perverted  either  by  altera- 
tion in  the  relative  proportion  of  its  constituents  or  by  the  introduction  in- 
to it  of  some  foreign  ingredient.  The  virine,  for  example,  may  be  exces- 
sive constituting  diabetes  insipidus;  or  it  may  be  diminished  as  in  the 
inflammations;  or  it  may  contain  less  or  more  than  the  normal  quantitv  of 
urea,  uric  acid,  and  salts,  or  it  may  contain  new  ingredients  as  albumen, 
sugar,  &c.  The  same  is  true  of  the  cutaneous,  gastric,  salivary,  and  all 
other  secretions.  Perhaps  it  will  aid  you  if  we  place  on  the  blackboard  the 
following  tabular  summary: 


Nutritive 
Constituents. 


'  Albumen 

White  Corpuscles. 
Fatty  Matter.... 

Salts 

Oxygea , 


Primary      T  Increased. 
Morbid      -|  Diminished. 
Conditions.    [.Perverted. 


FLUIDS 

OF  THE 

HUMAN 

BODY. 


^^^^^]    cLrtne:ts.{R<^<i  Corpuscles.    |do. 

rPibrin 1 

Effete       J  Extractive  matter.  |  -p^ 

Constituents.  1  Salts f 

y  Carbonic  Acid ....  J 


Secretions 


Saliva 

Gastric  Juice  . . . 
Pancreatic  Juice. 


used  in  the  -I  Mucus [-Do 


System. 


Synovial, 

and  Serous 
Fluids 


r  Increased. 

■{  Diminished. 

1^  Perverted. 

r  Increased. 

. .  <  Dimmished. 

l_  Perverted. 


1  Increased. 
,  >  Diminished, 
j  Perverted. 


Secretions.  < 


Secretions  f  Cutaneous  . .  .1 

wholly    iP^^?^°^^^ylDo 
T?^^^^*-^';.^         a-nd  Renal  | 
Excretory.  [     Secretions  ..  j 


1  Increased. 
V  Diminished. 
J  Perverted. 


r- 


n. 


Mixed      '  Hepatic    an d  ',  p    loiniiSfed.. 

Secretions.^      Intestmal.     J  JPei-verted. 

In  making  this  tabular  sketch,  I  have  not  included  in  each  division 
all  the  particular  secretions  that  belong  to  it,  but  the  most  important,  which 
will  be  sufficient  to  clearly  indicate  the  morbid  deviations,  we  are  endeav- 
oring to  point  out,  and  their  applicability  to  each  and  all  the  fluids  of  the 
human  body. 

If  we  turn  our  attention  to  the  solids  or  organized  structures  of  the 
body,  we  shall  find  them  capable  of  presenting  similar  deviations  from  the 
healthy  condition,  either  in  their  properties,  their  functions  or  their  struc- 
ture. 

For  instance,  the  elementary  properties  common  to  all  the  tissues  may 
be  increased  or  diminished  or  perverted.  In  speaking  of  these  properties, 
susceptibility  and  vital  affinity,  as  capable  of  increase  and  diminution,  I  do 
not  wish  to  convey  the  idea  that  they  are  separate  substances,  to  be  increased 
or  diminished  in  quantity  or  bulk,  as  we  would  the  quantity  of  air  or  water  or 
any  other  material  substance.  I  simply  mean  that  the  structures  endowed 
with  these  properties  are  capable  ol  being  so  influenced  as  to  manifest  them 


ANALYSIS    OF    DISEASE.  21 

in  a  greater  or  less  degree  of  activity,  or  in  some  unusual  direction.  We  see 
one  person  Avho  either  from  hereditary  or  acquired  influence,  has  become 
so  easily  aifected  l)y  ordinary  external  impressions,  that  the  slightest 
atmospheric  changes  are  liable  to  produce  exaggerated  effects.  His  sus- 
ceptibility is  too  great.  Another  presents  directly  the  opposite.  Neither 
atmospheric  changes  nor  other  excitants  produce  the  ordinary  influence, 
and  we  say  his  susceptibility  is  impaired. 

Again,  we  find  one  person  with  rich  blood,  active  atomic  or  molecular 
changes,  and  not  only  active  nutrition,  secretion  and  calorification,  but  the 
slightest  exudation  into  any  of  the  structures  or  upon  the  membranous  sur- 
faces, is  rapidly  organized  into  new  tissue,  causing-  indurations,  adhesions 
or  increased  growths.  In  such  the  play  of  vital  affinity  is  manifestly 
increased  above  the  normal  standard.  In  surgical  phrase,  he  has  a  hyper- 
plastic diathesis.  In  another  person  we  may  find  the  reverse  of  all  this. 
The  oi'dinary  organic  changes  are  slow  ;  nutrition,  secretion,  and  calorifi- 
cation are  but  feebly  maintained  ;  and  if  exuditions  take  place,  instead  of 
ra]")id  organization  and  acquisition  of  vitality,  they  degenerate,  causirg 
softening  of  tissue,  diffuse  suppuration,  and  diminished  nutrition  or  growtii. 
It  is  plain  that  in  such  we  have  impaired  or  feeble  vital  aiSnity,  and  pathol- 
ogists style  it  an  aplastic  diathesis.  Ln  still  another  case  or  class  of  cases, 
we  find  the  molecular  changes  not  merely  increased  or  diminished,  but  so 
altered  that  atoms  are  attracted  to  and  retained  in  tissues  where  they  do 
not  naturally  belong,  causing  metamorphosis  of  tissue  as  when  cartilage 
becomes  bone,  muscular  fibre  fatty  tissue,  &c.  Or  still  further,  causing 
the  primary  atoms  or  cells  to  be  formed  erroneously  and  to  accumulate  in 
the  form  of  tumors  or  morbid  growths.  These  are  evidently  all  results  of 
a  perverted  vital  afiinity.  The  several  alterations  in  the  elementary  prop- 
erties, constituting  primary  morbid  conditions,  may  take  place  in  all  the 
tissues  and  organs  at  once,  constituting  a  general  morbid  condition  of  the 
whole  system  ;  or  they  may  occur  in  only  one  tissue  or  organ  constituting 
local  predispositions  and  derangements.  If  the  deviation  is  general  and 
derived  from  hereditary  influences,  or  acquired  from  causes  acting  feebly 
but  continuously  through  a  long  period  of  time,  the  individual  will  present 
some  one  of  those  conditions  called  diatheses  or  predispositions,  such  as 
the  plastic  and  aplastic,  scrofulous,  cancerous,  rheumatic,  gouty,  &c.  But 
if  the  causes  act  with  more  suddenness  and  intensity,  producing  more 
abrupt  and  exaggerated  disturbance  of  the  properties,  there  "will  result 
some  one  of  the  more  acute  forms  of  disease,  such  as  fever,  inflammation, 
or  active  irritation. 

l^rimary  Alterations  of  Function. — The  fact  that  the  natural  or 
healthy  performance  of  any  function  depends  on  the  coincidence  of  three 
things,  namely:  the  proper  arrangement  of  atoms  constituting  normal  struc- 
ture, the  endowment  of  the  structure  with  the  properties  in  their  normal  de- 
gree, and  the  presence  of  the  proper  stimulus  in  the  normal  proportion,  it 
folhnvs  that  the  failure  or  disturbance  of  either  of  these  conditions  must 
be  follow^ed  by  corresponding  failure  or  disturbance  of  function.  And  as  I 
have  just  stated,  that  either  or  both  of  the  elementary  properties  are  capa- 
ble of  being  increased,  diminished  or  perverted,  so  we  may  have  the  same 
primary  deviation  from  the  natural  condition  in  any  one  or  all  of  the 
functions  in  the  human  body.  The  function  of  the  secreting  structure 
is  to  separate  from  the  blood  certain  materials  in  a  fluid  form,  called  a 
secretion.  The  secreting  cells  of  the  kidneys,  for  example,  elaborate 
urine.  And  few  things  are  more  familiar  than  the  fact  that  the  quantity 
secreted  in  a  given  time  maybe  excessive  or  deficient,  or  it  may  be  al- 
tered in  quality — perverted,  either  by  the  omission  of  one  or  more    of  its 


22 


ANALYSIS    OF    DISEASE. 


natural  constituents,  or  by  the  intermixture  with  it  of  foreign  sub- 
stances, as  albumen,  sugar,  coloring  matter  of  bile,  etc.  The  special 
fvinctions  of  the  nervous  structure  are  sensibility  and  transmissibility. 
x\nd  there  are  but  few  morbid  phenomena  more  familiar  to  the  physician 
than  increased  sensibility,  technically  called  hypercesthesia,  and  dimin- 
ished sensibility,  called  anesthesia,  and  many  cases  are  presented  in 
which  the  sensibility  is  altered  in  such  a  way  as  to  convey  an  impression 
of  a  morbid  charactei-,  such  as  heat  and  cold  when  there  is  no  real  change 
of  temperature;  or  a  sapid  substance  tastes  bitter,  or  a  bitter  one  sweet. 
These  constitute  perverted  sensibility.  These  familiar  illustrations  are 
sufficient  to  show  you  that  each  function  of  the  human  system  is  capable 
of  being  altered  from  the  standard  of  health  in  three  directions,  namely: 
increased  above,  diminished  below,  and  perverted.  Hence,  we  may  ex- 
press the  primary  morbid  conditions  of  the  organized  tissues  in  tabular 
form  as  follows: 


ELEMENTARY 

FORMS 
OP  DISEASE 


Elementary 
Properties. 


Susceptibility 


Vital  Affinity. 


f  Increased. 
I  Diminished. 


■\ 


r  Increased. 
Diminished. 


Perverted. 


'  o^    -1 -Tj.         1  r  Tncreased. 
Sensibihty  and      diminished. 
Transmissibihty|pg^.^^^.^g^_ 

f  Increased. 
Contractility...  <  Diminished. 
[_  Perverted. 


Elementary 
(.    Functions. 


-i  Secretion. 


f  Increased. 
^  Diminishec 
L  Perverted. 


CapillaiyTrans-  f  t„  „_„„„„ j 

.Elasticity IjSStd. 

Primary  Alterations  in  Structure. — The  same  analytical  mode  of  in- 
vestigation applied  to  the  study  of  structural  changes,  will  show  them 
capable  of  being  resolved  into  three  classes,  namely:  one  in  which  vital 
affinity  being  active  and  the  suj^ply  of  nutritive  material  abundant,  the 
addition  of  new  atoms,  constituting  nutrition,  exceeds  that  of  disin- 
tegration, and  hence  there  is  an  increased  growth,  a  hypertrophy. 
Another,  in  which  either  the  vital  affinity  is  diminished,  or  the  supply  of 
nutritive  material  is  deficient,  and  in  consequence  the  nutrition  is  less 
than  natural,  constituting  atrophy.  While  the  third  class  embraces  those 
cases  in  which  the  vital  affinity  is  perverted  or  altered  in  such  a  way  as 
to  cause  the  attraction  and  accumulation  of  atoms  not  belonging  to  the 
particular  structure  affected.  This  necessarily  yesults  either  in  the  trans- 
formation of  the  structure,  as  in  the  conversion  of  muscular  fibre  into  fatty 
matter,  cartilage  into  bone,  etc.,  or  in  some  one  of  the  morbid  growths,  or 
tumors.  These  latter  may  be  osseous,  fibrous,  fibro-cartilaginous,  cartil- 
aginous, fatty,  or  malignant. 


ANALYSIS    OF    DISEASE.  23 

From  this  rapid  review,  you  perceive  cloarly  that  we  may  have  regular 
deviations  from  the  standard  oi"  health,  either  in  the  direction  of  excess, 
diminution^or  perversion,  in  all  the  elements  that  go  to  make  up  the  ani- 
mal economy:  in  the  blood,  as  a  whole,  and  in  the  several  constituents 
separately;  in  the  secretions;  in  the  properties  common  to  all  the  tissues; 
and  in  the  functions  peculiar  to  each  structure.  To  complete  the  review, 
we  may  apply  the  same  lule  to  those  natural  excitors  that  act  habitually 
upon  the  living  organization  from  without,  they  being  capable  of  acting- 
in  excess,  or  deficiency,  or  with  properties  so  altered  as  to  make  impress- 
ions different  from  simple  excess  or  its  opposite,  and  hence  termed  pervert- 
ed. And  here,  gentlemen,  at  this  early  periodin  your  course,  you  can  readily 
see  why  evary  attempt  to  build  up  a  system  of  medicine,  founded  on  the 
idea  that  all  disease  is  a  unit,  or  traceable  to  some  one  theory  of  morbid 
action,  has  failed  in  the  past,  and  will  continue  to  fail  in  the  future.  It 
matters  not  whether  we  take  the  theory  of  Brown,  which  refers  all  disease 
primarily  to  either  direct  or  indirect  debility;  that  of  Rush,  Broussais,  and 
Paine,  which  traces  all  morbid  action  to  Yt'cxvusa-j  irritation  or  excitement; 
or  that  of  Hoffman  modified  by  CuUen,  which  refers  all  morbid  action  to 
a  primary  morbid  impression  on  the  nervous  system,  they  all  fail  to  recog- 
nize the  fact  that,  disease  being  a  simple  deviation  from  health,  must 
present  as  many  different  aspects  as  there  are  directions  in  which  devia- 
tions can  take  place.  Almost  all  theories  and  systems  contain  some  truth. 
Their  authors  and  supporters  seeing  clearly,  perhaps,  a  single  mode  of 
morbid  action,  and  looking  at  this  from  one  standpoint,  they  endeavor  to 
make  all  the  facts  of  science  and  the  observations  of  clinical  experience 
conform  to  the  one  central  idea  or  theory.  With  them  the  one  clearly 
perceived  mode  of  morbid  action  is  applied  to  all  diseases,  either  directly 
or  indirectly,  and  hence  in  their  minds  it  assumes  the  place  of  the  fabled 
iron  bedstead,  to  which  all  else  must  be  made  to  fit. 

Equally  futile  and  transitory  have  been  all  the  so-called  systems  of 
therapeutics,  founded  as  they  usually  have  been,  upon  some  preconceived 
theory  of  disease.  Thus  the  direct  and  indirect  debility  of  Brown  neces- 
sitated the  predominant  therapeutic  law  of  stimulation  so  generally  adopt- 
ed by  his  followers;  the  irritation  of  the  school  of  Rush,  as  certainly  gave 
rise  to  the  therapeutic  law  of  depletion,  while  the  restriction  of  the  irrita- 
tion primarily  to  the  nervous  system,  by  Hoffman  and  Cullen,  only  added 
to  the  general  law  of  depletion,  the  use  of  anodynes  and  antispasmodics. 
The  analytical  review  I  here  give  you  concerning  the  elementary  forms 
of  disease,  or  primary  modes  of  morbid  action,  will  enable  you  to  see  dis- 
tinctly just  how  far  any  one  or  all  of  the  special  theories  of  disease  and  ac- 
companying laws  of  cure  are  true,and  where  they  deviate  into  error.  By  that 
review  it  was  made  obvious  that  both  the  properties  of  the  living  tissues,  the 
functions  of  particular  organs,  and  the  molecular  or  atomic,  changes  were 
capable  of  being  so  far  increased  above  the  normal  standard  as  to  constitute 
disease  of  excitement,  and  therefore  requiring  an  application  of  the  thera- 
peutic law  of  depletion  or  sedation.  It  was  made  equally  obvious  that 
these  same  properties,  functions  and  molecular  changes,  might  be  so  far  di- 
minished as  to  constitute  disease  of  debility,  requiring  the  application  of  a 
law  of  stimulation,  or  active  support. 

And,  again,  itwasseen  that  the  properties  of  the  blood  and  tissues  were 
capable  of  such  alteration  as  would  cause  perverted  actions,  both  in  the 
molecular  changes  in  the  tissues  and  the  functions  of  particular  organs, 
thereby  requiring  neither  simple  sedation  or  stimulation,  but  alterant-, 
antidotes,  and  eliminants.  You  thus  see  that  all  these  theories  are  correct 
when  the  application  of  each  is  restricted  to  a  single  mode  of  morbid  action ; 


24  ANALYSIS    OF    DISEASE. 

hut  they  become  erroneous  and  highly  mischievous  the  moment  the  attempt 
is  made  to  apply  any  one  of  them  to  all  morbid  action. 

The  foregoing  observations  apply  equally  well  to  all  the  various  pathys 
and  isms  that  have  from  time  to  time  sprung  up  like  mushrooms  from  the 
fertile  soil  of  medical  science.  Whether  you  take  the  bluntly  expressed 
maxims  of  Samuel  Thompson,  the  founder  of  Thompsonianism  and  its 
modification  known  as  modern  Eclecticism,  that  "  heat  is  life  and  cold  is 
death,"  or  the  more  fanciful  dogmas  of  Hahnemann,  that  "  like  cures 
like,"  and  the  "smaller  the  dose  the  greater  the  therapeutic  power," 
they  are  equally  vain  attempts  to  make  the  varied  and  often  opposite  phe- 
nomena of  disease  subservient  to  a  single  partial  law. 

By  these  observations,  I  wish  to  impress  strongly  upon  your  minds  the 
important  fact,  that  the  only  true  basis  or  starting  point  for 'a  rational 
study  of  disease,  is  afforded  by  a  thorough  knowledge  of  the  anatomy  and 
physiology  of  the  human  body.  Once  possessed  of  a  full  knowledge  of 
the  composition,  properties  and  functions  of  the  human  system,  we  are 
prepared  to  appreciate  each  deviation,  in  any  direction,  from  the  natural 
condition  so  far  as  to  constitute  disease.  With  such  a  preparation,  you 
are  ready  to  receive,  arrange,  and  apply  the  facts  and  observations  of 
clinical  experience. 

Instead  of  espousing  some  theoretical  dogma  and  vainly  striving  to 
adjust  all  the  facts  of  science  and  observation  to  it,  or  bewildering  your- 
selves with  cumbersome  systems  of  nosology,  you  carefully  study  the 
causes  and  phenomena  of  disease  from  the  standpoint  of  health,  with  a 
view  to  remove  or  mitigate  the  first,  and  to  modify  the  second  in  the  direc- 
tion towards  its  [primarj''  point  of  departure,  in  other  words  towards  the 
re-establishment  of  health.  That  is,  if  you  find  the  phenomena  or  symp- 
toms of  disease  indicating  increased  activity  or  irritation,  you  strive  to 
reduce  or  subdue  the  excess  of  activity ;  if  indicating  depression  or 
impairment  of  activity  and  excitement,  you  endeavor  to  prop  up  or  sus- 
ta.n  ;  if  indicating  neither  simple  excitement  nor  depression,  but  perver- 
sion of  action,  you  call  to  the  aid  of  your  patient  such  alteratives  as 
are  best  adapted  to  correct  the  particular  perversion  ;  and  if  by  continu- 
ance of  morbid  actions,  obstructions  or  exudations  have  occurred,  either 
in  the  blood  or  the  tissues,  you  call  into  requisition  such  eliminants, 
alteratives,  and  tonics  as  will  be  most  efficient  in  promoting  their  removal. 

By  such  a  course  you  become  philosophical  practitioners  of  the  healing 
art,  true  handmaids  of  nature,  ever  studying  the  nature  and  tendencies  of 
her  embarrassments,  and  ever  striving  to  aid  in  correcting  them. 


GENEEAL    PROCESSES    AND    COMPLEX    EUNCTIOXS.  25 


LECTURE    III. 

G'^ncrnl  Processes  and   Complex    Functions— Their  Relations  to  Each    Other    in    Health    and 
Disease— What  Constitutes  Nature— The  Efforts  of  Nature— The  "Vis  Medicatrix  Naturee  " 

TN  the  two  preceding  lectures  I  have  endeavored  to  present  to  you  an  an- 
alytical view  of  the  elementar}-  structures,  properties,  and  functions  of 
the  human  system  in  their  natural  relations,  constituting  healtii;  and  the 
various  deviations  from  that  natural  relation  constituting  the  primary 
forms  of  morbid  action  or  disease.  Your  attention  is  now  invited  to  a  con- 
sideration of  certain  general  processes  and  complex  functions,  which  result 
from  the  anatomical  and  functional  union  of  the  various  elementary  struct- 
ures to  wdiich  I  have  alluded.  These  prc^cesses  differ  from  functions,  inas- 
much as  they  are  not  the  result  of  the  action  of  any  one  or  more  of  the 
structures,  but  are  constantly  going  on  in  all  the  structures  at  once.  They 
m-iy  be  termed  nutrition,  disintegration,  and  calorification.  By  the  first  is 
meant  the  direct  addition  of  new  atoms  to  the  organized  structures;  by 
the  second,  the  removal  of  the  old  atoms  as  they  become  useless  or  super- 
fluous; and  by  the  third,  the  evolution  of  heat  to  maintain  the  temperature 
of  the  body.  These  complex  functions  are  performed  by  four  groups  of 
organs,  which  may  be  designated  the  digestive,  the  excretory,  the  repro- 
ductive and  the  mental.  The  first  embraces  the  alimentary  canal  and  its 
appendages,  by  which  the  new  material  is  received,  digested,  and  assimi- 
lated, or  prepared  for  use  in  the  process  of  nutrition.  The  second  em- 
braces all  those  organs  and  structures  engaged  in  the  work  of  receiving 
lh3  products  of  disintegration  and  removing  them  from  the  system,  of 
which  the  skin,  kidneys  and  lungs  are  the  chief.  The  third,  consists  of 
the  male  and  female  organs  of  generation.  And  the  fourth  is  made  up  of 
the  cerebro-sjoinal  nervous  apparatus,  including  the  special  senses  and  the 
muscles  of  voluntary  motion. 

In  regard  to  the  general  processes,  it  may  be  remarked  that  the  two  first 
named  are  directly  antagonistic,  or  the  reverse  of  each  other.  Nutrition, 
which  consists  in  the  addition  of  the  new  material,  derived  from  the  di- 
gestive and  assimilative  organs,  directly  to  the  respective  tissues  for  which 
it  has  been  fitted,  is  undoubtedly  performed  in  obedience  to  the  attraction 
or  affinity  of  each  tissue  for  the  appropriate  atoms  or  cells  ;  these  latter 
passing  through  the  walls  of  the  capillaries  by  a  process  which  has  been  lik- 
ened to  that  of  exosraose.  The  escape  of  the  nutritive  material  from  the 
blood  in  the  capillary  vessels  and  its  lodgment  in  the  several  tissues,  dif- 
fers, however,  from  the  simple  physical  process  termed  exosmose,  inasmuch 
as  only  such  atoms  escape  from  the  vessels  into  each  tissue  as  are  prepared 
to  become  a  part  of  it,  although  they  are  all  in  one  mass  in  the  blood. 

This  fact  alone,  shows  that  there  is  in  the  living  structures  of  the  body 
some  inherent  power  of  selection,  which  I  have  thought  best  to  term  affinity, 
or  vital  affinity. 

As  the  capillary  vessels  have  no  open  ends  or  visible  termini,  but  are 
continuous  tubes  between  the  arterioles  and  veinous  radicles,  it  is  not 
easy  to  explain  how  the  nutritive  matter  passes  from  the  blood  in  the  ves- 
sels, into  the  adjacent  structures.  But  it  is  highly  probable  that  the  walls 
of  the  capillary  vessels  have  pores,  throuofh  which  the  primary  atoms  of 
matter  may  pass,  either  from  within  or  without. 


26  GENERAL    PROCESSES    AND    COMPLEX    FUNCTIONS. 

You  thus  see  the  admirable  adaptation  of  the  true  capillaries,  both  a? 
connecting  links  between  the  arterial  and  veinous  systems  of  vessels,  and 
as  the  medium  through  which  matter  is  conveyed  to  and  from  all  the  other 
structures  of  the  body  in  the  processes  of  nutrition  and  disintegration. 
When  the  matter  furnished  through  the  digestive  organs  is  perfect  in  its 
assimilation,  the  vascular  system  unobstructed,  and  the  vital  affinity  of  the 
tissues  natural,  the  process  of  nutrition  goes  on  healthily  and  the  integrity 
of  each  part  is  maintained.  During  the  period  of  development  or  growth, 
the  process  of  nutrition  predominates  over  that  of  disintegration  and 
excretion.  After  maturity  and  through  the  active  period  of  adult  life, 
these  two  processes  should  balance  each  other.  But  after  passing  the  last 
named  period,  disintegration  begins  to  gain  supremacy  over  the  nutrition 
and  generally  holds  it  in  increasing  ratio  until  death  by  old  age. 

The  conditions  essential  to  healtliy  nutrition,  are  the  presence  of  a  suffi- 
cient quantity  and  variety  of  perfectly  assimilated  material,  in  arterial- 
ized  or  oxygenated  blood  passing  with  a  certain  rate  of  motion  through 
the  capillaries  ;  and  the  existence  in  the  structure,  of  the  natural  proper- 
ties, susceptibility  and  vital  affinity.  If  the  quantity  or  variety  of  food  be 
insufficient,  or  if  the  digestive  apparatus  be  incapable  of  perfecting  its 
assimilation,  nutrition  will  be  retarded,  causing  loss  of  flesh  or  atrophy  of 
tissue  ;  and  if  this  is  carried  beyond  a  given  point  it  will  constitute  dis- 
ease. But  if  the  quantity  and  quality  of  food  and  its  assimilation,  are 
both  natural  and  complete,  yet  if  the  properties  of  the  tissues  are  altered 
from  the  natural  standard,  nutrition  will  be  altered  in  the  same  direction. 
If  these  properties  are  impaired  the  attraction  of  new  atoms  will  be  dimin- 
ished, causing  either  atrophy  or  softening  of  structure,  or  both,  as  you  will 
bye-and-bye  see  in  the  low  forms  of  fever.  If  the  properties  are  increased 
they  will  cause  too  rapid  an  addition  of  new  material,  and  unless  the  d's- 
integration  be  hastened  correspondingly,  an  increased  growth  or  hypertro- 
phy will  be  the  result.  If  the  properties  of  the  tissues  are  neither 
depressed  or  exalted,  but  by  the  presence  of  some  disturbing  agent,  are 
perverted,  it  will  result  in  the  attraction  and  lodgment  of  atoms  in  tissues 
where  such  atoms  do  not  naturally  belong,  thereby  causing  the  formation 
of  aplastic,  caco-plastic,  or  plastic  deposits,  constituting  either  transfoi  ma- 
tion  of  structures,  deposits,  or  morbid  growths,  as  explained  in  the  preceding 
lecture. 

The  process  of  disintegration  consists  essentially  in  the  displacement  of 
such  atoms  as  have  become  useless  or  superfluous  in  the  several  structures, 
and  their  return  through  the  capillary  walls  into  the  mass  of  the  bh  ol, 
constituting  what  I  have  already  pointed  out  to  you  as  the  efi"ete  conotitu- 
ents  of  that  fluid. 

The  conditions  essential  for  the  healthy  performance  of  this  process,  ap- 
pear to  be  the  presence  of  the  proper  proportion  of  oxygen  in  the  b  ood 
of  the  systemic  capillaries;  the  normal  rate  of  motion  of  the  blood  throu  vh 
these  vessels;  and  the  natural  condition  of  the  elementary  properties.  The 
presence  of  a  due  proportion  of  oxygen  is  probably  as  essential  to  healthy 
disintegration,  as  is  the  proper  supply  of  perfectly  assimilated  material  for 
the  process  of  nutrition.  The  efiete  matter  resulting  from  the  waste  of 
tissues  and  returned  into  the  blood,  is  separated  therefrom  and  cast  out  of 
the  sytem  through  the  agency  of  several  important  organs,  each  separating 
a  particular  class  of  ingredients,  and  thereby  holding  an  intimate  and  im- 
portant relation  to  each  other.  The  principal  organs  engaged  in  this  work 
are  the  skin,  lungs,  liver,  and  kidneys.  Their  relation  to  the  process  of 
disintegration,  is  as  intimate  and  important  as  is  that  of  the  digestive  or- 
gans to  nutrition.     The  functions  of  the  skin  and  kidneys  are   wholly  ex. 


GENERAL    PEOCESSES    AND    COMPLEX    FUNCTIONS.  27 

cretory,  their  secretions  consisting'  chiefly  of  the  saline  and  nitrogenous 
products  oi"  disintegration.  The  functions  of  the  lungj  and  liver  are,  in 
one  sense,  more  complex.  While  the  first  give  exit  to  a  large  part  of  the 
carbonaceous  products  of  disintegration,  with  aqueous  vapor  and  a  small 
amount  of  animal  matter;  it  also  receives  the  oxygen  which  is  to  be  sup- 
plied through  the  blood  to  the  whole  system.  So,  too,  the  liver  not  only 
separates  from  the  blood  the  products  of  disintegration  in  the  form  of 
cholesterin  and  coloring  matter  which  are  effete  and  disappear  through  the 
alimentary  canal;  but  also,  certain  alkaline  constituents  that  are  not  etfate , 
and  which  are  used  in  aiding  the  process  of  digestion.  So  important 
are  the  functions  performed  by  these  several  excretory  organs,  that  no  one 
of  them  can  be  entirely  suppressed,  even  for  a  brief  period,  without  en- 
dangering the  life  of  the  whole.  Yet  so  carefully  has  the  author  of  nature 
guarded  against  such  emergencies,  that  whenever  the  function  of  one  of 
these  organs  is  diminished,  another,  by  increased  activity,  may  in  part,  at 
least,  supply  the  deficiency.  This  close  sympathetic  relation  of  one  organ 
with  another,  is  most  easily  seen  in  the  functional  relations  of  the  skin  and 
kidneys.  Probably  none  of  you  have  failed  to  notice  the  fact,  that  when 
the  skin  is  unusually  active,  as  in  the  warm  drj^air  of  summer,  the  quantity 
of  urine  voided  in  a  given  time  is  much  less;  and  when  it  is  diminished  by 
the  cold  and  damp  atmosphere  of  spring  and  autumn,  the  quantity  of  urine 
is  proportionately  increased. 

Now,  so  long  as  these  organs  maintain  this  active  sympathy  and  mutu- 
ally compensating  action,  in  any  individual,  he  may  freely  expose  himself 
to  sudden  and  extreme  atmospheric  changes  without  harm.  But  let  ihis 
active  sympathy  fail,  and  the  very  first  exposure  to  marked  atmospheric 
vicissitudes  will  be  likely  to  result  in  the  development  of  the  phenomena 
of  disease. 

A  similar,  though  less  marked,  sympathetic  relation  exists  between  the 
excretory  functions  of  the  lungs  and  liver.  The  four  important  organs  or 
structures  under  consideration,  are  not  merely  the  principal  sewers,  if  I 
may  so  speak,  through  which  the  products  of  disintegration  and  waste  are 
conveyed  out  of  the  system,  but  they  are  equally  the  active  agents  for  sep- 
arating from  the  blood,  and  turning  out  of  the  body,  all  such  foreign  and 
disturbing  material  as  may  have  entered  it  from  without,  so  far  as  it  may 
be  capable  of  separation. 

The  idea  so  long  popular,  both  in  and  out  of  the  profession,  that  the 
blood  and  tissues  could  be  purified  from  the  presence  of  offending  and 
poisonous  material,  by  acting  directly  on  the  stomach  and  bowels  by 
emetics  and  cathartics,  is  erroneous. 

It  is,  indeed,  an  error  that  in  times  past,  led  to  great  abuses  in  the  use 
of  such  evacuants  in  the  treatment  of  disease;  and  from  which  the  non- 
professional part  of  the  community  have  not  yet  been  wholly  freed.  Before 
leaving  altogether  the  subjects  of  nutrition  and  disintegration,  I  must 
guard  you  against  another  error,  which  the  student  is  apt  to  espouse  from 
a  perusal  of  much  of  our  current  medical  literature.  I  allude  to  the  doc- 
trine, inculcated  by  many  writers,  that  to  retard  the  process  of  disintegra- 
tion by  which  old  atoms  are  removed  from  the  tissues,  is  equivalent  to  the 
addition  of  an  equal  amount  of  new  atoms  by  nutrition.  Hence,  those 
agents,  like  alcohol,  which  by  their  presence  in  the  blood  are  capable  of  so 
altering  the  vital  affinity  of  the  tissues  as  to  retard  disintegration,  are 
styled  by  them  indirect  food.  And  we  are  gravely  told  that  if  a  laboring 
man,  by  taking  a  certain  quantity  of  alcoholic  drink,  diminishes  the  gross 
amovint  of  the  excretory  products  of  disintegration  to  the  extent  of  half  a 
pound  in  the  twenty-four  hours,  it  is  equivalent  to  the   addition   of  that 


28  GENERAL    PEOCESSES    AND    COMPLEX    FUNCTIONS. 

amount  of  new  matter  through  the  organs  of  digestion  and  the  process  of 
nutrition. 

If  it  is  true  that  a  primary  atom  or  cell  of  organized  animal  matter,  once 
in  its  place  as  a  part  of  a  living  structure,  is  capable  of  performing  its  of- 
fice for  an  indefinite  period,  or  so  long  as  it  can  be  retained  in  its  position, 
then  indeed  retarded  disintegration  is  equivalent  to  additional  nutrition. 
And  it  will  only  be  necessary  to  find  some  agent  capable  of  arresting 
the  process  of  disintegration  altogether,  and  we  may  live  on  indefinitely 
without  further  expense  for  food,  or  further  loss  of  time  in  eating  it.  Un- 
fortunately for  this  theory,  however,  there  is  no  more  imperative  physio- 
logical law,  or  one  more  prominently  inscribed  on  all  living  animal  matter, 
than  that  active  life  and  molecular  changes  are  inseparable.  When  the 
germinal  matter  or  bioplasm  stored  in  the  dormant  germ,  once  receives  the 
impression  of  its  appropriate  stimulus,  and  the  active  phenomena  of  life 
have  begun,  there  has  commenced  coincidently  those  molecular  changes 
constituting  nutrition  and  disintegration.  And  throughout  the  whole  king- 
dom of  animal  life,  you  will  find  the  activity  of  these  changes  to  bear  a 
direct  ratio  to  the  activity  of  the  phenomena  of  life.  Hence  to  retard 
these  changes  is  to  retard  or  diminish  the  phenomena  of  life.  And  the 
ajrents  that  are  capable  of  retarding  disintegration,  instead  of  being  called 
indirect  food,  should  be  classed  as  organic  sedatives,  and  used  only  as 
medicines  where  such  sedatives  are  needed. 

To  counteract  the  ordinary  waste  of  tissues  by  retarding  disintegration, 
instead  of  furnishing  new  material  by  nutrition,  is  much  like  retaining  the 
limbs  of  a  tree  after  they  have  become  dead  and  dry.  It  may  indeed  serve 
to  retain  fullness  or  bulk,  but  only  to  embarrass  instead  of  to  sustain  the 
processes  of  life. 

And  at  the  bed-side  of  the  sick  you  cannot  be  too  careful  in  discrimina- 
ting between  those  cases  of  failure  in  flesh  from  deficient  assimilation  and 
nutrition,  and  those  from  excess  of  disintegration.  The  former  are  com- 
mon, and  the  latter  rare. 

Beside  the  general  processes  of  nutrition  and  disintegration,  I  named  a 
third,  which  was  called  colorification,  by  which  is  meant  the  evolution  of 
heat  sufficient  to  preserve  the  natural  temperature  of  the  human  body. 
All  classes,  genera,  species  and  varieties  of  living  animals  present  a  tem- 
perature peculiar  to  themselves,  and  generally  difi"ering  more  or  less  from 
the  temperature  of  the  medium  in  which  they  live. 

This  results  from  the  evolution  of  free  heat  by  the  changes  in  the  con- 
dition of  matter,  constantly  taking  place  in  the  tissues  of  living  animal 
l)odies.  It  is  a  well  known  law  in  physics  that  whenever  matter  passes 
from  a  rarer  to  a  denser  condition,  latent  heat  is  set  free  and  becomes 
sensible;  and  when  matter  passes  from  a  denser  to  a  rarer  state,  free  heat 
is  absorbed,  or  becomes  latent.  If  you  have  studied  properly  the  changes 
in  matter  produced  by  the  reception  and  assimilation  of  food,  and  other 
ingesta,  and  its  appropriation  to  the  several  tissues,  you  readily  see  that 
the  general  result  of  these  functions  and  processes,  is  to  change  the  mat- 
ter after  fairly  entering  into  the  system  from  a  rarer  to  a  denser  state, 
thereby  tending  to  increase  the  temperature  by  increasing  the  amount  of 
free  heat.  On  the  other  hand,  the  changes  in  matter  resulting  from  disin- 
tegration and  excretion  as  a  whole,  are  of  the  opposite  character,  and  con- 
sequently result  in  a  tendency  to  diminish  the  temperature  by  converting 
free  into  latent  heat.  In  the  natural  or  healthy  condition  of  the  human 
system,  these  opposing  processes  and  functions  bear  such  a  relation  to  each 
other  in  regard  to  the  evolution  and  absorption  of  heat  as  to  maintain  the 
average  temperature  of  the  body  at  55°  C.  (78.6°  F.)     It  is  neither  neces- 


GENERAL    PEOCESSES    AND    COMPLEX    FUXCTIOXS.  29 

sary  nor  proper,  at  this  time,  to  refer  to  the  former  theories    in    regard    to 
animal  temperature. 

For  many  years  after  organic  and  animal  chemistry  had  begun  to  attract 
attention,  the  evolution  of  heat  in  the  system  was  attributed  to  the  direct 
union  of  the  oxygen  and  carbon  in  the  lungs,  constituting  a  species  of 
combustion.  And  several  ingenious  theories  were  invented  for  explain- 
ino-  its  diffusion  so  equally  through  the  whole  system,  from  the  seat  of 
combustion  in  the  lungs.  The  discovery  of  the  fact  that  the  oxygen  was 
absorbed  from  the  air  cells  of  the  lungs  and  was  carried  with  the  arterial 
blood,  and  that  the  carbonic  acid  gas  evolved  through  the  lungs,  was  not 
formed  in  those  organs,  but  brought  in  the  veinous  blood  from  the  systemic 
capillaries,  destroyed  all  the  preceding  theories.  It  did  not,  however,  de- 
stroy the  idea  of  combustion  by  the  union  of  oxygen  with  carbonaceous 
matter.  It  simply  transferred  the  place  of  the  union  from  the  lungs  to 
the  systemic  capillaries,  where  Prof.  Liebig  and  his  co-laborers  of  the 
chemico-physiological  school  of  investigators,  still  retain  it.  And  not  only 
so,  but  they  divide  the  food  into  nitrogenous  and  carbonaceous,  and  rep- 
resent the  former  as  designed  to  nourish  the  tissues,  and  the  latter  to  unite 
with  oxygen  and  form  carbonic  acid  gas  to  be  evolved  through  the  lungs, 
and  heat  to  maintain  the  proper  temperature  of  the  body.  It  is  in  ac- 
cordance with  this  theory  that  you  find  in  nearly  all  your  books  the  car- 
bonaceous elements  of  our  ingesta,  styled  respiratory  food.  More  than 
twenty  years  since^  I  met  with  so  many  facts  connected  with  the  diet  of 
individuals  and  communities,  and  also  with  the  phenomena  of  diseases, 
which  seemed  difficult  of  explanation  without  denying  the  correctness  of 
the  theory  under  consideration,  that  I  instituted  during  the  years  1849  and 
1850,  several  series  of  experiments  and  observations,  designed  to  deter- 
mine positively  the  relations  of  certain  articles  or  constituents  of  food  and 
drink  to  the  evolution  of  heat  in  the  human  system.  The  details  of  many 
of  these  investigations,  with  the  results  or  inferences  to  be  deduced  from 
them,  were  embodied  in  a  paper  read  to  the  American  Medical  As-ocia- 
tion,  at  its  annual  meeting  in  Charleston,  South  Carolina,  in  May,  1851 ; 
and  subsequently  published  in  the  North- Western  Medical  and  Surgical 
Journal,  then  published  in  this  city.*  The  residts  of  those  investigations, 
together  with  much  subsequent  observation  relating  to  the  same  subject, 
satisfied  me  that  there  was  no  direct  relation  between  the  kind  of  food 
taken  and  the  amount  of  heat  evolved  ;  and  consequently  no  foundation 
for  calling  carbonaceous  matter  respiratory  food,  more  than  any  other 
matter  capable  of  assimilation.  On  the  contrary,  a  large  number  of  care- 
fully recorded  observations  of  the  temperature  of  a  healthy  individual, 
first,  under  an  ordinary  mixed  diet ;  second,  under  a  diet  exclusively  car- 
bonaceous ;  and  third,  under  a  diet  exclusively  nitrogenous,  showed  that 
the  temperature  of  the  body  uniformly  increased  during  the  active  pro- 
cesses of  digestion  and  nutrition,  and  decreased  as  these  declined.  The 
lowest  temperature  was  before  breakfast  in  the  morning,  after  the  long 
fast  of  the  night.  After  breakfast  it  increased  steadily  for  two  or  three 
hours,  and  attained  about  1°  C.  (1.8°  F.)  above  the  temperature  of  the 
early  morning. 

By  1  o'clock,  p.  m.,  it  had  generally  receded  again  about  0.4^  C.  or  from 
half  to  three-quarters  of  a  degree  F.  If  dinner  was  then  taken,  in  half 
an  hour  it  was  perceptibly  increasing  and  continued  to  do  so  for  the  next 
three  hours,  reaching  its  climax  about  the  middle  of  the  afternoon,  when  it 
would  be   from    LI""    to   1A°    C.   {2°  to   2.5''  F.)  higher  than  in  the  early 

*SeT  Experimental  Inquiries,  etc.,  iu  the  NortlL-VTestem  lied,  and  Surg.  Journal,  Vol.  IV, pa^e 
196,  ISol,  bj-  N.  S.  D^vis. 


30  GEXEEAL    PROCESSES    A^B    COMPLEX    FUNCTIONS?. 

morning.  From  that  time  it  declined  very  slowly  until  the  usual  time  for 
a  light  supper,  after  which  it  again  increased  moderately  for  two  or  three 
hours.  These  observations  fully  established  the  fact  that  the  temperature 
of  the  body  does  not  depend  on  kind  or  quality  of  the  food,  but 
directlv  on  the  activity  of  the  processes  of  assimilation  and  nutrition. 
Indeed,  it  appeared  that  when  the  individual  was  restricted  for  three  days 
to  a  diet  exclusively  carbonaceous,  the  average  temperature  was  slightly 
less  than  during  confinement  for  a  similar  period  to  a  diet  exclusively 
nitrogenous.  It  was  further  ascertained  that  some  of  those  articles  which 
have  been  represented  as  pre-eminently  respiratory  food,  alcohol  for  exam- 
ple, when  taken  into  the  system,  induced  a  positive  reduction  of  the  tem- 
perature below  the  natural  standard.  While  the  changes  in  matter  taking 
place  during  the  active  processes  of  digestion,  assimilation  and  nutrition, 
cause  the  evolution  of  heat  tending  to  increase  the  temperature  of  the 
body,  the  processes  of  disintegration  and  excretion  produce  the  opposite 
effect. 

More  especially  is  this  true  of  those  excretions  that  pass  through  the 
skin  and  lungs.  In  the  natural  condition  of  the  system,  these  pass  off  prin- 
cipally in  the  form  of  gases  and  aqueous  vapor.  If  you  remember  the 
large  amount  of  free  heat  rendered  latent  by  the  conversion  of  fluids,  and 
especially  water,  into  vapor  ;  and  that  this  process  is  constantly  taking 
place  from  the  whole  cutaneous  and  pulmonary  surfaces,  you  will  not  fail 
to  appreciate  the  actively  cooling  effect  upon  the  temjDerature  of  the  whole 
body  by  such  process.  In  view  of  the  teachings  of  the  past,  and  of  the 
language  of  many  of  the  books  you  study  at  present,  it  may  sound  to  you 
strangely,  when  I  speak  of  respiration  as  a  cooling  process.  Yet  that  it 
is  so,  is  not  only  apparent  from  the  well-known  fact  that  the  fluid  constant- 
ly bathing  the  extensive  mucous  membrane  lining  the  whole  extent  of  the 
respiratory  passages  is  being  constantly  converted  into  vapor  and  being 
exhaled  ;  but  also  from  the  additional  fact  that  both  man  and  the  lower 
orders  of  animals  instinctively  increase  the  frequency  of  respiration  when 
too  warm,  and  diminish  it  when  too  cold.  And  purely  instinctive  move- 
ments are  believed  to  be  always  in  harmony  with  physiological  laws. 
Have  you  noted,  gentlemen,  your  own  habits  in  regard  to  this  subject? 
While  sitting  here  in  a  warm  room,  you  breathe  freely  from  fourteen  to 
eighteen  times  per  minute.  But  when  the  lecture  is  ended  and  you  pass 
out  on  a  cold  winter  day,  do  you  continue  the  same  rate  of  breathing,  or 
do  you  almost  unconsciously  shrug  your  shoulders,  draw  your  overcoats 
around  you,  and  so  far  stifle  your  respirations  that  they  will  not  average 
ten  per  minute?  Again,  look  at  the  dog  on  your  door-step  on  a  hot  sum- 
mer day.  His  mouth  is  open,  his  tongue  out,  and  he  is  breathing  as  fast 
as  he  can.  But  you  never  saw  him  do  the  same  thing  on  a  cold  day,  unless 
in  immediate  connection  with  excessive  exercise.  And  many  an  ox  has 
been  whipped  for  endeavoring  to  cool  himself  on  a  hot  day  by  putting  out 
liis  tongue  and  breathing  fast,  or  "  lolling,"  as  his  unlearned  driver  would 
call  it. 

The  same  indications  are  afforded  by  the  natural  variations  in  the  cuta- 
neous function.  When  the  surrounding  atmosphere  is  warm,  tending  to 
accumulate  heat  in  the  body,  the  skin  relaxes  and  the  conversion  of  the 
cutaneous  fluid  into  vapor  increases.  In  other  words,  perspiration  is  in- 
creased. When  the  surrounding  atmosphere  is  cold,  just  the  opposite 
effect  on  the  function  of  the  skin  is  induced. 

So  also  in  diseased  or  morbid  states,  when  the  excretory  function  of  the 
lungs,  skin  and  kidneys  is  diminished,  the  temperature  of  the  body  in- 
creases; not  because  there  is  a  more  rapid  evolution  of  heat,  but  sim^^ly  on 


GENERAL    PROCESSES    AND    COMPLEX    FUNCTIONS.  31 

account  of  the  diminution  of  those  processes  or  functions  by  which  the  free 
heat  is  rendered  latent  and  conveyed  away. 

You  cannot  study  too  carefully  the  topics  presented  in  this  and  the  pre- 
ceding lectures.  To  comprehend  clearly  the  primary  tissues,  endowed 
with  tieir  elementary  properties;  the  primary  functions  each  perform;  and 
trace  their  combination  to  form  more  complex  organs,  and  groups  of  organs, 
each  working  for  the  accomplishment  of  a  given  purpose,  yet  each  bearing 
such  relation  to  the  o'hirs  that  a  disturbance  of  the  function  of  one  in- 
volves directly  or  indirectly  the  functions  of  all  the  rest,  is  the  only  way 
to  gain  any  clear  conception  of  what  is  meant  by  nature^  as  used  in  medi- 
cal parlance.  From  the  days  of  Hippocrates  to  the  present  time,  this  word 
"  nature  "  has  occupied  a  prominent  place  in  the  literature  of  our  profes- 
sion. In  all  ages,  it  has  been  clothed  with  the  attributes  of  intelligent 
personality,  and  sometimes  almost  those  of  deity.  Hence  the  expressions, 
"  the  powers  of  nature,"  the  "  efforts  of  nature,"  the  "  vis  meclicacrix 
natnrm^''  etc.  We  are  told  that  nature  does  this  and  that,  at  almost 
every  turn,  and  yet  very  few  have  attempted  to  explain  what  they  meant 
by  nature.  One  who  in  our  time  has  written  much  in  eulogy  of  nature^ 
and  her  power  to  heal  disease,  and  has  correspondingly  endeavored  to  be- 
little the  value  of  art,  defines  his  favorite  goddess  thus:  "Nature,  in  med- 
ical language,  means  a  trust  in  the  reactions  of  the  living  system  against 
ordinary  normal  impressions."* 

According  to  this  definition,  nature  is  not  a  physical  power  or  function, 
but  a  simple  mental  act- -an  exercise  of  faith  or  trust.  Comment  on  such 
a  definition  is  unnecessary.  But  suppose  the  author  of  this  definition 
meant  that  nature  consisted,  not  in  the  mental  act  of  trust  or  faith,  but  in 
the  '■'■reactions  of  the  living  system  against  ordinary  normal  impressions," 
the  question  would  then  arise,  what  are  these  reactions?  If  they  are  any- 
thing more  than  shadows  of  the  imagintion;  and  if  the  phrase,  "reactions 
of  the  living  system  against  ordinary  normal  impressions,"  means  anythino- 
more  than  a  rhetorical  display  of  words  to  cover  ignorance,  such  reactions 
must  consist  of  nothing  more  than  the  actions  induced  in  the  various 
structures  and  organs  by  the  impression  of  ordinary  exterior  agents,  as 
food,  air,  light,  etc.  The  impression  of  food  upon  the  digestive  apparatus, 
excites  activity  in  certain  secretory  and  muscular  structures  by  which  such 
food  is  both  dissolved  and  moved  onward,  until  its  ingredients  are  fitted 
for  addition  to  the  tissues. 

The  presence  of  such  prepared  material  in  the  blood  makes  a  normal 
impression  on  the  properties  of  the  tissues  and  the  resulting  action,  con- 
stitutes nutrition  or  the  active  addition  of  the  newly  prepared  material 
to  the  structures.  So  the  impression  of  oxygen  in  the  arterial  blood  of 
the  systemic  capillaries,  on  the  same  properties  of  the  different  structures 
causes  the  action^  or  reactions  if  you  prefer,  constituting:  disintegration. 
So,  too,  the  same  agent,  reaching  through  the  same  medium,  the  various 
nervous  centers  by  its  normal  impression  on  the  properties  of  the  nerve 
structure,  causes  that  action  which  is  styled  nerve-force  or  innervation. 
The  presence  of  the  materials  for  constituting  urine  in  the  blood,  making 
a  normal  impression  on  the  properties  of  the  secreting  cells  of  the  kidnevs 
causes  such  action  as  actively  combines  these  materials  into  urine  and 
passes  it  out  of  the  system. 

So  of  all  the  other  secreting  organs.  But  let  us  go  a  step  further,  and 
we  shall  find  that  the  various  tissues  and  organs  are  not  only  capable  of 
acting  or  reacting  against  ordinary  normal  impressions,  but    also    against 

*01iver  Wendell  Holmes. 


32  GENERAL   PROCESSES    AND    COMPLEX   FUNCTIONS. 

many  impressions  of  an  abnormal  character.  As  I  have  already  said, 
agents  may  enter  the  blood  with  the  ingesta,  either  through  the  digestive 
or  respiratory  organs,  which  are  not  capable  of  being  used  in  nutrition  or 
in  the  natural  process  of  disintegration,  but  which  are  capable  of  making 
an  abnormal  impression  on  the  properties  of  the  tissues  generally,  or  on 
those  of  some  particular  organ.  And  these  abnormal  impressions  cause 
unnatural  actions,  either  in  the  whole  body  (general  disease)  or  in  the 
particular  organ  for  which  the  agent  had  a  special  affinity  (local  disease.) 
Hence,  Dr.  Holmes  defines  disease  to  be  the  "reactions  of  the  living  sys- 
tem against  abnormal  impressions."  But  every  foreign  agent  that  gains 
access^ to  the  tissues  through  the  medium  of  the  blood,  and  makes  an 
abnormal  impression,  is  not  followed  by  disease.  On  the  contrary,  many 
of  these  agents  bear  such  a  relation  to  some  one  of  the  excreting  organs 
that  they  are  rapidly  separated  with  the  proper  secretion  of  such  organ, 
and  no  morbid  action  results,  thus  presenting  one  of  the  chief  conserviitive 
powers  of  the  living  body.  Indeed,  if  we  put  this  ability  of  the  different 
excretory  organs  and  structures  to  eliminate  from  the  blood  such  elements 
as  are  foreign  to  its  composition,  with  the  power  of  certain  organs  to  take 
on  increased  action  in  temporary  compensation  for  deficient  action  in 
others,  we  shall  have  a  correct  idea  of  the  true  vis  medicatrix,  or  rather 
vis  conservatrix  naturae.  If  you  choose  thus  to  use  the  word  nature,  with 
the  definite  imderstanding  that  it  means  simply  the  natural  activity  of  the 
aggregate  structures  and  organs  of  the  body  and  their  relations  to  each 
other,"there  is  no  objection  to  such  use.  It  is  a  convenient  and  famih"ar 
word,  and  may  be  used  to  express  the  aggregate  activities  of  a  complex 
living  body,  as  properly  as  any  other  in  our  language.  So,  too,  if  when 
you  use  the  expressions,  efforts  of  nature,  powers  of  nature,  vis  mecUcatrix 
natiirce^  etc.,  you  simply  mean  the  action  of  some  organ  to  eliminate  mor- 
bid material,  or  to  comjDensate  for  the  deficient  action  of  some  other  organ 
or  the  sedative  effect  of  some  retained  excretion  in  overcoming  the 
morbid  excitability  and  muscular  spasm  that  had  caused  its  re- 
tention, there  is  no  objection  to  such  use.  But  when  "na- 
ture" is  installed  in  the  human  system  as  a  personal  entity,  and 
clothed  with  attributes  of  intelligence,  and  tlie  phenomena  of  disease  rep- 
resented as  the  efforts  of  such  nature  to  resist  some  morbid  impression, 
and  consequently  not  to  be  interfered  with  by  art,  it  becomes  not  merely 
a  fanciful  goddess,  but  a  positive  hindrance  to  the  advancement  of  prac- 
tical medicine. 


MEDICINES    AND    THERAPEUTIC    PUKPOSES.  33 


LECTURE    IV, 

What  are  Medicines— What  the  Distinctions  Between  Food  and  Medicines— Their  Claisification  for 
Therapeutic  Purposes— Etiologj-. 

HAVING,  in  the  preceding  lectures  endeavored  to  explain,  as  famil- 
iarly as  possible,  the  nature  and  conditions  of  health  and  disease  in 
the  living  human  body,  I  must  next  direct  your  attention  to  some  thoughts 
on  the  nature  and  modus  operandi  of  medicines.  Remedial  agents  and 
influences  properly  embrace  everything  that  can  be  made  useful  in  allevi- 
ating or  curing  disease. 

In  this  sense,  an  encouraging  word  or  cheerful  look,  is  as  much  a  rem- 
edial agent  as  a  pill  or  powder  from  the  apothecary.  It  is  my  intention, 
however,  to  limit  your  attention  during  the  present  hour  to  those  material 
agents  ordinaril}''  styled  medicines,  reserving  the  consideration  of  other 
influences  for  another  occasion.  Medicines,  in  this  restricted  sense,  are 
such  agents  as  are  capable  of  being  introduced  into  the  living  system,  and 
exerting  a  modifying  influence  over  one  or  more  of  the  properties  or  func- 
tions of  the  body,  without  being  capable  of  assimilation  or  addition  as 
nutritive  matter,  to  any  of  the  tissues.  They  may  be  introduced  into 
the  system  through  the  digestive  organs:  through  the  lungs  by  inhalation; 
through  the  skin  by  absorption  ;  through  the  subcutaneous  tissue  by  hy- 
podermic injections  ;  and  by  injection  directly  into  the  blood  vessels. 
The  first  is  the  more  common,  and  practically  important  method.  But  in 
whatever  way  the  medicine  is  given,  it  enters  the  mass  of  the  blood  gen- 
erally unchanged  in  its  composition,  and  induces  its  efi"ects  by  passing 
with  the  blood  into  contact  with  the  various  structures  of  the  body,  and 
by  such  contact  modifying  either  the  properties  or  molecular  changes,  or 
both,  in  one  or  more  of  these  structures.  As  a  general  rule  they  are  also, 
sooner  or  later,  eliminated  from  the  blood  by  some  of  the  excretory  or- 
gans in  so  nearly  the  same  condition  as  when  they  were  introduced,  that 
they  can  be  readily  detected  by  the  proper  chemical  tests.  The  apparent 
exceptions  to  these  rules  are  such  alkalies  and  alkaline  earths  as  are  capa- 
ble of  tmiting  directly  with,  and  neutralizing  acids,  in  the  stomach  before 
time  for  absorption. 

Even  in  these  cases,  however,  the  resulting  compound  is  absorbed,  and 
after  passing  the  round  of  the  circulation,  is  eliminated.  The  real  excep- 
tions, are  those  agents  that  act  directly  on  the  structures  to  which  they  are 
applied,  as  in  the  case  of  sinapisms,  blisters,  caustics,  etc.  The  disposi- 
tion on  the  part  of  many  writers  to  call  all  the  hydro-carbonaceous  sub- 
stances respiratory  food,  and  those  substances  that  simply  retard  the  pro- 
cess of  disintegration,  indirect  food,  has  caused  some  confusion  in  regard 
to  the  distinction  between  food  and  medicine.  It  seems  to  me,  however, 
that  there  are  two  plain  and  essential  points  of  difference  between  these  two 
classes  of  substances.  The  first  is,  that  food  proper  never  passes  through 
the  digestive  and  assimilative  organs  without  important  changes  in  com- 
position and  form,  and  never  re-appears  in  the  excretions  from  either  skin, 
kidnej'-s  or  lungs,  in  the  same  form  as  it  entered  the  system.  For 
instance,  the  principal  proximate  elements  of  our  food  are  starch,  gum, 
sugar  or  glucose,  fat  or  oils,  gluten,  casein,  the  fibrin  and  albumen  of  flesh, 
and  the  inorganic  salts  with  which  thev  are  united.  If  you  note  carefully 
3 


34  MEDICINES   AND    THERAPEUTIC    PURPOSES. 

the  successive  changes  of  the  food  into  chyme,  chyle,  lacteal  fluid,  etc., 
you  will  find  all  these  proximate  elements  radically  changed  before  they 
reach  the  mass  of  the  arterial  blood.  And  you  will  seek  in  vain  for  any 
one  of  them  in  the  eliminations  from  the  true  excretory  organs  of  the 
body.  This  is  directly  opposite  to  what  I  have  represented  to  be  the 
behavior  of  medicine  in  passing  through  the  system. 

The  second  distinction  is  that  food  taken  in  a  healthy  state  of  the  sys- 
tem always  satiates  the  appetite  for  the  time  being;  and  that,  too,  in  about 
the  same  quantity,  without  regard  to  the  length  of  time  it  may  have  been 
used.  For  instance,  if  a  person  eats  bread  three  times  a  day  for  20  years, 
he  is  just  as  readily  satisfied  at  the  end  of  the  time  as  he  was  at  the  be- 
ginning. Natural  appetite  or  hunger  is  simply  the  demand  for  material 
to  supply  the  waste  of  tissue,  and  every  substance  capable  of  assimilation 
when  taken  will  satisfy  that  demand;  and  with  that  satisfaction  ceases  for 
the  time  being  all  relish  for  more. 

No  such  effect,  however,  will  follow  from  the  taking  of  materials  that 
cannot  be  assimilated  and  added  to  the  tissues  by  nutrition.  Hence,  daily 
observation  shows  that  all  those  excitants,  like  the  active  principles  of  tea 
and  coffee,  and  the  anaesthetics  or  retarders  of  tissue-disintegration  or 
waste,  like  alcohol,  ether,  chloroform,  tobacco,  etc.,  which  have  been 
classed  by  some  as  indirect  food,  have  no  power  to  satisfy  except  by  me- 
chanical fullness  of  the  stomach,  or  by  such  a  degree  of  stupor  or  anresthe- 
sia  as  renders  the  individual  for   the  time  oblivious  to  further  impressions. 

And  all  these  articles,  instead  of  producing  the  same  effects  in  the  same 
quantities  for  any  number  of  years,  as  is  the  case  with  real  food,  invariably 
create  a  steadily  increasing  demand  for  more.  You  see  the  young  lady 
who  sipped  daintily  a  cup  of  drink  at  her  breakfast  containing  a  tablespoon- 
ful  of  tea  or  coffee  diluted  with  milk  and  water,  ten  or  fifteen  years  later 
in  life  taking  two  cups  at  the  same  meal,  each  filled,  not  with  milk  and 
water  flavored  with  a  tablespoonful  of  tea,  but  with  a  strong  infusion  of  tea 
or  coffee. 

In  like  manner  you  see  the  young  man  at  18  years  taking  but  one  cigar 
and  one  glass  of  beer  or  wine  per  day,  at  30  years  consuming  five  or  six 
cigars  and  as  many  drinks  of  beer,  with  now  and  then  a  glass  of  distilled 
spirits;  and  at  40  years  he  consumes  a  dozen  cigars  a  day,  and  the  num- 
ber of  drinks  is  limited  only  by  the  quantity  required  to  induce  intoxica- 
tion. It  is  true  that  most,  if  not  all,  of  these  agents,  used  habitually,  in- 
duce such  a  morbid  condition  of  the  stomach  as  to  impair  or  destroy  the 
appetite  for  proper  food,  but  not  for  themselves.  On  the  contrary,  the 
latter  grows  stronger  and  stronger,  more  and  more  insatiable,  until  it  too 
often  becomes  the  ruling  despot  of  the  individual's  life.  Having  thus  de- 
fined what  is  meant  by  medicines  as  distinguished  from  food  or  aliments, 
1  will  divide  the  whole  into  two  great  classes,  as  follows: 

First,  those  substances  that  are  capable,  by  their  presence  in  the  blood, 
of  modifying  the  properties  common  to  all  the  tissues,  in  such  a  way  as  to 
produce  a  perceptible  change  in  one  or  more  of  the  general  processes  tak- 
ing place  in  the  living  body.  These  may  be  called  general  remedies,  be- 
cause in  modifying  the  general  processes  of  nutrition,  disintegration,  and 
calorification,  they  necessarily  influence  in  some  degree  all  the  functions 
of  the  animal  economy. 

Second,  those  substances  which,  though  introduced  into  the  mass  of  the 
blood,  exhibit  an  affinity  for,  or  special  action  on,  some  particular  organ  or 
group  of  organs,  and  hence  may  be  termed  local  remedies. 

The  remedies  included  in  the  first  class,  maybe  arranged  in  four  groups, 
called  general  stimulants  or  excitants;  general  tonics;  general  sedatives, 
and  general  alteratives. 


MEDICINES    AXD    THERAPEUTIC    PURPOSES.  OO 

The  first  group  embraces  those  substances  that  increase  or  exalt  the 
susceptibility  of  the  tissues  simply — as  tea,  coffee,  heat,  oxygen,  etc. 

The  second  includes  such  agents  as  are  capable  of  increasing  the  play 
of  vital  aftinitv,  either  alone  or  in  connection  with  a  moderate  increase  of 
su-ceptiWility,  thereby  giving  an  increased  tonicity  to  the  structures  of  the 
body,  and  generally  an  increase  in  the  evolution  of  heat.  To  this  group 
belong  the  preparations  of  iron,  the  mineral  acids,  guaiac,  cantharides, 
phosphorus,  many  of  the  bitter  vegetable   alkaloids,  etc. 

The  third  group  embraces  those  agents  that  are  capable  of  influencing 
either  the  susceptibility  or  the  vital  affinity,  or  both,  in  the  opposite  direc- 
tion from  either  of  the  preceding  groups.  That  is,  they  either  depress  the 
susceptibility  or  impair  the  play  of  vital  affinity,  or  both,  at  the  same  time. 
Consequently  they  diminish  the  molecular  changes  constituting  nutrition, 
disintegration  and  secretion,  and  diminish  both  the  evolution  of  heat  and 
the  capacity  to  receive  impressions.  To  this  group  belong  the  hydrocy- 
anic and  carbonic  acids,  the  alkalies,  the  bromides,  alcohol,  ether,  chloro- 
form, etc.  Some  of  you  may  be  surprised  to  see  the  alcoholic  liquids 
included  among  the  general  sedatives.  But  all  the  experiments  with  alco- 
hol, from  the  days  of  Dr.  Prout  to  the  present  time,  have  shown  that  while 
present  in  the  blood  it  directly  diminishes  the  temperature  of  the  tissues, 
retards  the  atomic  changes  and  the  amount  of  eliminations,  and  diminishes 
the  general  susceptibility.  If  these  eff"ects  do  not  constitute  it  a  general 
organic  sedative,  it  would  be  difficult  to  conceiye  what  should  be  ranked  as 
such. 

The  fourth  group  embraces  such  agents  as  are  capable  of  modifying  the 
properties  of  the  tissues  in  a  manner  different  from  that  of  simple  increase 
or  diminution,  and  hence  they  are  called  alteratives.  To  this  group  belong 
iodine,  mercury,  arsenic,  and  their  several  preparations  ;  together  with 
those  agents  that  are  supposed  to  neutralize  poisons  in  the  blood,  or  to 
prevent  what  are  called  zymotic  changes  in  that  fluid,  such  as  the  sul- 
phites, permanganates,  carbolic  acid,  etc. 

These  definitions  are  sufficient  to  give  you  a  correct  idea  of  what  is 
meant  by  general  remedies. 

They  produce  their  effects,  by  acting  on  those  elementary  properties 
that  are  common  to  all  the  structures  of  the  body.  When  they  increase 
or  exalt  these  properties  they  are  stimulants  and  tonics.  When  they  im- 
pair or  depress,  they  are  sedatives.  When  they  modify  the  properties 
different  from  either  increase  or  diminution,  they  are  alteratives. 

But  much  the  larger  part  of  the  remedies  in  the  works  on  materia  med- 
ica,  belong  to  the  second  class,  called  local  remedies.  Quite  a  number 
even  of  those  I  have  enumerated  as  general  remedies  will  be  found  to 
possess,  in  addition,  a  direct  local  influence  on  some  structure  or  organ. 
Thus,  alcohol,  by  its  presence  in  the  blood,  not  only  retards  molecular 
changes  throughout  all  thejtissues  as  a  general  remedy,  but  like  all  true 
anaesthetics,  it  also  diminishes  locally  the  sensibility  of  the  cerebro-spinal 
nervous  centers.  So,  too,  the  tea  and  coffee,  which  have  been  ranked  as 
general  excitants,  are  capable  of  exerting  a  special  local  influence  over 
certain  portions  of  the  nervous  system,  inducing  wakefulness,  palpitations, 
muscular  tremors,  etc. 

The  group  of  remedies  usually  styled  narcotics  or  soporifics,  act  more 
exclusively  upon  the  brain  and  nervous  centers.  They  directly  diminish 
the  sensibility  of  the  nerve  structures,  and  thereby  relieve  pain  and  favor 
sleep.  In  large  doses  they  are  capable  of  so  completely  suspending  cere- 
bral sensibility  as  to  cause  coma  and  death.  To  this  group  belong  opium, 
conium,  hyoscyamus,  lactuca,  chloral,  etc.     Though  all  these  agents  dimin- 


36  MEDICINES    AND    THEEAPEUTIC    PUKPOSES. 

ish  cerebral  sensibility,  they  do  not  all  act  alike.  Thus,  opium  and  its 
preparations  cause  dilatation  of  the  smaller  vessels  of  the  nervous  centers, 
and  consequently  increased  accumulation  of  blood  ;  while  hyoscyaraus, 
belladonna  and  stramonium,  cause  contraction  of  the  vessels,  and  thereby 
lessen  the  quantity  of  blood  in  the  part.  The  action  of  the  former  is  ac- 
companied by  contraction  of  the  pupil  of  the  eyes,  the  latter  by  dilata- 
tion. Although  the  n  'rcotics  act  primarily  on  the  nervous  tissues,  yet  by 
diminishing  nerve  sensibility,  they  secondarily  diminish  the  influence  of 
the  nervous  over  the  muscular  structures,  and  thereby  impair  the  respira- 
tory movements,  circulation,  the  peristaltic  motion  of  the  bowels,  and  to 
some  extent,  the  action  of  muscles  of  voluntary  motion. 

Another  class  of  agents  when  introduced  into  the  system  are  capable  of 
so  modifying  the  circulation  and  properties  in  the  cutaneous  tissue  as  to 
cause  a  marked  increase  in  the  amount  of  exhalation  from  the  surface  ; 
and  you  call  them  diaphoretics  or  sudorifics.  Another  class  exert  a  simi- 
lar influence  on  the  mucous  membrane  of  the  respiratory  passages,  and 
you  call  them  expectorants.  Another  class  so  influence  the  kidneys  as  to 
increase  the  quantity  of  urine  secreted  in  a  given  time,  and  they  are  called 
diuretics.  Still  another  class  so  modify  the  condition  of  the  mucous  mem- 
brane of  the  stomach  and  bowels  and  quicken  the  peristaltic  motion,  as 
to  result  in  increased  gastric  and  intestinal  discharges,  and  they  are  called 
emetics  and  cathartics.  The  last  four  groujDS  of  remedies  so  alter  the  play 
of  affinity  in  the  organs  on  which  they  act  as  to  increase  secretory  action. 
But  there  are  remedies  acting  on  the  several  organs  in  the  opposite  direc- 
tion; that  is,  in  such  a  manner  as  to  diminish  secretion,  and  they  are  called 
astringents.  Again,  we  have  remedies  of  more  or  less  value  that  do  not 
directly  modify  either  the  structure  or  function  of  any  part  of  the  system, 
but  which  exert  a  purely  chemical  or  mechanical  influence.  Thus,  you  may 
give  acids  to  neutralize  an  excess  of  alkalies,  either  in  the  stomach  or  the 
blood;  or  alkalies  to  neutralize  an  excess  of  acids.  Pepsin,  hydrochloric 
acid,  and  many  other  substances,  may  be  used  as  gastric  solvents,  when 
the  natural  gastric  juice  is  deficient. 

There  are  also  remedies  of  great  value  that  do  not  properly  belong 
either  to  the  group  of  general  organic  sedatives  or  to  the  local  narcotics. 
Wiien  properly  administered  they  are  capable  of  either  diminishing  the 
action  of  the  heart  and  arteries,  or  of  lessening  the  excitability  of  the 
cerebro-spinal  and  vaso-motor  nervous  centers.  Those  that  appear  to 
directly  diminish  the  action  of  the  heart  and  arteries,  as  the  veratrum  viride, 
aconite,  digitalis,  cold,  and  venesection,  may  be  called  vascular  sedatives. 
Those  that  more  prominently  diminish  the  excitability  of  certain  portions 
of  the  nervous  apparatus,  as  the  gelseminum,  calabar  bean,  ergot,  cimicif- 
uga,  etc.,  may  be  styled  nervous  sedatives. 

In  thus  glancing  rapidly  over  a  therapeutic  arrangement  of  remedial 
agents,  it  is  no  part  of  my  purpose  to  enter  upon  the  discussion  of  the 
inodus  operandi  of  medicine,  but  simply  to  give  an  outline  of  such  a  clas- 
sification as  would  correspond  with  the  views  expressed  in  the  preceding 
lectures,  concerning  the  nature  and  varieties  of  disease.  If  an  accurate 
knowledge  of  physiology,  or  the  conditions  of  function  and  structure, 
which  constitute  health,  is  essential  as  a  starting  point  for  acquiring 
a  knowledge  of  disease,  so  is  a  thorough  study  of  the  nature  and  modus 
operandi  of  medicines  essential  as  a  preparation  lor  their  intelligent 
ap})lication  in  the  treatment  of  disease.  It  is  to  be  hoped,  therefore, 
that  all  of  you  have  given  due  attention  to  this  branch  of  medical  science 
during  the  earlier  part  of  your  studies.  If  not,  I  cannot  too  strongly  urge 
upon    you  the  importance  of  early  supplying  th3    deficiency.     To  note 


MEDICINES    AXD    THEEAPETJTIC   PURPOSES.  87 

clown  formulas  or  prescriptions  and  apply  them  in  the  treatment  of  par- 
ticular diseases,  simply  because  they  were  recommended  by  your  teachers, 
without  an  accurate  knowledge  of  each  of  their  constituents  and  the  spe- 
cial effect  it  is  expected  to  produce,  is  to  exhibit  a  blind  dependence  on 
Authority  degrading  to  the  practitioner  and  dangerous  to  his  patients.  The 
conditions  essential  for  the  rational  practice  of  medicine  are  a  clear  con- 
ception of  the  morbid  conditions  affecting  the  patient,  an  equally  reliable 
knowledge  of  the  nature  and  actions  of  medicines,  and  the  discipline  of 
mind  necessary  for  accurately  adjusting  the  latter  to  the  fulfillment  of  the 
indications  presented  by  the  former. 

Etiology. — The  general  indications  for  the  employment  of  remedial 
agents  have  been  variously  classified  by  different  writers.  The  most  sim- 
ple and  convenient  arrangement  is,  to  consider  first,  those  having  for  their 
object  the  removal  of  the  cause  or  causes  ;  second,  those  arising  from 
the  essential  pathology  of  the  disease  ;  and  third,  those  afforded  by  the 
secondary  symptoms  or  consequences  of  the  primary  pathological  condition. 

There  are  many- morbid  conditions  which  speedily  cease  by  simplv 
removing  the  causes  that  have  induced  them.  There  are  others,  which 
when  fairly  commenced,  continue,  though  generally  with  less  activity,  after 
the  causes  have  wholly  ceased  to  act.  Hence  a  correct  knowledge  of  the 
nature  and  modus  operandi  of  the  causes  capable  of  giving  rise  to  partic- 
ular forms  of  disease  is  of  great  importance  both  to  the  physician  and  the 
community.  Such  knowledge  not  only  enables  the  physician  to  treat 
individual  cases  of  disease  more  successfully,  but  it  enables  both  individ- 
uals and  communities  to  adopt  such  sanitary  and  hygienic  measures,  as  to 
greatly  lessen  the  prevalence  and  fatality  of  many  of  the  most  important 
diseases  to  which  our  race  is  subject. 

Etiology,  therefore,  affords  the  only  reliable  foundation  for  the  sanitary 
improvement  of  cities,  populous  towns,  and  even  rural  districts.  To  this 
department  of  medical  science  the  world  is  indebted  for  all  the  advantages 
it  derives  from  systems  of  sewerage,  scavengering,  water  supply,  modes 
of  ventilation,  improved  construction  of  dwellings,  etc. 

And  yet,  there  is  no  field  in  which  more  careful  and  patient  labor  is 
needed,  or  which  will  yield  the  laborer  a  richer  reward.  For  though  very 
much  has  been  accomplished  in  ascertaining  the  special  circumstances 
which  favor  the  development  of  many  morbid  causes,  the  laws  that  gov- 
ern their  diffusion,  and  their  influence  on  the  human  system,  yet  but  little 
progress  has  been  made  in  the  work  of  isolating  and  studying  the  nature, 
composition  and  properties  of  the  several  causes  themselves.  What  has 
already  been  accomplished  affords  a  broad  foundation  for  most  important 
sanitary  improvements,  both  of  an  individual  and  municipal  character,  but 
what  remains  to  be  done  in  this  department  would  add  much  to  this  foun- 
dation, and  still  more  to  our  success  in  endeavoring  to  remove  the  causes 
acting  injuriously  on  our  individual  patients.  Diseases  are  often  produced 
by  the  joint  action  of  several  causes,  some  of  which  act  with  feeble  inten- 
sity, but  continuously,  through  considerable  periods  of  time.  Others  act 
more  abruptly  and  with  greater  intensity.  The  first  usually  produce  their 
effects  slowly,  merely  modifying  slightly  the  properties  of  the  tissues  or 
the  functions  of  one  or  more  organs,  without  at  once  developing  the  phe- 
nomena of  active  morbid  action,  and  hence  are  called  remote  or  predispos- 
ing causes.  The  second,  acting  with  more  intensity,  and  more  directly  de- 
veloping marked  symptoms  of  disease,  are  called  exciting  causes.  The 
division,  however,  is  an  artificial  one,  as  nearly  all  the  predisposing  causes 
become  direct  exciting  ones  by  simply  increasing  their  intensity  or  pro- 
longing their  duration.  A  more  natural  division  of  causes  would  be  into 
external  and  internal. 


Ob  MEDICINES   AND    THEEAPEUTIC   PUEPOSES* 

The  first,  embracino-  all  ao^ents  and  influences  orio-inatino:  exterior  to  the 
living  body,  and  capable  of  making  an  unnatural  impression  upon  any  of  its 
parts  ;  and  the  second,  such  as  originate  within  the  living  organization. 
The  external  causes  are  resolvable  into  two  classes,  name- 
ly: such  as  consist  in  changes,  either  in  composition,  quality 
or  quantity  of  the  natural  ingesta,  including  under  this  latter  term 
the  air,  water  and  food,  and  such  as  consist  of  agents  not  belonging  to  the 
natural  ingesta,  but  capable  of  being  received  into  the  system  through  the 
same  channels.  I  need  hardly  remind  you  that  the  air  we  breathe  is  com- 
posed of  nitrogen,  oxygen,  ozone  or  active  oxygen,  carbonic  acid,  heat, 
and  electricity,  and  that  these  constituents  are  subject  to  constant  varia- 
tions. When  such  variations  do  not  exceed  certain  limits  they  are  con- 
sistent with  a  continuance  of  health  in  the  animal  economy.  But  when 
they  are  too  abrupt,  or  extreme,  they  are  productive  of  morbid  conditions, 
often  of  the  most  dangerous  character.  The  atmospheric  elements  most 
subject  to  such  extreme  changes  are  the  ozone,  heat  and  electricity. 

The  most  superficial  observer  knows  that  there  is  habitually,  a  wide  dif- 
ference between  the  character  of  diseases  prevailing  during  the  high  tem- 
perature of  summer  and  the  low  temperature  of  winter.  The  influence 
of  heat  in  increasing  the  susceptibility  and  lessening  the  vital  afiinity  or 
tonicity  of  living  structures,  is  as  apparent  as  its  power  to  lessen  the  affin- 
ity by  which  the  atoms  of  inorganic  matter  are  held  together.  Many  facts 
point  to  an  intimate  relation  between  extreme  changes  in  the  ozone,  heat, 
electricity  and  aqueous  vapor  of  the  atmosphere,  and  the  production  of 
such  diseases  as  influenza,  catarrh,  rheumatism,  cholera,  etc.,  and  there  is 
much  need  of  further  careful  investigation  in  this  direction.  The  second 
division  of  the  external  causes  of  disease,  consisting  of  agents  not  natur- 
ally entering  into  the  composition  of  air,  water  or  food,  but  capable  of 
being  mixed  with  one  or  more  of  these  and  imbibed  into  the  system  through 
the  same  channels,  arise  mostly  from  the  disintegration  or  decay  of  dead 
organic  matter,  both  animal  and  vegetable. 

Hence,  from  a  remote  period  in  the  history  of  medicine,  they  have  been 
styled  miasms.  Idio-miasms,  when  the  product  of  the  decomposition  of 
animal  matter  or  animal  excretions;  and  koino-miasms,  when  from  the  de- 
composition of  vegetable  matter.  Until  a  comparatively  recent  period  these 
deleterious  products  were  very  generally  regarded  as  inorganic  gaseous  or 
chemical  compounds,  although  so  subtle  and  attenuated  as  to  be  ever 
eluding  the  best  directed  efi'orts  of  the  chemist  to  isolate  and  examine 
them.  By  a  few,  however,  like  Copeland  and  Holland,  in  Europe,  and  J. 
K.  Mitchell,  in  America,  they  were  regarded  as  organic  living  germs,  either 
vegetable  or  animal,  fungi  or  animalcula3.  And  since  the  general  use  of 
the  microscope  in  medical  investigations,  the  tendency  to  regard  all  the 
deleterious  products  of  the  decomposition  of  organic  matter,  as  organized 
microscopic  germs  capable  of  self-propagation,  and  free  diffusion  in  con- 
nection with  the  aqueous  vapor  of  the  atmosphere,  has  greatly  increased 
throughout  all  ranks  of  the  profession.  Still  there  is  very  little  agreement 
among  the  various  observers,  and  the  whole  subject  needs  much  more  ex- 
tended and  patient  investigation. 

In  all  our  researches  with  the  microscope,  concerning  the  nature  of 
morbid  causes,  great  care  is  required,  lest  we  mistake  the  mere  products 
or  results  of  morbid  action,  for  the  causes.  For  instance,  if  we  examine 
the  surface  of  a  sore  on  the  skin,  or  of  an  ulcer  in  the  mucous  membrane 
of  the  mouth,  and  find  it  covered  with  fungi  or  vegetable  germs,  it  does 
not  necessarily  follow  that  such  fungi  were  the  cause  of  the  diseased  spots 
iii  either  place.     Neither  docs  it  follow  as  a  legitimate  deduction  that  cer- 


MEDICINES    AND    THEEAPEUTIC    PURPOSES.  39 

tain  violent  epidemic  diseases,  as  cholera,  for  example,  arise  from  organic 
germs  merely  because  such  have  been  seen  in  the  excretions.  To  furnish 
data  for  any  legitimate  deductions  from  this  class  of  observations,  they  must 
be  made  at  the  very  incipient  indications  of  disease,  and  repeated  at  the  dif- 
ferent stages  of  its  progress,  and  after  full  recovery.  Similar  observations 
must  also  be  made  during  the  progress  of  other  diseases  affecting  the  same 
organs  or  structures.  The  first  series  of  observations  are  necessary  to  de- 
termine whether  the  supposed  germs  are  always  present  in  a  given  dis- 
ease ;  and  whether  present  in  all  stages  of  its  progress,  or  only  at  certain 
periods.  The  second  series  are  necessary  to  determine  whether  they  are 
peculiar  to  the  one  disease  or  present  in  many  and  dissimilar  diseases. 
One  observer  places  a  few  specimens  of  cholera  evacuations  on  the  micro- 
scopic field,  and  observing  certain  organic  germs,  which  on  keeping  a  cer- 
tain length  of  time,  develop  into  a  species  of  fungus,  and  he  straightway 
announces  the  discovery  of  the  direct  cause  of  cholera.  Another  places 
a  specimen  of  the  blood  of  a  syphilitic  patient  on  the  microscopic  field, 
and  after  patiently  watching  it  for  two  or  three  days,  a  crop  of  living 
bodies  make  their  appearance,  and  we  have  another  grand  pathological 
discovery. 

But  just  as  the  literature  of  the  profession  has  become  well  filled  with 
the  important  discoveries,  and  the  many  practical  applications  of  which 
they  are  capable,  behold  some  one  else  has  also  discovered  that  the  special 
cholera  fungus  can  be  found  as  well  in  any  serous  intestinal  evacuation, 
and  that  the  so-called  syphilitic  germs  are  easily  found  in  the  blood  of  per- 
sons who  never  dreamed  of  having  had  that  disease,  either  hereditary  or 
acquired.  It  is  thus  that  one  set  of  investigators  are  constantly  employed 
in  correcting  the  errors  of  another  class,  and  our  literature  is  kept  full  of 
contradictory  statements. 

Hasty  generalization,  or  the  deduction  of  important  conclusions  from 
imperfect  and  inadequate  data,  has  ever  been  one  of  the  greatest  hindran- 
ces to  genuine  progress  in  both  the  science  and  the  art  of  medicine. 

The  second  class  of  causes,  those  that  originate  in  the  living  system, 
may  be  called  mental  and  physical.  That  either  deficient  or  excessive 
mental  exercise,  and  either  sudden  or  long  continued  action  of  the  emo- 
tions and  passions  are  capable  of  inducing  morbid  action  in  the  physical 
structures  of  the  body,  is  too  well  known  to  need  illustration.  That  the 
physical  processes  of  metamorphosis  and  disintegration  may  be  so  imper- 
fect or  perverted  as  to  cause  unnatural  products  to  be  returned  into  the 
blood,  or  that  the  secretory  action  of  one  or  more  secreting  organs  may 
be  so  perverted  as  to  cause  the  secretion  to  be  unnatural  in  quantity  or 
quality,  and  thereby  become  a  cause  of  irritation  and  derangement,  is 
equally  obvious.  This  simple  and  hasty  glance  at  the  subject  of  etiology 
will  be  sufficient  to  show  you  both  the  importance  of  the  indication  for 
removing  the  causes  of  disease,  and  the  practical  difficulties  in  the  way  of 
fulfilling  it. 

I  stated  that  the  second  indication  for  the  use  of  remedies  in  medical 
practice  was  founded  on  the  nature  of  the  disease.  For  instance,  if  the 
nalure  of  the  disease  is  such  as  to  present  increased  activity  and  excite- 
ment, it  indicates  the  use  of  soothing  and  sedative  remedies;  if  increased 
sensibility  and  suffering,  either  narcotics  or  anaesthetics;  if  impaired  activ- 
ity and  relaxation,  excitants  and  tonics;  if  perverted  vital  affinity,  alter- 
atives, etc.  I  need  not  tell  you  that  a  very  large  part  of  the  skill  and  suc- 
cess of  the  practitioner  will  depend  on  the  clearness  of  his  appreciation  of 
the  nature  of  the  morbid  actions  involved  in  any  given  case,  and  the  ac- 
curacy with  which  he  adjusts  the  remedial  agents  to  meet  the  indications 
afforded  thereby. 


40  EXAMII^TATION    OF   THE   SICK. 

The  third  indication  was  founded  on  the  secondary  effects  of  the  pri- 
mary disease,  and  the  compMcations  that  supervene  during  its  progress. 
The  several  organs  and  functions  of  the  human  body  are  so  intimately 
connected  with,  and  dependent  on,  each  other,  that  it  is  almost  impossible 
to  have  disease  invade  one  without  soon  causing  disturbance  in  others.  And 
there  are  few  individuals  who  do  not  have  a  greater  susceptibility  in  some 
organs  than  in  others,  and  hence,  when  attacked  by  general  diseases,  such 
sensitiveness  often  becomes  so  increased  as  to  constitute  active  local  dis- 
ease. And  it  often  happens  that  the  secondary  affections  become  the  most 
dangerous  to  the  life  of  the  patient.  This  is  illustrated  strikingly  when 
any  one  of  the  princiiDal  excretory  organs  is  involved.  Thus,  disease  of 
the  kidneys  may  be  of  such  a  nature  as  to  jDre vent  a  proper  elimination 
of  urea,  which  being  retained  in  the  blood,  poisons  the  cerebro-spinal 
nervous  system,  producing  convulsions,  coma  and  death.  Or  valvular  dis- 
ease of  the  heart,  by  keeping  up  for  a  long  time  irregular  circulation  of 
the  blood,  causes  general  derangement  of  secretion,  especially  scantiness 
of  urine  and  general  dropsy. 

The  practitioner,  therefore,  should  study  carefully  the  mutual  relation 
and  dependencies  of  one  function  on  another,  that  he  may  be  prepared, 
not  only  to  treat  the  secondary  derangements  when  they  occur,  but  to 
enable  him  often  to  anticipate  their  occurrence  by  appropriate  preventive 
measures. 

All  details  concerning  etiology,  pathology,  diagnosis,  and  therapeutic 
action  of  medicine,  will  be  given  in  connection  with  the  consideration  of 
particular  diseases  and  groups  of  diseases  ;  my  present  object  being  sim- 
ply to  give  you  such  an  outline  as  would  challenge  your  attention,  and  sys- 
tematize your  thoughts  in  relation  to  these  topics. 


LECTURE    V. 


The  Examination  of  the  Sick.— By  Inspection,  Oral  Questions,  Palpation  or  Touch;  Instrumental 
Aid— The  Principles  of  Diagnosis — Therapeutic  Methods,  etc. 

ONE  of  the  most  delicate  and  important  duties  of  the  physician  is  to  ex- 
amine his  patient.  The  object  of  such  examination  is  to  ascertain  the 
location,  extent,  nature,  stage  of  progress,  and  coincident  derangements, 
of  whatever  disease  or  diseases  may  afflict  the  patient,  together  with  the 
causes  that  may  have  been  efficient  either  in  producing  it  or  perpetuating 
its  existence.  To  accomplish  this  object  fully,  requires  on  the  part  of  the 
practitioner,  patience,  kindness,  gentleness  of  manijDulation,  close  undi- 
vided attention,  the  mental  discipline  that  gives  quickness  of  perception 
and  accuracy  of  comparison  and  induction,  with  that  easy  boldness  which 
quietly  assumes  nothing  to  be  immodest  that  is  necessary  for  a  full  under- 
standing of  the  nature  and  extent  of  the  disease,  and  yet  which  sacredly 
avoids  all  not  thus  necessary.  To  place  the  patient  at  ease,  and  at  the  same 
time  secure  attention,  it  is  best  to  commence  the  examination  with  a  few 
leading  questions,  such  as,  "How  long  have  you  been  unwell  ?"  "  How  did 
your  sickness  commence  ?"  "  Do  you  suffer  much  pain;  and  if  so,  where?" 
"Is  it  sharp,  dull,  burning,  constant,  or  paroxysmal  ?" 


EXAMINATION    OF    THE   SICK.  41 

Having  thus  introduced  the  examination  far  enough  to  allow  anv  feel- 
ing of  trepidation  or  embarrassmeut  that  might  have  been  felt  by  the 
patient,  to  have  subsided,  and  at  the  same  time  to  have  o})tained  an  out- 
line of  his  particular  suffering,  you  should,  without  apparent  design,  pass 
directly  to  a  methodical  examination  so  complete  as  to  elicit  a  correct 
knowledge  of  all  the  important  functions  and  processes  performed  in  the 
system.  By  simple  insjoection  you  observe  the  physiognomy  or  expression, 
the  hue  of  the  skin,  the  position  or  attitude,  voluntary  and  involuntary 
movements,  general  contour  or  relative  development  of  parts,  and  the  par- 
ticular appearance  of  the  tongue,  with  such  other  parts  as  may  be  the  seat 
of  special  complaint.  All  this,  except  the  two  last  items,  may  be  accom- 
plished while  proceeding  with  the  oral  part  of  the  examination. 

After  the  leading  introductory  questions  already  suggested,  the  further 
prosecution  of  the  oral  examination  should  take  such  direction  as  to  elicit 
as  full  an  account  of  the  several  important  functions  as  the  patient  is  capa- 
ble of  givino-.  Perhaps  the  most  natural  and  easy  method  is  to  interro- 
gate consecutively  concerning  the  organs  engaged  in  the  work  of  digestion, 
assimilation  and  nutrition;  those  engaged  in  the  opposite  processes  of  dis- 
integration and  excretion;  then  those  constituting  the  nervous  system,  both 
cerebro-spinal  and  ganglionic;  and  finally,  those  concerned  in  re-produc- 
tion, especially  in  females  past  the  age  of  puberty.  When  the  patient  is 
too  young  or  too  sick  to  answer  properly  the  necessary  inquiries,  the  same 
should  be  directed  to  the  nurse  or  whoever  has  immediate  care  of  the  pa- 
tient. There  are  some  diseases,  like  those  of  a  typhoid  character,  that  al- 
ways blunt  more  or  less  the  sensibilities  of  the  patient,  and  often  render 
the  manifestations  of  mind  so  inactive  as  to  cause  very  imperfect  or  er- 
roneous answers  to  be  given.  In  other  cases  we  have  just  the  opposite, 
namely,  such  an  increase  of  nervous  sensitiveness  as  to  cause  the  most  ex- 
travagant expressions  and  the  wildest  exaggerations.  It  is  proper  and  de- 
sirable always  to  have  the  nurse  or  some  reliable  member  of  the  family 
present  during  the  examination  of  such  patients,  because  they  will  greatly 
assist  in  correcting  erroneous  statements  and  in  supplying  defects  in  the 
patient's  memory.  And  it  is  a  good  rule  in  all  delicate  cases,  and  such  as 
involve  apparent  mental  derangement,  to  have  a  free,  confidential  inter- 
view with  the  nurse  alone,  during  which  you  can  canvass  the  statements 
and  condition  of  the  patient,  without  danger  of  exciting  either  his  suspi- 
cions or  his  anger.  I  need  not  say  this  should  be  done  entirely  out  of  the 
sight  and  hearing  of  the  patient.  Nothing  so  quickly  excites  the  fears  or 
the  suspicions  of  a  conscious  patient,  as  private  conversation  or  vjhispeving 
in  his  room.  All  conversation  in  the  presence  of  the  sick  should  be  in  a 
mild,  kindly  tone  of  voice,  just  loud  enough  to  be  easily  understood,  but 
wholly  free  from  all  abrupt  and  boisterous  qualities. 

The  correctness  of  the  information  obtained  from  patients  will  depend 
much  on  the  manner  in  which  questions  are  asked.  If  they  are  too  gen- 
eral in  their  character,  the  patient  will  often  fail  to  comprehend  their  full 
meaning,  and  give  erroneous  answers  in  consequence.  For  instance,  many 
when  asked  if  their  food  digests  well,  answer  promptly,  yes;  and  yet  when 
asked  more  particularly,  acknowledge  that  the  food  often  lies  heavy  in  the 
stomach  after  eating,  or  that  they  have  frequent  belching  of  gases,  and 
sometimes  acid  eructations.  So,  too,  in  regard  to  excretions.  I  have  seen 
many  patients  who,  when  asked  "  if  their  bowels  were  regular  ?  "  answered 
without  any  hesitation,  "  Yes,  they  were  all  right."  But  when  asked  spe- 
cifically how  often  they  had  a  fecal  evacuation,  some  said  once  in  three  or 
four  days  ;  others,  three  or  four  times  every  day;  while  others  said  once  a 
day.     The  better  way  is  to  ask  directly  how  often  the  patient  has  an  evac- 


42  EXAMINATION    OF   THE   SICK. 

uation  from  the  bowels  ?  and  what  is  the  color  and  consistency  of  the 
evacuation  ?  The  same  rule  is  still  more  necessary  in  obtaining  a  knowl- 
edge of  the  renal  secretion.  Unless  their  attention  has  been  previously 
called  to  the  subject,  many  patients  will  not  be  able  to  give  a  reliable 
statement  either  as  to  the  quantity  or  quality  of  the  urine,  but  will  answer 
in  general  terras  that  they  thhik  it  is  about  natural.  Others  will  say  they 
"  make  a  great  deal  more  "  than  natural,  when  they  really  make  it  very 
often^  but  only  a  little  at  a  time.  Patients  laboring  under  low  forms  of 
fever  and  paralytic  affections,  not  unfrequently  have  either  partial  or  com- 
plete paralysis  of  the  muscular  coat  of  the  bladder.  This  is  liable  to 
cause — first,  retention  until  a  certain  degree  of  distention  of  the  bladder, 
and  then  dribbling  so  as  to  keep  the  clothing  wet,  or  the  passage  of  only 
a  few  spoonfulls  at  a  time.  In  all  such  cases,  in  addition  to  careful  inqui- 
ries of  the  nurse,  the  physician  should  daily  examine  the  hypogastric  re- 
gion sufficient  to  determine  whether  the  bladder  is  distended  or  not.  I 
have  known  a  neglect  of  this  latter  rule  to  lead  to  several  serious  mis- 
takes. It  is  only  a  few  weeks  since  that  I  was  requested  to  see  a  young 
man  reported  to  be  very  dangerously  sick  from  disease  of  the  brain.  On 
calling  at  the  house,  I  met  the  attending  physician,  and  after  listening  to 
a  brief  history  of  the  case,  entered  the  sick  man's  room.  The  patient  was 
entirely  comatose  ;  chin  dropped  ;  pupils  a  little  dilated  ;  breathing  irrej,-- 
ular  ;  skin  clammy  ;  pulse  frequent  and  very  feeble  ;  and  frequent  irregu- 
lar muscular  twitchings.  The  latter  with  a  strong  urinous  odor  about  the 
bed,  caused  me  to  inquire  whether  the  patient  had  passed  his  water  regu- 
larly. The  attending  physician  answered  in  the  affirmative.  Turning  to 
the  nurse,  I  asked  when  he  passed  his  water  last  ?  Her  answer  was,  "  he 
passes  it  every  little  while,  and  his  bed  is  wet  now."  "How  long  has  he 
passed  his  water  in  the  bed  ?"  I  inquired,  at  the  same  time  passing  my 
hand  down  over  the  region  of  the  bladder.  "  Three  days"  was  her  reply. 
The  hand  at  once  detected  a  great  degree  of  fullness  in  the  hypogastrium, 
which  further  examination  proved  to  be  owing  to  the  presence  of  a  bladder 
so  much  distended  that  its  fundus  reached  the  umbilicus.  The  introduc- 
tion of  a  catheter  gave  exit  to  an  ordinary  chamber  vessel  full  of  ammoni- 
acal  urine.  The  attending  iDhysician,  not  a  little  chagrined,  excused  him- 
self by  saying  he  had  not  examined  the  region  of  the  bladder  because  the 
nurse  had  assured  him  every  day  that  the  patient  had  passed  his  water 
freely.  In  most  cases  of  chronic  disease  presenting  obscure  questions  in 
relation  to  their  pathology,  and  especially  if  accompanied  by  serous  or 
dropsical  effusions,  the  physician  should  directly  examine  the  urine,  aided 
both  by  chemical  tests  and  the  microscope. 

Palpation  or  Touch.  —  While  the  acquisition  of  an  easy,  systematic 
and  accurate  method  of  oral  examination  is  of  great  importance  to  the 
physician,  it  is  never  sufficient  to  give  him  a  full  and  correct  knowledge  of 
the  condition  of  his  patient,  without  the  aid  of  direct  contact  or  touch. 
By  the  latter  we  gain  ^  knowledge  of  the  temperature  and  other  qualities 
of  the  skin;  the  state  of  the  circulation  as  indicated  by  the  force,  frequency 
and  regularity  of  the  pulse;  the  fullness  and  regularity  of  respiration;  the 
tensionor  flaccidity  of  muscles;  the  existence  of  hyperaesthesia  and  anaesthe- 
sia, the  existence  or  non-existence  of  indurations,  enlargements,  tumors, 
abscesses,  dropsical  effusions,  etc.;  and  the  physical  condition  of  the  parts 
withi.'i  the  chest  and  the  abdomen.  In  young  children,  and  in  patients  of 
all  ages,  whose  mental  perceptions  are  disordered  by  disease,  direct  physi- 
cal examination,  coupled  with  inspection,  constitute  our  chief  means  for 
acquiring  a  knowledge  of  the  morbid  conditions  under  which  they  may  be 
laboring. 


EXAMINATION    OF    THE   SICK.  43 

Instrumental  Aid. — To  render  this  part  of  the  examination  of  patients 
more  complete,  various  instruments  have  been  constructed,  some  of  which 
are  of  great  practical  value.  The  ophthalmoscope,  otoscope,  rhinoscope, 
laryngoscope, 'stethoscope,  microscope,  sphygmograph,  thermometer,  urin- 
ometer,  speculuras,  with  test-tubes,  spirit  lamp,  and  chemical  re-agents,  con- 
stitute the  chief  instruments  which  the  physician  of  to-day  may  bring  to 
his  aid  in  determining  the  existence,  nature,  stage  of  progress,  and  ten- 
dencies of  disease.  I  do  not  say  that  a  physician  cannot  acquire  skill,  and 
even  superior  skill,  both  in  the  diagnosis  and  treatment  of  disease,  without 
familiarity  with  the  use  of  many,  and  j^erhaps  all  of  these  instruments. 
And  yet  it  must  be  admitted  that  each  one  of  them,  properly  used,  is  capa- 
ble of  adding  both  to  the  extent  and  accuracy  of  our  knowledge  concern- 
ing the  morbid  conditions  it  is  designed  to  aid  in  investigating.  It  is  de- 
sirable, therefore,  that  every  general  practitioner  should  be  familiar  with 
the  use  of  all  these  instruments,  and  as  far  as  practicable,  keep  them  con- 
stantly within  his  reach.  No  detailed  descriptions  or  illustrative  drawings 
can  give  you  an  adequate  knowledge  of  the  articles  themselves,  or  of  their 
practical  application.  Such  knowledge  can  be  obtained  only  by  direct  ex- 
amination and  actual  clinical  use.  Happily  for  you  as  a  class,  the  daily 
hospital  and  dispensary  clinics,  which  constitute  a  prominent  part  of  the 
course  of  instruction  in  this  institution,  will  .give  you  ample  opportunities 
for  becoming  acquainted,  individually,  with  the  practical  application  of 
every  instrument  and  appliance  that  may  aid  in  the  examination  and  treat- 
ment of  the  sick.  As  a'ready  intimated,  the  primary  object  of  all  our  ex- 
aminations of  the  sick,  is  to  ascertain  whether  they  are  afHicted  by  disease, 
and  if  so,  its  nature,  extent,  duration,  etc. — in  other  w^ords,  to  arrive  at  as 
full  and  complete  a  diagnosis  as  pos-iible. 

But  what  constitutes  a  complete  diagnosis  ?  Certainly  not  the  mere 
classification  or  naming  of  the  disease  ;  for  a  very  superficial  examination 
may  enable  the  practitioner  to  determine  that  a  patient  has  typhoid  fever, 
pneumonia  or  rheumatism,  and  yet  leave  him  with  a  very  imperfect  knowl- 
edge of  the  pathological  changes  that  had  taken  place  in  the  solids  and 
fluids  of  the  body.  A  full  and  practical  diagnosis  in  any  given  case  em- 
braces, first,  a  knowledge  of  the  general  nature  of  the  disease  ;  second, 
the  pathological  changes  that  have  taken  place,  which  determines  the 
stage  of  advancement ;  third,  the  nature  and  extent  of  the  complications, 
if  any,  that  have  supervened  ;  and  fourth,  the  physical  and  mental  condi- 
tion and  habits  of  the  patient  prior  to  the  present  sickness.  The  first 
of  these  items  gained,  will  enable  you  to  name  the  disease  ;  the  second 
and  third,  to  clearly  comprehend  the  present  pathological  condition  of  the 
patient,  and  found  thereon  rational  indications  for  treatment ;  while  the 
fourth,  will  often  enable  you  to  anticipate  the  tendencv  or  direction  which 
other  changes  will  take,  during  the  further  progress  of  the  case. 

The  making  of  a  full  practical  diagnosis  is,  therefore,  the  most  impor- 
tant, and  often  the  most  perplexing  of  all  the  duties  devolving  on  the  med- 
ical practitioner.  If  he  succeeds  in  obtaining  a  clear  and  correct  knowl- 
edge of  the  nature,  progress  and  tendencies  of  the  disease  under  wdiich 
his  patient  is  laboring,  it  requires  but  a  short  and  easy  process  of  induc- 
tion to  arrive  at  the  rational  indications  for  treatment.  That  is,  to 
determine  what  needs  to  be  done  for  the  purpose  of  either  mitigating  or 
curing  the  disease,  and  re-establishing  the  health  of  the  patient.  And 
having  determined  thus  logically  the  indications  for  treatment  which  the 
case  requires,  a  competent  knowledge  of  the  principles  of  hygiene,  and  of 
the  materia  medica,  will  readily  suggest  the  best  means  for  fulfilling  the 
indications  presented.     I  say  a  competent  knowledge  of  the  principles  of 


44  EXAMi:srATroN  of  the  sick. 

hyfjiene^  as  well  as  of  materia  medica,  because  I  hope  none  of  you  -will 
make  so  great  a  mistake  as  to  suppose  the  treatment  of  disease  consists 
solely  in  the  administration  of  drugs. 

A  large  part  of  the  diseases  coming  under  the  care  of  the  physician  are 
caused  by  errors  in  diet,  drinks,  clothing,  ventilation,  and  other  matters  in- 
cluded under  the  term  hygiene;  and  no  one  can  attain  the  highest  degree 
of  success  as  a  practitioner  who  does  not  fully  appreciate  the  importance 
of  careful  attention  to  the  hygienic  influences  affecting  his  patients. 

The  object  of  such  attention  is  twofold,  namely:  to  remove  or  correct  such 
erroneous  habits  and  conditions  as  may  be  still  acting  as  causes;  and  the 
substitution  of  such  as  will  positively  aid  in  the  restoration  of  the  patient. 
A  comfortable  temperature;  a  sufficient  supply  of  fresh,  pure  air;  clean 
linens;  a  careful  adaptation  of  the  quantity  and  quality  of  food  and  drink  to 
the  capacity  of  the  digestive  organs  to  receive  and  assimilate  it;  and  a  quiet, 
cheerful,  hopeful  mental  influence,  are  hygienic  conditions  of  universal 
applicability  in  the  management  of  the  sick.  I  by  no  means  approve  of 
the  modern  doctrine  of  expectancy^  which  assumes  that  diseases  must  run 
their  natural  course,  and  that  art  can  do  little  more  than  proj^erly  regulate 
the  hygienic  conditions  of  the  patient,  and  leave  the  rest  to  that  intangi- 
ble something  called  nature. 

And  yet  I  cannot  too  strongly  urge  upon  you  the  importance  of  making 
yourselves  thoroughly  familiar  with  the  facts  and  principles  of  public  and 
personal  hygiene,  and  constant  attention  to  their  application  in  the  daily 
routine  of  practice.  It  would  not  be  inappropriate  to  represent  hygiene 
proper  as  bearing  much  the  same  relation  to  materia  medica  that  physi- 
ology does  to  pathology. 

Therapeutic  Methoch. — Before  closing  this  lecture,  1  must  invite  your 
attention  to  a  few  thoughts  concerning  the  principal  therapeutic  methods, 
or  systems,  as  they  are  sometimes  called,  that  have  found  advocates  among 
the  leading  members  of  the  profession  in  this  and  the  preceding  genera- 
tions. Since  the  earliest  periods  of  medical  history,  therapeutics,  or  the 
application  of  remedies  in  the  treatment  of  disease,  have  been  made  to 
conform  more  or  less  closely  to  the  co-existing  ideas  or  doctrines  in  rela- 
tion to  the  nature  of  disease  itself.  When  the  nature  and  phenomena  of 
diseases  were  regarded  as  dependent  on  certain  chemical  processes  called 
concoction,  fermentation,  crisis,  etc.,  the  prevalent  therapeutic  system  was 
founded  on  corresponding  chemical  notions,  and  had  for  its  leading  objects 
the  hastening  of  the  supposed  concoctions,  the  maturing  of  the  morbid 
humors,  and  their  expulsion  or  neutralization. 

When  the  theories  of  vitalism  gained  the  ascendancy,  and  all  diseases 
were  regarded  as  involving  either  debility  (direct  or  indirect),  or  irrita- 
tion, the  prevalent  therapeutic  ideas  were  soon  found  aggregated  into  two 
leading  and  opposing  systems.  The  one,  founded  on  the  pathological  doc- 
trine of  debility,  had  for  its  leading  object  stimulation.  The  other,  sug- 
gested by  the  idea  of  irritation,  excitement,  etc.,  had  for  its  purposes  dimi- 
nution of  excitement  by  sedation  and  evacuation,  and  hence  popularly 
termed  antiphlogistic.  During  the  first  quarter  of  the  present  century  the 
jiathological  doctrines  of  irritation  and  inflammation  gained  their  most 
complete  control  over  the  mind  and  practice  of  the  profession.  Almost 
every  morbid  condition  was  referred  to  one  or  the  other  of  these  processes  ; 
and  as  a  consequence,  bleeding,  general  and  local,  emetics,  purgatives  and 
alteratives,  were  in  constant  requisition  in  the  treatment  of  even  the  most 
trivial  ailments.  But  coincident  with  this  supremacy  of  the  antiphlogistic 
method  in  therapeutics,  came  the  rapid  development  of  organic  chemistry, 
the  application  of  the  microscope  to  the   study   of  minute   anatomy,  both 


EXAMINATION    OF    THE   SICK.  45 

healthy  and  morbid,  and  the  discovery  of  the  fact  that  many  acute  dis- 
eases were  self-limited  in  duration,  and  capable  of  progressing  to  recov- 
ery without  the  active  interference  of  art.  By  the  first,  our  knowledge  of 
the  composition  and  properties  of  the  various  morbid  products,  whether 
in  the  tissues,  the  blood,  or  the  secretions,  was  greatly  increased  ;  and  the 
doctrines  of  exclusive  vitalism  began  to  yield  to  a  recognition  of  zymotic 
and  blood  diseases.  By  the  second,  histological  investigations  were  pushed 
in  every  direction,  unfolding  the  minute  anatomy  of  all  structures,  healthy 
<ind  morbid,  and  culminating  in  the  doctrine  of  cell  growth  as  the  basis 
of  organic  structures,  and  in  the  cellular  pathology  of  Virchow. 

By  the  third,  a  distrust  or  skepticism  concerning  the  curative  powers 
of  medicines  was  rapidly  engendered,  and  a  confidence  in  the  restorative 
processes  of  nature  correspondingly  increased. 

This  tendency  soon  found  marked  expression  in  the  writings  of  Jacob 
Bigelow,  John  Forbes,  O.  W.  Holmes,  and  others,  and  did  not  stop  until 
it  had  eifectually  checked  the  heroic  use  of  active  remedial  agents  that 
had  been  developed  under  the  precedjng  doctrines  of  inflammation  and 
antiphlogistic  therapeutics.  Under  these  various  influences,  the  former 
theories  or  systems  of  medicine  have  been  abandoned,  and  yet  no  other 
one  law,  either  pathological  or  therapeutical,  has  succeeded  in  gaining 
any  general  control  over  the  professional  mind.  The  last  twenty  years 
have  been  characterized  by  great  activity  in  the  accumulation  of  facts, 
and  the  multiplication  of  experiiaients,  in  almost  every  department  of  med- 
ical science. 

Indeed,  it  may  be  regarded  as  pre-eminently  an  era  of  observation  and 
independent  research,  untrammeled  by  authority.  And  yet,  you  must 
not  imagine  that  the  present,  with  all  its  independence  of  thought,  ac- 
tivity of  observation,  and  vast  accumulation  of  facts,  is  free  from  the  influ- 
ence of  fanciful  theories  and  bold  attempts  at  generalization.  The  human 
mind,  in  the  present,  as  in  all  the  ages  of  the  past,  is  not  only  prone  to 
generalize — to  frame  hypotheses  based  on  a  limited  number  of  facts,  but 
having  gained  a  favorite  standpoint,  to  see  all  else  through  light  radiating 
from  that  focus.  Hence  the  enthusiastic  microscopist,  after  tracing  all 
organized  structures  to  formation  out  of  primary  cells;  and  structural 
changes,  whether  healthy  or  morbid,  to  normal  and  abnormal  cell  evolu- 
tions, naturally  enters  upon  the  study  of  etiology  with  the  favorite  instru- 
ment in  hand,  and  soon  finds  organic  germs,  either  animal  or  vegetable,  in 
the  blood,  the  secretions  or  the  excretions  of  patients  laboring  under  al- 
most every  variety  of  diseese.  And  these  germs  are  at  once  heralded  as 
the  efficient  cause  of  the  diseases  with  which  they  are  associated.  It  re- 
quires but  a  hasty  glance  over  the  medical  literature  of  the  day  to  see  that 
we  have  a  large  class  of  writers  and  investigators  who  are  already  refer- 
ring the  origin  and  propagation  of  cholera,  yellow  fever,  influenza  and 
other  epidemics,  as  well  as  many  of  the  endemics,  to  organic  germs.  As 
all  these  organic  germs  have  their  definite  periods  of  development,  ma- 
turity, propagation,  and  decline,  it  is  consistent  and  natural  to  infer  that 
the  diseases  to  which  they  give  rise  should  also  have  a  definite  course  to 
run,  which  cannot  be  materially  altered  by  treatment.  Hence  the  thera- 
peutic doctrines  of  this  class  are  fairly  expressed  in  the  words  palliation 
and  expectancy,  while  they  place  great  emphasis  on  hygiene  and  prevent- 
ive measures.  Another  class,  with  their  standpoint  of  observation  in  the 
laboratory  of  the  organic  chemist,  see  in  the  living  system  only  a  com- 
plicated series  of  chemical  actions  and  reactions  taking  place  in  the  blood, 
and  between  the  constituents  of  that  fluid  and  the  organized  tissues.  So 
long  as  these  processes  are  well  balanced,  the  evolution  of  heat,  electricity 


46  EXAMINATION   OF   THE    SICK. 

and  nerve-force  is  natural,  and  health  is  preserved.  But  when,  from  any 
cause,  the  equilibrium  is  disturbed  by  some  change  in  the  chemical  factors, 
the  results  are  also  abnormal  and  disease  is  established.  By  this  class  we 
have  all  the  ancient  doctrines  of  humoralism  revived  under  the  modern 
terms  septicferaia,  zymosis,  blood  degeneration,  etc.  Their  therapeutics 
are,  of  course,  largely   antiseptic  and  antidotal. 

A  third  class  have  their  standpoint  of  observation  in  the  physiology  and 
pathology  of  the  nervous  tissues,  and  they  find  little  apparent  difficulty  in 
satisfying  themselves,  at  least,  that  almost  every  variety  of  action  that 
takes  place  in  living  matter,  whether  healthy  or  morbid,  is  under  the  con- 
trol of  nervous  influence.*  With  such,  the  chief  end  of  therapeutics  is  to 
modify  the  various  morbid  conditions  of  structure  and  function  in  nerve 
matter. 

But  a  fourth,  and  much  larger  class  than  either  of  the.  foregoing,  pos- 
sessing no  definite  scientific  or  theoretical  standpoint  of  observation,  being 
swayed  by  the  general  current  of  reaction  from  the  antiphlogistic  system, 
and  captivated  partly  by  the  simplicity  of  the  doctrine  tlaat  all  disease  is 
a  diminution  of  life,f  and  partly  by  the  plausable  eulogies  of  "nature" 
and  her  all-controlling  powerj  over  disease,  they  have  become  essentially 
skeptical  in  therapeutics,  and  content  to  regulate  the  hygiene  of  the  sick- 
room, amuse  the  patient  with  placebos,  and  wait  for  "  nature "  to  cure 
the  disease.  Or,  more  properly,  perhaps,  wait  for  the  disease  to  com- 
plete its  course  and  disappear;  for  we  find  the  greater  part  of  this  class, 
not  only  skeptical  in  regard  to  the  curative  powers  of  medicines,  but  also 
firm  believers  in  the  doctrine  that  diseases  have  an  independent  existence 
marked  by  growth,  maturity  and  decline,  which  makes  them  in  a  great 
measure  independent  of  the  influence  of  medication .§  At  a  period  when 
investigations  are  pushed  with  so  much  vigor  in  every  direction;  when  new 
facts  are  constantly  appearing,  and  old  facts  are  being  presented  in  new- 
aspects;  and  when  so  much  that  is  recognized  as  a  part  of  medical  science 
is  but  partially  or  imperfectly  known,  it  is  not  strange  that  our  litera- 
ture should  be  filled  with  contradictions,  better  calculated  to  bewilder  than 
to  enlighten  the  student. 

And  yet,  gentlemen,  if  you  will  patiently  study  the  views  I  have  pre- 
sented to  you  in  the  preceding  lectures,  concerning  the  elementary  forms 
of  disease,  the  methods  of  investigation,  the  indications  for  treatment,  and 
the  principles  governing  the  application  of  remedies,  you  will  be  able  to 
follow  me  in  the  study  of  special  pathology  and  therapeutics  in  such  a 
way  as  to  become  rational  and  efficient  practitioners;  neither  investing 
disease  with  the  attributes  of  independent  existence  and  self-determined 
duration,  nor  regarding  the  curative  powers  of  medicine  with  a  melancholy, 
vacilating  skepticism. 

There  is  one  fact  in  therapeutics  that  I  wish  to  impress  indelibly  upon 
your  minds.  It  is  that  the  special  influence  of  any  and  every  remedial 
agent  depends  much  upon  the  actual  condition  of  the  patient  at  the  time 
it  is  administered.  For  instance,  a  remedy  that,  administered  in  health,  or 
in  some  conditions  of  disease,  would  produce  a  direct  sedative  or  debilita- 
ting influence,  if  given  in  some  other  conditions,  would  result  in  relieving 
the  sense  of  oppression  and  weakness,  and  adding  to  the  strength  of  the 
patient.  All  writers  class  veratrum  viride,  aconite,  and  digitalis  among 
the  sedatives,  yet  I  have  seen  many  patients  so  debilitated  by  insufficient 
oxygenation  and  decarbonization  of  the  blood,  caused  by  an  irregular,  trem- 

*See  Brown-Sequard's  lecture  in  the  Toner  course,  at  Washington,  D.  C,  1873. 

+  See  Chanibers'. 

i  See  Essays  of  Hizelow,  Forbes  and  Holmes. 

i  Sec  Dr.  Gibson's  Address  before  the  British  Medical  Association  in  1870. 


EXAMINATION    OF   THE   SI(;K.  47 

ulons  action  of  the  heart,  that  they  could  not  walk  across  their  room,  who, 
when  placed  enough  under  the  influence  of  these  articles  to  render  the 
heart  slow  and  steady  in  its  beat,  could  walk  or  ride  with  ease.  I  have 
seen  patients  in  the  first  stage  of  pneumonia,  with  the  face  deeply  suffused 
with  redness,  the  breathing  short  and  oppressed,  the  pulse  frequent  and 
weak,  and  the  feeling  of  prostration  so  marked  that  they  were  unable  to 
rise  from  the  bed,  so  relieved  by  one  prompt,  free  bleeding  that  they  could 
not  only  sit  up,  but  walk  about  their  room  with  ease.  AVhat  are  recog- 
nized as  tonics  and  stimulants,  given  to  the  same  patients  in  the  same 
stage  of  the  disease,  instead  of  strengthening,  would  have  added  to  the  de- 
bility of  the  patients  by  increasiiig  the  local  vascular  fullness.  Again,  the 
same  quantity  of  an  anodyne  or  anaesthetic  that  might  be  required  simply 
to  render  a  patient  comfortable  when  suffering  from  delirium  tremens  or 
severe  neuralgia,  might  produce  dangerous,  or  even  fatal,  effects,  if  given 
to  the  same  patient  when  well,  or  the  nervous  system  not  disturbed. 
Hence,  I  repeat,  that  the  general  effect  of  any  and  every  remedy  will  be 
determined  very  much  by  the  condition  of  the  patient  at  the  time  of  its 
administration.  And  1  can  give  you,  gentlemen,  no  more  important  thera- 
peutic law,  or  general  rule  of  action,  than  to  so  investigate  every  case 
as  to  gain  a  clear  and  definite  conception  of  the  existing  pathological  condi- 
tions, and  then  apply  such  remedies  as  are  most  accurately  calculated  to 
remove  both  the  morbid  conditions  and  the  causes  on  which  they  depend, 
without  regard  to  either  nosological  arrangements  or  classifications  of  the 
materia  medica.  When  the  case  is  so  obscure  that  a  satisfactory  idea  of 
the  actual  morbid  conditions  cannot  be  obtained  wnth  all  the  aids  for 
making  a  proper  diagnosis  that  are  wathin  our  reach,  then  be  content  to 
palliate  symptoms  as  they  are  presented  from  day  to  day,  by  mild  means, 
rather  than  hazard  doing  positive  injury  by  a  blind  exhibition  of  more 
active  remedies. 


PART   II. 

CONSIDERATION    OF  INDIVIDUAL    DISEASES  OR 
PRACTICE  OF  MEDICINE. 


LECTURE    VI. 

Classification  of  Diseases— The  Object  to   be   Attained— Extended   Nosological  Arrangements  "of 
Little  Practical  Value— The  Simplest  Classification  the  Best. 

HAVING  in  the  preceding  lectures  completed  the  discussion  of  those 
elementary  principles  and  facts  which  are  deemed  important  as  an  in- 
troduction to  the  study  of  special  pathology  and  therapeutics,  or  practical 
medicine  proper,  I  shall  now  enter  ujjon  the  consideration  of  individual 
diseases  and  their  treatment. 

To  secure  order  or  method  in  our  progress,  and  avoid  repetition,  it  will 
be  necessary  to  form  some  classification  by  which  those  diseases  having 
a  number  of  important  facts  relating  to  their  etiology,  pathology,  or  symp- 
tomatology, in  common,  may  be  grouped  together.  At  a  former  period  in 
the  history  of  medicine,  great  importance  was  attached  to  the  subject  of 
Nosology;  and  as  much  learning  and  skill  were  exhibited  in  arranging  dis- 
eases into  classes,  orders,  species,  and  varieties,  as  was  shown  by  LinnjBus 
in  classifying  the  vegetable  kingdom.  You  may  find  one  of  the  most  com- 
plete specimens  of  these  extended  nosological  arrangements,  in  the  great 
work  entitled  the  "  Study  of  Medicine,"  by  Dr.  John  Mason  Good.  All 
such  extensive  and  complicated  arrangements,  however,  have  been  found 
imperfect  and  unprofitable. 

During  the  last  quarter  of  a  century,  some  writers  have  attempted  to 
classify  diseases  in  accordance  with  their  supposed  causes,  calling  one 
group  Zymotic,  another  Parasitic,  etc.  Others  have  made  anatomical 
structures  the  basis  of  their  arrangement  ;  and  still  others  have  made  the 
important  organs  and  groups  of  organs  the  basis.  But  both  these  latter 
methods  lead  to  the  grouping  together  of  diseases  the  most  dissimilar  in 
their  nature,  and  our  knowledge  of  etiology  is  too  imperfect  to  render  it 
reliable  as  the  basis  of  a  general  classification.  For  our  purposes  the  fol- 
lowing arrangement,  which  I  sketch  before  you  on  the  blackboard,  will  be 
found  sufficient  : 


CLASS  I. 
GENERAL  DISEASES, 


Sub-class  I.  Idiopathic  fevers,  J  Continued, 
or  acute  general  diseases  .  .  1  ^^noaicai, 

Of  the  Blood. 


Sub-class  II.  Constitutional 
diseases  or  chronic  general 
diseases (.Of  Nutrition.- 

(48) 


CLASSIFICATION    OF    DISEASES.  49 

'Sub-class  1.,  Inflammations. 
CLASS  11.  Sub-class  II.,  Fluxes. 

LOCAL  DISEASES.         j  Sub-class,  III.,  Neuroses. 

(,SuB-CLASs  IV.,  Miscellaneous. 

You  will  see  that  I  have  arranged  all  diseases  first  into  two  great  classes, 
simply  denominated  general  and  local.  By  a  general  disease  I  mean  one 
whose  primary  or  initial  symptoms  are  such  as  to  indicate  disturbance  of 
those  properties  and  processes  that  are  common  to  all  the  organs  and 
structures  of  the  body.  When  any  morbific  cause  is  permitted  to  act 
upon  the  living  system  in  such  a  way  as  to  disturb  the  general  properties, 
susceptibility  and  vital  affinity,  it  necessarily  disturbs  the  processes  of  nu- 
trition, disintegration,  and  calorification;  in  other  words,  it  develops  at 
once  symptoms  of  general  disturbance.  It  is  proper,  therefore,  to  desig- 
nate the  disease  thus  induced  a  general  disease. 

On  the  other  hand,  when  the  primary  symptoms  of  disease  are  limited 
to  disturbance  of  the  function  of  a  single  organ  or  group  of  organs,  and 
the  system  generally  remains  undisturbed  or  becomes  involved  onlv  sec- 
ondarily, the  disease  is  called  local.  Nearly  all  of  the  more  active  or 
acute  local  affections  so  interfere  with  some  important  function  as  to  in- 
duce more  or  less  general  disturbance  during  their  progress. 

In  like  manner,  all  the  general  diseases  are  liable  to  become  compli- 
cated with  strictly  local  affections  during  some  part  of  their  course. 

The  general  diseases  constituting  the  first  class,  may  be  conveniently 
divided  into  two  sub-classes,  which  I  shall  call  idiopathic  fevers  or  acute 
general  diseases,  and  constitutional  or  chronic  general  diseases.  The 
first  are  essentially  acute  or  active  in  their  progress,  self-limited  in  dura- 
tion, and  accompanied  by  appreciable  changes,  both  in  the  qualities  of  the 
blood  and  the  properties  and  molecular  changes  of  the  tissues.  The  sec- 
ond, are  not  acute  except  in  the  development  of  local  disease;  not  self 
limited  in  duration;  and  often  existing  for  years  without  inducing  appre- 
ciable changes  in  the  blood  or  active  disturbance  of  the  more  general  pro 
cesses  of  the  animal  economy.  The  first,  or  febrile  division,  originates 
from  such  causes  as  are  capable  of  diffusion  in  the  atmosphere,  probably 
in  connection  with  aqueous  vapor,  and  of  suspension  in  water,  or  from 
changes  in  one  or  more  of  the  natural  constituents  of  the  atmosphere  itself 
Whea  the  causes  depend  on  certain  local  conditions,  and  are  limited  to 
certain  geographical  and  geological  districts,  becoming  active  in  the  pro- 
duction of  disease  at  certain  parts  of  every  year,  they  are  termed  endemic 
When  they  are  developed  to  a  state  of  activity  at  irregular  intervals,  with- 
out strict  regard  to  geological  foi'mations,  and  causing  disease  to  attack 
large  numbers  in  any  given  community,  they  are  called  epidemic. 

The  second,  or  constitutional  division,  have  their  origin  from  causes 
that  generally  act  with  feeble  intensity,  but  persistently  through  long  pe- 
riods of  time,  such  as  errors  in  diet,  drinks,  exercise,  clothing,  and  heredi- 
tary influences.  These  may  result  in  impoverishment  of  the  blood,  spa- 
naemia,  from  insufficient  assimilation  of  food;  or  in  rendering  the  blood 
impure  by  interfering  with  the  processes  of  disintegration  and  excretion, 
thereby  retaining  the  products  of  tissue  metamorphosis  until  they  excite 
irritation  in  particular  structures,  as  in  gout  and  rheumatism.  Some  of 
these  causes  may  induce  not  merely  insufficient  but  imperfect  assimilation, 
and  consequent  perverted  nutrition,  as  in  scrofula  and  the  various  mor- 
bid growths  and  deposits. 

4 


50  CLASSIFICATION    OF    DISEASES. 

A  closer  study  of  this  class  of  diseases  -will  enable  us  to  arrang-e  them 
into  two  groups;  one,  in  which  the  prominent  and  constant  characteristic 
condition  is  an  unnatural  or  morbid  state  of  the  blood;  and  the  other, 
in  which  the  more  jDrorainent  characteristic  is  altered  nutrition  and  its 
results. 

The  first  group  includes  gout,  rheumatism,  and  constitutional  syphilis. 
The  second,  scrofula,  tuberculosis,  carcinoma,  and  leucocythsemia. 

That  gout  and  rheumatism  are  results  of  retention  in  the  blood  of  cer- 
tain chemical  substances  resulting  from  the  processes  of  tissue  metamor- 
phosis, and  which  in  the  healthy  condition  are  excreted  chiefly  through 
the  skin  and  kidneys,  is  now  well  understood.  The  abnormally  acid  con- 
dition of  the  fluids  in  rheumatism,  and  the  excess  of  uric  acid  in  the 
blood  of  patients  afiiicted  with  gout,  clearly  indicate  the  essential  pathol- 
ogy of  these  afi'ections,  and  fully  justify  their  classification  as  blood  dis- 
eases. The  well-known  fact  that  syphilis  in  all  its  stages  originates  from 
the  primary  introduction  of  a  specific  poison  into  the  blood,  renders  any 
comments  on  its  iDroper  classification  unnecessary.  That  these  three  forms 
of  disease  are  constitutional,  is  shown  by  increased  susceptibility  to  at- 
attacks  acquired  by  every  new  outbreak;  the  persistent  tendency  to  be- 
come chronic,  and  the  liability  to  hereditary  transmission. 

Patients  affected  with  any  one  of  the  second  group  of  constitutional 
diseases,  present  no  uniform  changes  in  the  chemical  constituents  of  their 
blood,  or  in  the  secretions  directly  eliminated  from  that  fluid.  When- 
ever changes  from  the  natural  condition  are  traceable  in  the  blood  of  such 
patients,  they  relate  to  the  organic  ingredients  derived  from  the  process 
of  assimilation,  such  as  the  albumen,  fatty  matter,  and  colorless  corpuscles; 
and  when  local  changes  are  manifested,  they  take  the  form  of  either  caco- 
plastic  deposits  or  morbid  growths.  The  first  are  seen  chiefly  in  scrofula 
and  tuberculosis,  and  the  last  in  carcinoma  and  leucocythaemia.  Those 
•of  you  who  are  familiar  with  that  part  of  medical  literature  relating  to  the 
last  named  disease,  may  be  surprised  that  I  should  place  it  in  this  group, 
as  writers  generally  have  represented  it  as  pre-eminently  a  blood  disease, 
on  account  of  the  existence  of  an  excess  of  colorless  corpuscles  in  that 
fluid.  It  is  probable,  however,  that  such  excess  of  corpuscles  is  only  an 
efi'ect  or  symptom  resulting  from  an  error  in  the  assimilative  and  nutritive 
processes,  as  I  shall  endeavor  to  show  hereafter. 

The  second  general  division  of  diseases,  called  local,  may  be  conven- 
iently subdivided  into  four  groups:  which  will  be  designated  phlegmasia,, 
or  local  inflammations;  fluxes,  or  such  as  are  characterized  by  excessive 
flow  of  fluids;  neuroses,  or  non-inflammatory  afi'ections  of  nerve  tissues; 
and  miscellaneous,  or  unclassifiable  cases.  The  individual  inflammations 
receive  names  in  accordance  with  the  organs  or  structures  they  aifect. 
Thus  we  have  in  the 

r  Meningitis. 

Ckanium \   Cerebritis. 

L  Cerebro-Spinal  Meningitis,  &c. 

Eye  and  Ear  -]  Opthalmia  and  Otitis. 


Chest  , 


Abdomen  . . .  - 


Pleuritis. 

Pneumonia. 

Bronchitis. 

Carditis  and  Pericarditis. 

Gastritis. 
Enteritis. 
Peritonitis. 
Hepatitis. 
^  Splenitis,  &c. 


CLASSIFICATIOxX    OF    DISEASES. 


51 


Pelvis 


Sktx. 


Cystitis. 
Meti-itis. 
Vaginitis. 
Cellulitis,  &c. 

Cutaneous  Inflammations. 


The  enumeration  raig-hfc  be  extended  to  the  bones,  muscles,  nerves, 
blood-vessels,  lymphatics,  areolar  tissue,  and  the  skin,  all  of  which  are 
liable  to  attacks  of  inflammation;  but  the  foregoinjr  -will  sufficiently  indi- 
cate the  principle  which  governs  the  application  of  names  to  inflammation 
in  any  of  the  structures  or  organs  of  the  body. 

The  word^^/,«  ov  fluxes^  which  I  have  chosen  to  designate  the  second 
division  of  local  diseases,  may  not  appear  altogether  appropriate  or  free 
from  liability  to  criticism. 

Yet  I  have  not  been  able  to  choose  a  better  one.  The  group  of  diseases 
included  in  this  sub-class  are  all  characterized  by  an  undue  exudation  or 
effusion  of  fluids  from  some  one  or  more  of  the  structures  of  the  body.  The 
fluid  effused  may  be  only  the  water  holding  in  solution  more  or  less  of  the 
soluble  constituents  of  the  blood,  or  it  may  be  the  blood  itself.  The  first 
may  be  denominated  serous,  and  the  second  sanguineous,  fluxes. 

The  serous  fluxes  are  ag-ain  de\'isible  into  such  as  take  place  from  free 
surfaces,  and  such  as  occur  into  shut  sacs.  The  free  surfaces  consist 
chiefly  of  the  cutaneous  tissue  covering  the  exterior  of  the  body,  and  the 
mucous  membranes  lining  the  interior  of  the  digestive  apparatus.  When 
the  flow  takes  place  from  the  former  it  is  called  diaphoresis;  when  from 
the  latter  it  is  called  serous  diarrhoea,  cholera  morbus  or  epidemic  cholera, 
according  to  the  degree  of  its  severity.  If  the  flow  takes  place  into  the 
shiit  sacs,  consisting  chiefly  of  the  serous  and  synovial  membranes,  it 
having-  no  outlet,  accumulates,  distends  the  sac,  and  constitutes  what  is 
usually  styled  dropsy.  It  is  not  limited,  however,  strictly  to  the  mem- 
branous sacs,  but  may  take  place  in  the  interstitial  spaces  of  the  areolar 
tissue  and  the  parenchyma  of  some  of  the  organs. 

The  same  remarks  are  applicable  to  the  sanguineous  fluxes.  The  blood 
may  flow  from  a  free  surface  like  the  mucous  membranes  of  the  respiratory 
organs,  the  alimentary  canal,  and  the  pelvic  viscera  and  be  at  once  dis- 
charged, or  it  may  extravasate  into  the  areolar  tissues  in  different  parts  of 
the  body,  and  be  retained  an  indefinite  period.  The  several  diseases  in- 
cluded in  this  subdivision  may  be  conveniently  tabulated  as  follows: 


'from  free  surfaces  of  ^ 


Serous^ 


Skin — Diaphoresis. 


Mucous  mem- 
branes . 


[.  shut  sacs  - 


Serous  mem- 
branes of 


FLUXES.     ^ 


f  Serous  diarrhoea 
■{  Cholera  morbus 
[^Epidemic  cholera 
'  Brain — Hydrocephalus 
Lungs — Hydrothorax 
Heai-t — Hydropspericardii 
Abdomen — Ascites 
Articulations — Synovial  Dropsy 


Interstitial  tissues — (Edema  or  Anasarca 


f  from  free  sur- 
faces of 


Sanguineous 


f  IsTostrils — Epistaxis 
I  Lungs — Hsemoptysis 
J  Stomach — Htematemesis 
'  Bladder — Hsematuria 
Uterus — Menorrhagia 
^Intestuies — Intestinal  Hemorrhage 


l^into  interstitial  tissue — Hoematocele,  etc. 


52  GENERAL  PATHOLOGY  OF  FEVEKS. 

The  third  division  of  the  second  class  of  diseases,  termed  Neuroses,  in- 
ckides  all  those  morbid  conditions  of  the  nervous  structures  that  are  not 
strictly  inflammatory  in  their  nature.  Pathologically,  they  are  suscepti- 
ble of  arrangement  into  such  as  are  accompanied  by  appreciable  change 
of  structure,  altered  nutrition  ;  and  such  as  are  manifest  by  disturbance  of 
function  only.  Under  the  first  head  we  might  include  atrophy,  or  defect- 
ive nutrition  ;  hypertrophy,  or  excessive  nutrition  ;  disarrangement  of 
atoms  or  cells,  constituting  softening  ;  hypertrophy  of  the  connective  tis- 
sue, with  atrophy  of  nerve  matter  constituting  sclerosis  and  metamorpho- 
sis of  structure,  as  in  fatty  degeneration. 

Under  the  head  of  functional  disturbances  might  be  mentioned  increas- 
ed sensibility — hyperesthesia  ;  diminished  sensibility — anaesthesia  ;  per- 
verted  sensibility — morbid  sensations  and  tastes  ;  and  corresponding  alter- 
ations of  transmissibility,  inducing  derangement  of  muscular  action,  such 
as  rigidity,  convulsions,  and  paralysis.  At  present,  however,  both  the 
physiological  and  pathological  conditions  of  the  nerve  structures  are  sub- 
jects of  the  most  active  investigation  ;  and  the  exact  relations  between 
clinical  facts  and  symptoms,  and  the  different  pathological  conditions 
just  mentioned,  are  not  sufficiently  established  to  justify  an  attempt  to 
maintain  a  strictly  pathological  classification  of  nervous  diseases. 

Therefore,  I  shall  follow  the  more  common  practice  and  arrange  the  af- 
fections of  the  nervous  structures  under  the  following  heads  : 

APOPLEXY,  epilepsy;,  chorea, 

CATALEPSY,  CONVULSIONS,  TETANUS, 

HYDROPHOBIA,  HYSTERIA,  PARALYSIS, 

HYPERESTHESIA,  ANESTHESIA,  LOCOMOTER    ATAXY, 

NEURALGIA,  INSOMNIA,  SUN-STROKE, 

DELIRIUM  TREMENS,  METHOMANIA,  MENTAL  DISORDERS. 

I  have  enumerated  a  fourth  subdivision  or  groups  of  local  diseases,  and 
given  to  it  the  name  of  Miscellaneous^  because,  in  the  routine  of  general 
practice  I  have  met  with  a  number  of  morbid  conditions  so  persistent  and 
troublesome  as  to  require  much  attention,  and  yet  they  could  not  be  ap- 
propriately classified  in  either  of  the  other  divisions.  These  I  shall  de- 
scribe to  you  in  the  closing  part  of  the  present  term. 


GENERAL  DISEASES. 


LECTUEE  VII. 

General  Pathology  of  Fevers— Ancient  and  Modern  Views  Compared— The  Unity,  or  Oneness  of  al] 
Fevers,  and  their  Diversity— Pathological  Conditions  Common  to  them  all. 

IN  the  preceding  lecture  your  attention  was  directed  to  a  simple,  general 
classification  or  grouping  of  diseases,  convenient  for  use  in  the  lecture- 
room.  The  first  order,  or  sub-class  of  diseases  named  in  that  arrangement 
was  the  idiopathic  fevers.  It  was  then  stated  that  the  particular  dis- 
eases included  in  this  order  could  be  conveniently  grouped  into  three  fam- 
ilies, each  characterized  by  certain  prominent  phenomena  distinguishing  it 
from  the  others,  and  yet  each  presenting  other  imjjortant  phenomena  com- 
mon to  the  whole.     In  commencing  the  study  of  this    important   order  ot 


GEXEEAL  PATHOLOGY  OF  FEVEES.  03 

diseases,  the  first  question  that  challeni^es  our  attention  is  the  same  which 
has  perplexed  the  minds  of  all  medical  philosophers  from  the  days  of  Hip- 
pocrates to  the.  present,  namely:  W/iot  is  fever  ?  Dr.  James  Copland, 
author  of  the  Dictionary  of  Practical  Medicine,  and  one  of  the  most  philo- 
sophical of  English  writers,  first  defines, /eyer  by  simply  enumerating  its 
more  constant  sj'mptoms,  as,  "  painful  lassitude,  debility  of  the  corporeal 
and  mental  faculties,  alterations  of  the  animal  heat  and  of  the  secreting 
functions,  accelerated  circulation,  increased  thirst,  and  abolition  of  the  ap- 
petites." In  another  place  he  says,  "  Fever  is  a  disease  of  all  the  vital  en- 
dowments, functions,  and  faculties  of  the  fluids,  and  of  the  whole  organi- 
zation." Dr.  William  Aitken,  a  more  recent  English  writer,  collating 
largely  from  the  writings  of  Virchow,  Parkes,  and  Jenner,  says:  "Fever 
essentially  consists  in  elevation  of  temperature,  which  must  arise  from  an 
increased  tissue  change,  and  have  its  immediate  cause  in  alterations  of  the 
nervous  system."  This,  however,  is  simply  returning  to  the  brief  defini- 
tion of  Galen — "  calor  prjeter  naturam." 

Dr.  George  B.  Wood,  one  of  the  best  writers  on  practical  medicine  in 
this  country,  defines/ever  to  be  "an  acute  affection  of  the  sj'stem,  in  which 
all  the  functions  are  more  or  less  deranged  ;  the  most  striking  phenomena 
being  sensorial,  or  nervous  irregularity,  increased  frequency  of  pulse,  in- 
crease^d  heat,  and  disinclination  for  food."  Most  of  the  writers  of  the 
present  day  make  no  attempt  to  give  a  special  definition  of  fever,  but  pro- 
ceed directly  to  consider  its  history,  symptoms,  causes,  effects  and  treat- 
ment. While  Hippocrates  and  Galen  regarded  increased  heat  as  the  es- 
sence of  fever,  they  attributed  such  increase  to  some  morbid  condition  of 
the  fluids  of  the  body,  which  were  then  supposed  to  consist  of  bile,  atra- 
bile,  phlegm  and  blood. 

The  active  phenomena  of  the  fever  were  supposed  to  result  from  the  con- 
coctions taking  place  in  the  humors  or  fluids,  and  the  efforts  of  nature 
to  expel  the  morbid  products.  This  was  the  ancient  humoral  doctrine, 
familiar  to  all  students  of  medical  history,  that  under  some  modification 
held  sway  over  the  professional  mind  until  the  time  of  Hoifman  and  Cul- 
len.  The  progress  of  anatomy  and  physiology  had  developed  some  knowl- 
edge of  the  special  functions  of  the  nervous  structures  and  their  influence 
over  the  blood-vessels;  and  Hoffman  was  one  of  the  first  to  trace  many 
of  the  more  prominent  symptoms  of  fever  to  a  morbid  condition  of  the 
nerves.  Spasm  of  the  capillaries  under  nervous  influence  he  regarded  as 
the  first  step  in  the  development  of  fever;  while  the  subsequent  heat  and 
arterial  excitement  was  caused  by  the  reaction  or  efforts  of  the  system  to 
overcome  this  spasm. 

CuUen  enlarged,  revised  and  moulded  these  crude  ideas  of  Hoffman 
into  a  nervous  theory  of  fever  so  plausible  and  popular  that  it  soon  gained 
complete  supremacy  over  the  doctrines  of  the  Humoralists  ;  and  so  fullv 
concentrated  the  attention  of  investigators  and  writers  upon  the  functions 
of  the  solids  or  organized  structures,  that  all  theories  of  disease  or  morbid 
action  soon  became  as  exclusively  6■o/^V^*s^^c  as  they  had  previously  been /iw- 
moral.  Of  course,  the  doctrines  of  Cullen  were  modified  from  time  to 
time,  with  each  important  advance  in  the  departments  of  physiology  and 
organic  chemistry,  and  yet  it  is  not  difiicultto  recognize  some  of  them  still 
holding  an  important  place  in  the  writings  and  teachings  of  many  eminent 
members  of  the  profession  in  our  own  time.  Thus,  Dr.  John  Eberle,  au- 
thor of  one  of  the  earliest  systematic  works  on  Practical  Medicine  in  this 
country,  says  :  "  The  first  link  in  the  chain  of  morbid  actions,  which  oc- 
cur in  the  development  of  fever,  always  commences  in  the  nerves."  * 

*See  Eberle's  Practice  of  Medicine,  2ucl  Ed.  Vol.  I,  pg.  12. 


54  GENERAL  PATHOLOGY  OF  FEVEES. 

Dr.  George  B.  Wood,  in  his  most  excellent  work  on  Practical  Medicine, 
wliich  for  many  years  was  one  of  the  best  text-books  in  our  language,  says: 
"Whether  the  fever  is  idiopathic  or  symptomatic,  the  fii'st  decided  step 
towards  its  formation  seems  to  be  some  morbid  impression  upon  the  nervous 
system,  and  this  impression  seems  to  be  of  a  depressing  nature."  *  It  is 
by  this  supposed  depressing  influence  on  the  nervous  system  that  all  this 
class  of  neuro-pathoio-^^-ists  endeavor  to  explain  the  formation  of  the  initial 
chill  or  cold  stage  that  ushers  in  most  fevers,  while  the  fever  proper  is  rep- 
resented as  the  reaction  of  the  system  against  this  depression.  But  Dr. 
Wood  was  too  close  and  accurate  an  observer  at  the  bedside,  not  to  rec- 
ognize the  fact  that  there  was  something  here  more  than  mere  nervous 
depression  and  consequent  reaction.  Hence,  on  the  same  page  from 
which  I  have  quoted,  he  adds,  with  characteristic  candor:  "  We  may  thus 
partially  explain  the  condition  of  the  chill,  but  there  is  something  more 
which  we  do  not  fathom;  something  in  which  the  chill  of  fever  differs  from 
other  instances  of  nervous  depression."  And  in  reference  to  the  re-action, 
he  adds:  "But  there  is  here  also  something  more  than  mere  re-action. 
There  is  the  continued  action  of  the  cause,  a  diversified  play  of  sympathies 
in  one  case,  a  widely  pervading  influence  from  some  unknown  agent  in 
another;  and  fever  is  not  purely,  as  some  have  maintained,  the  resilience 
of  the  depressed  system." 

Dr.  Southwood  Smith,  physician  to  the  London  Fever  Hospital,  and  one 
of  the  ablest  and  most  logical  English  writers,  in  the  latter  part  of  the  first 
half  of  the  present  century,  in  his  interesting  work  on  fevers,  published 
in  1830,  not  only  claims  a  unity  or  oneness  in  the  essential  pathology  of 
all  fevers,  but  he  places  that  pathology  in  disturbance  of  the  functions  of 
the  nervous,  circulating,  and  secreting  organs,  not  taking  place  simul- 
taneously but  in  an  invariable  order  of  sequence.  Plence  he  says:  "The 
order  of  events,  then,  is  first,  derangement  in  the  nervous  and  sensorial 
functions;  this  is  the  invariable  antecedent;  secondly,  derangement  in 
the  circulating  function;  this  is  the  invariable  sequent;  and  thirdly,  de- 
rano-ement  in  the  secretinar  and  excreting  functions;  this  is  the  last  re- 
suit  in  the  succession  of  morbid  changes."f  Dr.  Daniel  Drake,  in  his 
valuable  work  on  the  Topography  and  Diseases  of  the  interior  valley  of 
the  North  American  Continent,  does  not  discuss  the  pathology  of  fevers  as 
a  class,  but  in  alluding  to  the  inodus  operandi  of  the  efficient  cause  of  pe- 
riodical fevers,  says:  "The  paroxysmal  character,  not  less  than  the  symp- 
toms that  characterize  this  stage,  shows  that  the  function  of  innervation 
is  deeply  involved  and  embarrassed.  We  may,  in  fact,  admit  that  it  is 
the  first  affected.''^;  And  again,  in  discussing  the  pathology  of  the  ty- 
phous family  of  fevers,  he  says:  "The  history  of  the  typhous  fevers  indi- 
cates an  early,  if  not  ^  primary^  morbid  state  of  the  m^^er'ya(f^■ow,  which  all 
the  phenomena  declare  to  be  one  of  adynamia  with  irritation,  a  failure  of 
the  vis  nervosa  with  perversion;  a  degradation  with  abnormal  molecular 
actions."  §  These  allusions  to  some  of  the  most  eminent  writers  on  prac- 
tical medicine,  are  sufficient  to  show  that'  even  to  the  present  time,  the 
doctrine  that  the  first  step  or  link  in  the  chain  of  morbid  actions  taking- 
place  in  the  development  of  idiopathic  fevers,  is  a  disturbance  of  the 
functions  of  the  nervous  system.  Indeed,  most  medical  writers  appear  to 
recognize  no  mode  by  which  an  impression  can  be  made  upon  the  organ- 
ized structures  of  the  body,  except  by  a  primary  action  on  the  nerves. 
They  appear  to  recognize  no   properties    common  to  all  tissues,  by  which 

*  See  Wood's  Practice  of  iMedicine,  5th  Edition,  Vol.  I.  p.  112. 
fSee  A  Treatise  on  Fever  by  Southwood  Smith,  ^r.  D.  p.  r)2,  ]S"0. 
X  See  Drake  on  the  Principal  Diseases  of  tlie  Intcirior  Valley,  &c.,Vol.  II,  p.  51. 
g  See  idem,  page  408. 


GENERAL  PATHOLOGY  OF  FEVERS.  55 

tliev,  like  the  primary  germinal  cell  or  aggregation  of  bioplasm,  are  capa- 
ble" of  receiving  impressions  and  undergoing  molecular  changes,  both 
healthy  and  morbid,  independent  of  mere  nervous  influence. 

Indeed,  Dr.  Austin  Flint,  in  writing  on  this  subject,  says  directly: 
"  There  would  seem  to  be,  in  fact,  in  the  body  only  two  anatomical  sys- 
tems having  relations  so  extensive  as  to  be  able  to  give  rise  to  the  train 
of  morbid  phenomena  in  fever,  viz:  the  nervous  system  and  the  blood."* 
Yet  he,  like  many  of  thorse  who  have  written  during  the  last  two  decades, 
places  the  pYimary  morbid  changes  in  the  blood,  rather  than  in  the  nervous 
structvires.  / 

If  you  examine  carefully  the  current  literature  on  this  subject,  you  will 
find  a  large  majority  of  the  writers  of  our  own  time,  referring  all  fevers 
to  specific  causes,  such  as  organic  germs  or  infectious  miasms  that  gain 
access  to  the  blood  and  produce  their  primary  deleterious  impression  on 
some  of  the  constitiients  of  that  fluid.  Partly  to  these  morbid  changes  in 
the  blood,  and  partly  to  the  direct  presence  and  influence  of  the  infection, 
is  attributed  the  primary  morbid  impression  upon  the  functions  of  the 
nervous  system,  and  through  it  upon  all  the  other  functions  of  the  body. 
Not  a  few,  however,  place  all  the  more  important  primary  changes  consti- 
tuting the  essential  pathology  of  fevers  in  the  blood  itself  ;  and  thereb;y 
adopt  doctrines  as  strictly  humoral  as  were  entertained,  by  any  of  the 
ancients.  Whatever  may  be  the  opinions  entertained,  however,  in  regard 
to  the  primary  changes  or  first  links  in  the  chain  of  morbid  actions  in  the 
development  of  idiopathic  fevers,  there  is  a  very  general  disposition,  at 
the  present  time,  to  regard  the  pyrexia  or  increased  heat  as  the  one  essen- 
tial pathological  condition  common  to  all  fevers.  So  prominent,  indeed, 
is  the  place  assigned  to  increased  heat  as  the  essential  morbid  condition  in 
fevers,  by  writers  of  the  present  day,  that  to  it  are  attributed  nearly  all  the 
molecular  or  structural  changes  that  take  place  in  the  organized  structures 
of  the  body  ;  and  its  control  within  proper  limits  is  presented  as  the 
chief  object  of  treatment.  Indeed,  the  expressions  used  by  many,  both 
in  speaking  and  writing,  fairly  convey  the  impression  that  increased  heat 
and  fever  are  convertable  terms  ;  or  in  other  words  that/euer  is  essentially 
increased  heat.  Yet,  a  moderate  amount  of  careful  observation  at  the 
bedside,  is  sufficient  to  demonstrate  that  in  every  case  of  general  fever, 
there  is  a  co-existence  of  many  functional  disturbances,  of  which  calori- 
fication, or  increased  heat  is  only  one;  innervation  another;  circulation, 
secretion,  nutrition,  and  tissue  disintegration  are  others.  And  an  ade- 
quate amount  of  impartial  clinical  observation  shows,  also,  that  there  is  no 
uniform  order  of  sequence  in  these  disturbances,  but  rather  that  they  are 
developed  coincidmtly  from  some  cause  capable  of  disturbing  all  simul- 
tanously,  though  not  always  in  the  same  degree,  nor  in  the  same  direc- 
tion. To  call  either  increased  heat  or  disturbed  innervation  fever,  is 
simply  to  mistake  a  prominent  symptom  or  effect  of  disease  for  the  disease 
itself." 

To  define  fever  as  the  "  reaction "  of  living  structures  or  vital  forces 
against  primary  impressions  of  a  depressing  character,  or  as  the  "  effort  of 
nature"  to  throw  off  or  expel  some  offending  material,  as  has  been  done 
so  long,  is  simply  to  use  words  and  phrases  that  convey  no  definite  patho- 
logical meaning,  as  I  have  already  explained  to  you  in  the  second  lecture 
of"  the  present  "course.  If  the  complex  and  very  important  morbid  condi- 
tion universally  recognized  as  a /eye?-,  is  not  merely  increased  heat,  nor 
the  reaction,  or  '•'•resUience^''  of  the  system  from  nervous  depression,  nor  yet 

*  See  Flint's  Practice  of  Medicine,  3d  Edition,  p.  808. 


56  GENERAL  PATHOLOGY  OF  FEVEES. 

a  mere  alteration  of  the  blood,  the  question  recurs:  what  is  it?  Must  we 
agree  with  Dr.  Wood,  that  it  is  something  we  cannot  fathom — something 
too  remote  in  the  intricate  processes  of  the  living  system  to  be  observed, 
analyzed,  and  understood  by  the  human  mind?  I  think  not.  On  the  con- 
trary, it  has  seemed  to  me  that  the  obscurity  resting  upon  this  subject  has 
depended  entirely  on  the  failure  to  recognize  the  existence  of  those  gen- 
eral properties  belonging  to  all  living  matter,  M^hich  I  endeavored  to 
explain  to  you  fully  in  the  second  lecture  of  the  present  course.  While 
fever  does  not  consist  primarily  in  either  an  alteration  in  the  blood,  a  de- 
pression or  disturbance  of  the  nervous  functions,  the  circulatory,  the  secre- 
tory, the  nutritive,  or  calorific  processes,  alone  ;  it  does  consist  in  the 
action  of  some  cause  capable  of  disturbing  the  general  elementary  prop- 
erties common  to  all  the  organized  structures,  which  I  have  called  suscep- 
tibility and  vital  affinity;  and  it  is  the  active  disturbance  of  these  proper- 
ties that  soon  involves  disturbance  of  all  the  functions  and  processes 
named;  not  in  any  fixed,  consecutive  order,  but  simultaneously,  as  from  a 
common  cause.  The  nervous  structures  have  special  well-defined  func- 
tions, imparting  sensibility,  voluntary  and  organic;  and  directing  muscular 
action,  both  voluntary  and  involuntary. 

By  thus  receiving  and  transmitting  impressions  and  regulating  muscu- 
lar action,  they  serve  the  purpose  of  placing  one  organ  in  relation  with  an- 
other ;  they  influence  the  caliber  of  all  vessels  containing  muscular  fibres 
in  their  coats,  and  thereby  influence  the  quantity  and  motion  of  the  blood 
in  the  vessels  of  each  part ;  by  thus  influencing  the  quantity  and  motion 
of  the  blood,  they  indirectly  influence  the  activity  of  secretion  and  mole- 
cular motion,  and  consequently  to  a  certain  extent  nutrition  and  disinte- 
gration ;  and  by  influencing  all  these  they  carry  an  influence  to  a  limited 
extent  over  calorification.  It  can  thus  be  seen  that  morbid  impressions 
made  on  the  nervous  system,  may  consecutively  and  indirectly  involve  ail 
the  functions  and  jDrocesses  of  the  living  system.  But  it  is  also  true,  that 
the  derangements  thus  produced  by  primary  impressions  on  the  nerves, 
whether  of  a  depressing  or  exciting  character,  dift'er  widely  from  the  phe- 
nomena of  an  idiopathic  fever.  If  you  study  closely  every  recognized 
morbid  state  of  the  nervous  system,  from  the  highest  state  of  nervous  ex- 
citement to  the  lowest  stage  of  nervous  depression,  you  can  find  nothing 
either  in  the  symptoms,  progress  or  results,  that  bear  even  a  moderate 
resemblance  to  the  symptoms  and  progress  of  a  general  fever.  On  the 
other  hand,  it  must  be  admitted  that  mere  alterations  in  the  blood  alone 
cannot  produce  the  phenomena  of  general  fever.  The  blood  may  be,  and 
doubtless  generally  is,  the  vehicle  into  which  the  morbific  agents  consti- 
tuting the  efficient  causes  of  fever,  are  received,  and  in  which  such  agents 
are  conveyed  to  every  structure  of  the  body.  And  it  is  the  impression  of 
these  morbific  agents,  thus  conveyed  simultaneously  to  all  parts  of  the 
organized  structures,  directly  upon  the  properties  common  to  all,  that 
produces,  Goincidently,  general  disturbance  of  all  the  functions  and  pro- 
cesses performed  in  the  system.  It  is  the  action  of  some  agent,  conveyed 
in  the  blood,  capable  of  producing  an  active  disturbance  of  the  elementary 
properties — susceptibility  and  vital  affinity — by  which  the  excitability  and 
molecular  changes  in  all  the  tissues  are  controlled,  that  constitutes  true 
fever.  It  is  this  simultaneous  disturbance  of  all  the  functions  and  pro- 
cesses, by  active  impressions  on  the  properties  common  to  all  living  struc- 
tures, that  essentially  distinguishes  general  fever  from  local  diseases  of  an 
irritative  or  inflammatory  character. 

While  most  of  the  general  diatheses  and  constitutional  diseases  and  ten- 
dencies result  from  causes  acting  with  feeble  intensity,  but  persistently 


GENERAL    PATHOLOGY    OF    FEVERS. 


57 


upon  the  same  general  properties;  the  general  fevers  all  result  from  causes 
acting  temporarily,  but  with  greater  intensity,  and  thereby  producing 
acute  general  functional  disturbance,  instead  of  mere  modifications  of  nu- 
trition and  temperament.  If  it  be  true  that  fever  consists  essentially  in  an 
acute  general  disturbance  of  the  functions  and  processes  of  the  animal 
economy,  from  the  impressions  of  some  toxremic  agent  acting  upon  the 
general  elementary  properties  common  to  all  living  organized  matter,  as  I 
have  claimed,  you  can  readily  appreciate  the  truth  of  Dr.  Copland's  as- 
sertion that  there  is  a  '•'■oneness''''  or  unity  in  all  fevers.  Such  oneness  or 
common  bond  of  union  consists  in  the  primary  disturbance  of  the  same 
general  properties,  from  the  direct  impression  of  any  and  all  causes  cap- 
able of  inducing  general  fever.  But  while  all  the  causes  capable  of  pro- 
ducing fever  act  primarily  upon  the  same  general  properties,  thereby  mak- 
ing a  common  point  of  departure  in  the  establishment  of  pathological 
changes,  yet  each  specific  cause  impresses  these  properties  in  a  direction 
peculiar  to  itself;  and  hence  leads  to  the  development  of  symptoms  and 
pathological  changes  equally  peculiar,  thereby  explaining  the  diversities 
seen  in  the  different  forms  of  fever.  For  example,  one  cause  or  group  of 
causes,  may  so  act  as  to  increase  both  the  susceptih'dity  and  the  vital 
affinity^  thereby  producing  a  fever  of  direct  excitement,  corresponding  to 
the  Synocha  of  the  ancients,  and  the  irritative,  evanescent,  or  transitory 
fever  of  later  writers. 

Another  may  so  act  as  to  depress  both  properties,  and  thereby  lead  to 
the  phenomena  characteristic  of  the  typhoid  and  typhus  family  of  fevers. 

Another  may  produce  such  an  impression  as  to  increase  or  exalt  the 
susceptibility,  while  it  impairs  the  vital-afBnity,  thereby  inducing  fevers  of 
high  temporary  excitement  with  impaired  tonicity  of  tissue,  represented 
by  the  family  known  as  periodical  fevers.  Still  another  group  of  causes 
may  act  in  such  direction  as  to  increase  the  excitability  or  susceotibility, 
while  they  pervert  the  vital  affiiuty  in  a  manner  differing  from  simple  in- 
crease or  diminution,  and  by  which  specific  molecular  changes  and  combi- 
nations are  effected,  as  seen  in  the  group  of  specific  eruptive  fevers.  These 
diversities  in  the  primary  pathological  conditions  resulting  from  the  action 
of  different  causes  on  the  same  general  properties,  may  be  seen,  perhaps 
more  clearly,  by  the  following  tabular  statement,  which  I  place  before  you 
on  the  blackboard: 

Rn=;rpnh"bilitv    (  (  ^^^^^  °^  ^^^  Excitement. 

Altai  Affimty   (  Febrictjla. 


ELEMEXTART 
PROPERTIES. 


Susceptibility 

Yital  Affinity 


Susceptibility 
Vital  Affinity 


-  Both  diminished 


Increased 
Impaired 


f  Fever  tending  directly  to  De- 
I      bility   or   Functional    Im- 
j      pairment. 
1^        Typhoid  Group. 


Fever  of  high  temporary  Ex- 
citement,   with    impaired 
Tonicity,  etc. 
i_        Periodical,  Group. 


f  Fever  of   Excitement,   with 
Sn^rpTiti'l.ib'tv      Tnrrpaqpd  '      specific  local  developments 

V?Sffi5j      p"S.Sed :::::;:         amWormation  of  SpeciSc 

L        Eruptive  Group. 

Having  thus  stated  as  clearly  as  possible  the  first  and  essential  link  in 
the  chain  of   mo:  bid  actions  constituting   the    pathology  of   fevers,  I  will 


58  GENERAL  PATHOLOGY  OF  FEVEES. 

next  direct  your  attention  to  the  more  important  subsequent  changas,  at 
least  so  far  as  they  are  common  to  this  >vhoIe  class  of  diseases.  The  first 
important  effect  resulting  from  a  disturbance  of  the  general  elementary 
properties,  is  an  alteration  of  the  molecular  movements  in  the  various  tis- 
sues, which  necessarily  involves  coincident  disturbance  of  the  processes 
of  nutrition,  disintegration,  secretion,  calorification  and  innervation. 

The  movement  of  atoms,  cells,  or  molecules  in  all  the  tissues  taking 
place  under  the  guidance  of  these  properties,  and  adjusted  to  certain  nat- 
ural relations  between  the  motion  of  the  blood  in  the  capillaries,  the  sen- 
sibility of  the  vaso-motor  nerves,  and  the  atfinity  of  the  structural  ele- 
ments ;  whatever  alters  the  latter,  must  of  necessity  alter  in  a  correspond- 
ing direction  the  movements  themselves. 

And  as  the  evolution  of  heat  in  the  living  body  is  the  result  of  atomic 
changes  in  the  tissues,  it  must  increase  or  diminish,  2)^^  pasm,  with  the 
increase,  diminution,  or  perversion  of  such  changes.  The  idea  that  car- 
bonaceous foods  are  used  in  the  living  system  for  the  support  of  respira- 
tion and  animal  heat,  as  taught  by  the  chemico-physiological  schoo'  of 
Liebig,  is  contrary  to  many  well-known  physiological  and  pathological 
facts,  and  was  fully  disproved  by  a  series  of  experiments  performed  by 
myself  in  1850,  the  results  of  which  were  presented  to  the  American 
Medical  Association  in  May,  1851,  and  published  in  the  Chicago  Medical 
Journal  the  following  month.* 

You  must  remember,  however,  that  the  accumulation  of  heat,  or  the 
actual  temperature  of  the  living  body,  as  indicated  by  the  clinical  ther- 
mometer, does  not  necessarily,  or  even  generally,  correspond  with  the 
rapidity  of  direct  heat  production,  either  in  sickness  or  health.  For  while 
all  those  atomic  or  molecular  changes  taking  place  in  the  tissues  by  which 
the  moving  matter  passes  from  a  rarer  to  a  denser  condition,  increases 
the  sensible  heat;  those  by  which  the  matter  passes  from  a  denser  to  a 
rarer  condition,  absorb,  or  render  sensible  heat  latent. 

It  is  plain,  therefore,  that  the  actual  temperature  of  the  body  at  any  given 
time  will  depend  as  m\ich  upon  the  diminution  of  the  latter  processes,  as 
upon  an  increase  of  the  former. 

Among  the  most  important  of  the  latter  processes  are  the  eliminations 
from  the  lungs  and  skin.  From  the  mucous  membrane  lining  the  whole 
extent  of  the  respiratory  passages  and  the  cutaneous  surface,  water  is  con- 
stantly being  converted  into  aqueous  vapor,  by  which  a  large  amount  of 
sensible  heat  is  rendered  latent  and  the  temperature  of  the  body  corres- 
pondingly reduced.  As  a  general  rule,  during  the  active  stage  of  all 
fevers,  these  extended  surfaces  are  drier  than  natural,  audit  is  highly  prob- 
able that  the  accumulation  of  sensible  heat  is  due  more  to  the  diminished 
exhalation  of  aqueous  vapor  than  to  any  other  one  cause.  From  these  re- 
marks you  will  readily  perceive  that  while  the  evolvement  of  heat  in  the 
living  human  body  results  directly  from  the  molecular  or  tissue  changes,  its 
retention  in  a  free  state  depends  more  upon  the  degree  of  activity  in  tha 
conversion  of  water  into  aqueous  vapor  in  the  processes  of  elimination 
from  the  cutaneous,  pulmonary  and  intestinal  surfaces. 

Therefore,  while  the  increased  heat  in  one  case  of  fever  may  depend  on 
an  increased  activity  of  molecular  changes  in  the  tissues;  in  another  it  may 
depend  partly  on  increase  of  these  changes,  and  partly  on  lessening  of  the 
exhalations  of  aqueous  vapor;  and  in  still  another,  the  same  elevation  of 
temperature  may  be  owing  entirely  to  the  diminished  exhalations  from  the 

*  The  maintenance  of  a  nearly  uniform  temperature  throua;hout  the  whole  forty  days  of  recent 
fastin}^  by  Dr.  Tanner,  is  also  strong  evidence  that  the  production  of  heat  in  the  system  is  not  de- 
pendent on  the  ingestion  of  any  particular  kind  of  food. 


GEXEI5AL    PATHOLOGY    OF    FEVERS.  59 

free  surfaces  of  the  body,  while  the  rapidity  of  the  tissue  changes  may  be 
only  natural,  or  even  less.  I  am  aware  that  many  neuroloi^-ical  experiment- 
alists reo-ard  it  as  an  established  physiological  law  that  the  metamorphosis 
of  tissues  and  the  production  of  heat,  are  regulated  by  the  nervous  system.* 
But  an  attentive  study  of  the  results  of  experiments,  in  connection  with 
abundant  clinical  observation,  has  satisfied  me  that  the  only  influence  ex- 
erted by  the  vaso-motor  or  trophic  nerves  over  tissue  changes  and  tempera- 
ture, results  from  their  power  to  increase  or  diminish  the  contraction  of  the 
blood  vessels,  and  thereby  alter  the  quantity  and  motion  of  the  blood  in  any 
a'iven  part.  Yet  a  mure  or  less  profound  disturbance  of  the  functions  of 
the  nervous  structures  of  the  body  is  present  in  all  fevers.  The  direction 
and  intensity  of  such  disturbance  will  vary,  however,  not  in  any  strict  con- 
sonance with  the  variations  of  febrile  heat,  but  rather  with  the  character 
and  intensity  of  the  exciting  cause,  and  the  previous  predispositions  of  the 
individual  patient. 

Another  condition  common  to  all  general  fevers,  is  a  profound  disturb- 
ance of  those  molecular  changes  which  constitute  secretion,  and  tissue 
change.  But  while  such  disturbance  always  exists  in  a  febrile  condition, 
there  is  no  uniformity  in  its  direction  or  activity.  As  I  have  already  told 
you,  most  of  the  writers  on  fevers  at  the  present  time  regard  the  increase  of 
heat  in  fevers  as  the  direct  result  of  increased  tissue  changes.  If  this 
were  true,  we  ought  to  find  a  uniform  ratio  between  the  rapidity  of  such 
changes  as  shown  by  the  quantity  of  the  excreta^  and  the  degree  of 
fever  heat.  But  the  results  of  my  own  observations,  as  well  as  those  of 
Parkes,Virchow,  Wunderlech,  Joseph  Jones,  and  many  others,  show  no 
such  uniform  relation.  On  the  contrary,  the  quantity  of  the  excreta  pass- 
ing from  the  skin,  lungs,  kidneys,  and  bowels,  whether  considered  as  a 
whole,  or  from  each  source  separately,  varies  much  in  the  different  varie- 
ties of  fever,  and  in  different  cases  of  the  same  variety.  And  these  vari- 
ations are  found  to  have  no  tf/i^/brm  relation  to  the  variations  in  the  febrile 
heat.f 

Again,  we  find  in  the  progress  of  all  the  varieties  of  idiopathic  fever, 
decided  changes  in  the  quality  and  constituents  of  the  blood. 

If  you  keep  in  mind  the  fact  that  the  blood  is  the  primary  receptacle  for 
all  the  products  of  tissue  changes,  as  well  as  for  the  new  material  received 
through  the  organs  of  digestion  and  assimilation,  you  will  see  how  readily 
the  condition  of  the  blood  must  be  affected  by  whatever  seriously  disturbs 
the  processes  of  either  assimilation,  nutrition,  or  disintegration.  And,  as  I 
have  already  shown  these  processes  to  be  profoundly  altered  by  the  action 
of  all  causes  capable  cjf  inducing  general  fever,  you  would  expect  to  find 
the  blood  more  or  less  changed  as  a  necessary  coincident  condition.  But 
if  it  were  possible  for  the  processes  just  named  tcj  remain  natural  during 
the  progress  of  a  general  fever,  and  the  function  of  excretion  through 
the  skin,  lungs,  kidneys  and  bowels,  by  which  the  products  of  tissue- 
change  and  other  materials  are  separated  from  the  blood,  was  interfere.d 
with,  speedy  alterations  in  that  fluid  would  necessarily  result.  Again,  the 
specific  poison  that  constitutes  the  direct  exciting  cause  of  the  disease, 
may,  on  entering  the  blood,  exert  a  morbid  influence  on  the  constituents 
of  that  fluid,  as  suggested  by  Murchison,  Flint,  and  many  other  recent 
writers. 

It  is  probable  that  all  the  three  modes  by  which  the  quality  and  quan- 
tity of  the  constituents  of  the  blood  are  capable  of  being  changed,  co-ex- 

*  See  the  recent  very  interesting  researches  of  Dr.  H.  C.  Wood,  ,of  Philadelphia,  Published 
by  the  Smithsonian  Institute. 

t  See  Aitken's  Science  and  Practice  of  Medicine,  p.  262,  Vol.  L 


60  GENEEAL  PATHOLOGY  OF  FEVEES. 

ist  in  most  cases  of  general  fever,  but  in  very  varying-  degrees  of  import- 
ance in  different  cases.  For  instance,  in  those  constituting  the  group, 
which,  in  the  preceding  lecture  I  classed  as  conthmed  fevers,  we  find  an 
excess  of  most  of  the  elements  derived  from  tissue  changes,  with  little  de- 
ficiency of  those  of  a  nutritive  and  formative  character,  but  a  decided  im- 
pairment of  the  quality  or  properties  of  both  classes  of  constituents.  The 
coagulability  of  the  fibrin  is  impaired  or  entirely  destroyed  ;  the  red  cor- 
puscles are  darker  color,  and  cease  to  attract  each  other  in  forming  rou- 
leaux as  in  health  ;  the  hajmatin  escapes,  tinging  the  serum  and  the 
fluids  often  found  in  the  serous  cavities,  a  redish  color;  and  in  typhus,  as 
well  as  in  the  more  malignant  cases  of  other  members  of  this  group,  there 
is  an  excess  of  ammonia,  with  an  unusual  tendency  to  putrifactive  changes. 

On  the  other  hand,  in  the  members  of  the  group  classed  as  periodical, 
characterized  by  frequent  critical  or  periodical  evacuations,  as  in  the 
copious  sweats  that  terminate  each  paroxysm  of  an  intermittent,  there  is 
seldom  found  any  excess  of  the  ordinary  products  of  tissue  changes,  or 
much  apparent  impairment  of  the  properties  of  either  fibrin  or  red  cor- 
puscles, but  a  marked  diminution  in  the  quantity,  or  relative  proportion, 
of  all  the  nutritive  and  formative  constituents,  more  especially  of  the  al- 
bumen and  red  corpuscles.  The  latter  I  have  found  in  many  cases  re- 
duced much  below  one-half  of  their  natural  proportion.  Frierich,  J.  For- 
syth Meigs,  and  others,  have  shown  by  numerous  microscopic  examina- 
tions, that  the  blood  in  this  class  of  fevers  geiierally  contains  a  notable 
quantity  of  a  black  pigment,  in  the  form  of  small,  dark  granules.  The  same 
material  is  also  found  in  the  structures  of  the  lungs,  spleen,  and  liver.  It 
is  highly  probable  that  this  pigment  is  developed  in  some  way  from  the 
rapid  disappearance  of  the  red  corpuscles. 

Finally,  another  important  circumstance  common  to  all  the  essential  fe- 
vers, or  acute  general  diseases,  is  their  self-limited  duration.  This  re- 
sults in  part  from  the  essential  nature  of  the  morbid  conditions  which  con- 
stitute a  general  fever,  and  in  part  from  the  nature  and  special  affinities 
of  the  specific  causes  that  give  rise  to  those  morbid  conditions.  If  I  am 
correct  in  asserting  that  a  direct  disturbance  of  the  elementary  properties 
of  the  living  structures,  sufficiently  acute  to  profoundly  alter  the  general 
processes  and  functions  of  assimilation,  nutrition,  secretion,  innervation, 
and  calorification,  constitutes  the  essential  pathology  of  all  general  fevers, 
it  must  be  evident  to  all  of  you,  that  such  active  universal  disturbance 
cannot  be  maintained  indefinitely.  It  must  terminate  within  a  limited 
period  of  time,  or  it  will  necessarily  work  such  changes  in  the  organized 
tissues,  as  well  as  in  the  blood,  that  the  life  of  the  patient  must  cease.  A 
careful  study  of  the  natural  progress  and  results  of  all  the  varieties  of  this 
great  and  important  class  of  diseases,  has  shown  that  all  the  milder  cases 
inherently  tend  to  recovery  within  from  one  to  six  weeks,  and  thft  more 
severe  to  the  destruction  of  life  within  a  similar  period  unless  modified  by 
the  interference  of  appropriate  remedies. 

Having  thus  explained  the  nature  of  the  morbid  impressions  and  result- 
ing morbid  actions  wiiich  constitute  the  true  pathology  of  idiopathic  fevers, 
and  the  more  important  facts  and  conditions  common  to  them  all,  I  must 
next  direct  your  attention  to  the  special  consideration  of  each  group  sep- 
arately. I  shall  therefore  enter  upon  the  consideration  of  the  continued 
fevers  at  the  beginning  of  the  next  lecture  hour. 


CONTINUED    FEYEKS.  61 


LECTUEE  VIII. 

Continued  Fevers— Their  General  Characteristics— Individual  Members  of  the  Class— Divisible 
into  Three  Groups,  with  Distinct  Etiological  Characteristics— First  Group,  Simple  Continued 
Irritative  or  Transient  Fever,  or  Febricula. 

GENTLEMEN: — Having,  in  the  preceding'  lecture,  presented  a  brief 
review  of  the  opinions  that  have  been  entertained  in  regard  to  the 
general  pathology  of  fevers,  and  pointed  out  those  changes  and  symptoms 
common  to  the  whole  class,  I  now  invite  your  attention  to  that  subdivision 
or  group  of  acute  general  diseases  called  continued  fevers.  The  members 
of  this  group,  though  presenting  considerable  variety  in  regard  to  their 
etiology,  symptoms  and  results,  still  present  a  sufficient  number  of  items 
common  to  the  whole  to  justify  the  placing  of  them  vmder  one  head. 
First,  in  all  of  them  the  febrile  symptoms  may  be  regarded  as  continuous 
from  the  beginning  to  the  end  of  the  disease — at  least  from  the  initial 
stage  to  the  approach  of  convalescence.  It  is  this  continuity  of  the  febrile 
symptoms  throughout  the  covtrse  of  these  diseases  that  has  given  to  them 
the  title  of  continued  fevers.  By  continuity  I  do  not  mean  evenness  or 
uniformity  in  the  symptoms,  for  in  each  member  of  the  group  the  temper- 
ature and  other  active  symptoms  may  vary  much  in  intensity  from  day 
to  day,  or  at  different  parts  of  the  same  day;  but  they  do  not  wholly 
disappear  and  return  again  at  such  regular  intervals  as  to  constitute  peri- 
odicity. Second,  while  all  the  members  of  this  group  are  self-limited  in 
duration,  in  the  same  sense  that  I  have  defined  the  self- limitation  of  all 
acute  general  diseases — that  is,  they  must  terminate  within  a  limited  pe- 
riod of  time,  either  in  the  convalescence  or  the  death  of  the  patient;  yet  no 
one  of  them  presents  such  an  approach  to  exactness  in  the  duration,  either  of 
its  successive  stages,  or  of  its  whole  course,  as  is  seen  in  the  fevers  classed 
as  eruptive.  On  the  contrary,  they  vary  much,  both  in  the  relative  and 
absolute  duration  of  their  several  stages,  and  of  their  entire  course.  For 
instance,  the  prodromic  or  forming  stage,  may  vary  in  length  from  a  few 
hours  to  one  or  two  weeks.  The  active  febrile  stage  may  last  only  a  day, 
or  continue  four  weeks.  The  defervescence,  or  stage  of  decline,  may  be 
abrupt,  and  marked  by  critical  evacuations,  or  gradual.  These  remarks  are 
not  only  true  when  comparing-  one  member  of  this  group  with  another,  but 
in  relation  to  the  different  stages  of  the  same  variety  of  fever.  If  you 
take  typhoid  fever  as  the  most  important  member  of  the  group,  you  may 
find  the  forming  stage  varying,  in  different  cases,  from  three  days  to  two 
weeks;  the  active  febrile  stage,  from  two  to  four  weeks;  and  the  stage  of 
defervescence,  from  three  to  seven  days;  making  the  whole  duration  of 
the  disease  in  different  cases  from  three  to  six  weeks.  This  is  in  marked 
contrast  with  the  more  definite  length  of  each  stage  of  the  eruptive  fevers, 
and  also  with  the  limited  duration  and  regularity  of  the  return  of  the  par- 
oxysms of  the  periodical  or  malarious  group.  Third,  in  the  members  of 
this  class  or  group  there  is  not  that  manifest  tendency  to  eliminate  the 
specific  cause  through  one  or  more  of  the  excretory  organs,  as  seen  in  the 
copious  sweats  that  end  each  distinct  paroxysm  of  the  periodical  group; 
nor  to  fix  it  by  some  special  affinity  in  a  single  structure,  as  seen  in  the 
lodgment  of  the  specific  viruses  or  contagions  in  the  skin  and  portions  of 
the  mucous  membrane,  in  the  members  of  the  eruptive  group. 


62  CONTINUED    FEVEES. 

In  consequence  of  this  failure  to  effect  an  early  separation  of  the  special 
exciting-  cause  or  fever  poison,  when  such  exists,  and  its  consequent  longer 
retention  in  the  blood,  together  with  the  coincident  accumulation  of  some 
of  the  products  of  disintegration  or  waste  of  tissues,  the  blood  undergoes  a 
more  marked  and  uniform  deterioration  of  the  quality  of  its  constituents 
than  in  either  of  the  other  groups  of  fever. 

The  particular  fevers  which  I  shall  include  in  the  group  called  continued^ 
are  the  following:  Simple  Irritative  or  Accidental  Fever,  Influenza,  Den- 
gue, Typhoid,  Typhus,  Relapsing,  Plague,  Yellow  fever,  Erysipelas,  and 
Diphtheria. 

Causes. — While  all  these  varieties  of  fever  are  properly  grouped  to- 
gether as  acute  general  diseases  of  a  continued  type,  they  differ  much  in 
their  causes,  symptoms  and  results. 

The  three  first  named  appear  to  be  caused  principally  by  the  influence 
of  atmospheric  conditions  acting  primarily  on  the  cutaneous  and  pulmo- 
nary surfaces  in  such  a  way  as  to  interfere  with  the  proper  eliminations, 
thereby  causing  the  retention  of  effete  material  capable  of  disturbing  the 
properties  of  the  tissues  and  suddenly  developing  a  fever  of  marked  excite- 
ment but  of  brief  duration.  The  atmospheric  conditions  alluded  to  may 
consist  in  sudden  and  extreme  changes  in  the  temperature  and  moisture, 
or  in  the  quantity  of  active  oxidizing  agents,  as  ozone,  hydrogen  peroxide, 
etc.,  and  do  not  include  a  specific  contagion,  infection  or  fever-poison.  Be- 
ing thus  produced  mostly  by  alterations  in,  what  I  may  term,  the  natural 
constituents  and  qualities  of  the  atmosphere,  these  varieties  of  fever  are  lia- 
ble to  attack  large  numbers  of  people  almost  simultaneously,  and  to  extend 
rapidly  over  large  districts  of  country.  On  the  other  hand,  the  typhoid, 
typhus,  relapsing  fever  and  plague,  are  supposed  to  originate  from  the  ac- 
tion of  specific  poisons,  developed  either  from  the  decomposition  of  animal 
matter,  or  from  the  excretions  of  those  sick  with  the  same  disease.  These 
specific  poisons  are,  by  some  writers,  styled  icUo -miasms, 'hj  others,  infec- 
tions or  contagions;  and  by  others,  sim-^Ay  fever-poisons.  They  are  capable 
of  suspension  in  air,  water,  milk,  and  probably  in  many  other  articles  of 
food  and  drink  ;  and  with  these  they  may  be  introduced  into  the  human 
system,  either  through  the  lungs  or  stomach,  and  possibly  by  cutaneous  ab- 
sorption. Suspended  in  these  various  articles,  they  may  be  transported 
from  place  to  place,  and  retain  their  activity,  provided  they  are  kept  in 
confined  limits,  as  in  unventilated  rooms,  holds  of  ships,  trunks,  boxes  of 
goods,  or  clothing,  etc. 

But  free  exposure  to  unconfined  and  pure  air,  either  destroys  or  dilutes 
them  to  such  a  degree  that  they  become  harmless. 

Whether  the  infections  which  give  rise  to  the  typhoid,  typhus,  relapsing 
fever  and  plague,  are  so  many  specific  agents  existing  in  the  form  of  bac- 
teria, micrococci,  or  other  microscopic  germs,  the  propagation  of  which  is 
favored  by  the  accumulation  of  animal  excretions  in  a  moist  state;  or 
whether  they  are  inorganic  gaseous  products  of  the  decomposition  of  such 
matters,  is  not  satisfactorily  determined.  A  majority  of  the  writers  and 
investigators  of  the  present  day  favor  the  germ  theory.  Whatever  may 
be  the  special  form  of  these  specific  fever-poisons,  however,  investigations 
have  fully  established  the  important  fact  that  they  accumulate  and  mani- 
fest their  activity  in  the  production  of  fevers,  in  direct  ratio  to  the  accumu- 
lation of  animal  matter  and  excretions  in  poorly  ventilated  and  over- 
crowded dwellings,  narrow  streets  and  alleys,  cellai^s,  cesspools,  and  the 
moist  soil  of  yards  and  lots  around  dwellings,  whether  in  the  city  or  the 
country. 

Hence,  the  fevers  they  produce  are  found  wherever  the  population  by  itg 


CONTINUED    FEVERS.  63 

density  or  carelessness,  causes  the  accumulation  of  excrementitious  matters 
sufficient  to  contaminate  either  the  air  of  dwelling  houses,  or  -the  water 
furnished  for  domestic  use,  with  little  or  no  regard  to  latitude,  longitude, 
elevation  or  .geological  formations.  The  facts  I  have  just  stated  furnish 
the  basis  of  a  large  part  of  the  sanitary  improvements  of  modern  times. 
Practically,  it  matters  but  little  whether  we  know  the  identity  of  any  spe- 
cific fever-poison  or  not,  provided  we  gain  an  accurate  knowledge  of  the 
conditions  governing  its  production  and  the  laws  of  its  diffusion  ;  for  so 
far  as  such  conditions  are  under  human  control,  they  enable  us  to  limit  its 
evolution  and  spread  as  effectually  as  could  be  done  by  an  antidote  to  a 
known  poisonous  agent.  Concerning  the  three  remaining  fevers  in  this  group, 
namely,  yellow  fever,  erysipelas,  and  diphtheria,  each  appears  to  depend  on 
a  causation  peculiar  to  itself,  which  may  be  more  appropriately  considered 
in  connection  with  the  clinical  history  of  each  disease  than  at  the  present 
time.  Like  the  influenza  and  dengue,  they  prevail  chiefly  in  an  epidemic 
form,  attacking  large  numbers  in  a  community  within  a  limited  time  ;  but 
more  limited  in  their  topographical  range,  and  much  more  plainly  depend- 
ent on  the  direct  action  of  some  specific  infection. 

Definition  of  the  words  infection^  contagion.,  and  miasm. — As  the  words 
infection,  specific  infection,  contagion  or  contagium,  and  miasm,  will  neces- 
sarily be  frequently  used  when  speaking  of  the  causes  of  disease  through- 
out the  succeeding  lectures  of  this  course,  it  is  necessary  that  I  should  ex- 
plain the  meaning  of  each;  or  rather  the  sense  in  which  I  shall  use  them. 
It  is  the  more  necessary  that  1  should  do  this,  because  some  authors  and 
teachers  use  them  simply  as  synonyms,  freely  interchangeable;  while  others 
attach  a  definite  meaning  to  each,  and  yet  differ  much  in  defining  such  mean- 
ing. By  the  word  infection.,  I  mean  a  substance  or  materies  morbi  developed 
from  the  deteriorative  changes  in  animal  matter  and  animal  excretions  out- 
side of  the  living  body,  which  is  both  capable  of  perpetuating  and  propa- 
gating itself  where  the  atmospheric  impurities  and  other  local  conditions 
are  favorable,  and  also  of  producing  sickness  when  introduced  into  the 
living  body,  either  by  inhalation  with  the  air,  or  imbibition  with  food  and 
drink  ;  but  is  not  itself  re-produced,  at  least  not  in  an  active  form,  in  the 
living  bodies  of  those  laboring  under  the  disease  it  has  induced. 

While  the  agents  thus  called  infections  may  re-produce  and  perpetu- 
ate themselves  in  an  atmosphere  of  the  proper  temjDerature  and  containing 
the  necessary  impurities,  and  thereby  give  rise  to  the  prevalence  of  dis- 
eases of  an  epidemic  character  in  localities  to  which  they  have  been  trans- 
ferred in  connection  with  baggage,  articles  of  merchandise,  etc.,  they  are 
wholly  incajoable  of  doing  so  in  localities  where  such  temperature  and  im- 
purities do  not  exist.  By  a  specific  infection,  I  mean  one  developed  from 
S(mie  particular  animal  excretion  or  organic  matter  derived  from  patients 
laboring  under  some  form  of  disease,  and  which  is  capable  of  producing  the 
same  disease  in  other  parties  with  whom  it  may  come  in  contact.  For  in- 
stance, many  claim  that  there  is  in  the  discharges  from  the  alimentary  ca- 
nal of  patients  sick  with  typhoid  fever,  cholera,  etc.,  some  constituent,  which 
though  harmless  at  the  time  of  being  voided,  is  capable  of  development 
by  exposure  to  the  air  into  an  active  infection  that  may  produce  the  same 
diseases  in  other  parties  if  imbibed  either  with  the  air,  water  or  food.  You 
will  thus  perceive  that  an  infection  is  a  substance,  or  disease-producing 
agent,  developed  into  activity  outside  of  the  human  body  and  under  cer- 
tain local  conditions,  by  which  it  may  so  rapidly  multiply  or  propagate 
itself  as  to  infect  the  whole  atmosphere  of  cities  or  districts  of  country,  and 
attack  such  large  numbers  of  people  as  to  constitute  an  epidemic  of 
greater  or  lesser  severity. 


04  CONTINUED    FEVEES, 

By  contagion,  or  contagium,  I  mean  a  materies  morhi,  or  specific  poison 
developed'  in  the  body  of  the  sick,  which,  when  brought  in  contact  with 
another  unprotected  person,  will  produce  in  such  person  the  same  disease, 
thereby  communicating  a  particular  form  of  disease  from  individual  to 
individual  without  regard  to  local  conditions  of  any  kind.  For  instance, 
if  you  place  a  patient  affected  with  small-pox  or  measles  in  contact  with 
another  unprotected  individual,  in  any  atmosphere,  however  pure  and  at 
whatever  temperature,  the  person  so  exposed  will  imbibe  the  contagion, 
or  virus,  and  suffer  from  the  same  disease,  during  the  progress  of  which 
the  morbid  material  will  be  reproduced  in  quantity  sufficient  to  inoculate 
any  number  of  others  who  may  come  within  its  influence.  The  various 
contagiums  developed  in  the  bodies  of  those  laboring  under  the  acute 
general  diseases  to  which  they  give  rise,  may  escape  with  the  cutaneous 
and  pulmonary  exhalations  in  sufficient  quantity  to  impregnate  the  air 
immediately  around  the  patient,  and  may  communicate  the  same  form  of 
disease  to  those  who  may  be  brought  in  contact  with  such  air;  or  they  may 
be  communicated  by  inoculation  with  the  blood  or  with  the  virus  gathered 
from  sores  on  the  body  of  the  sick.  The  contagium  of  syphilis,  and  per- 
haps a  few  other  diseases,  does  not  appear  sufficiently  volatile  to  impreg- 
nate the  atmosphere  surrounding  the  patient,  and  consequently  is  commu- 
nicable only  by  inoculation  or  actual  contact.  All  contagions,  however,  are 
capable  of  becoming  attached  to  the  clothing  worn  by  the  sick,  and  with 
such  clothing  may  be  transported  in  trunks,  boxes,  etc.,  to  any  other  place, 
and  retain  sufficient  activity  to  communicate  disease  to  such  parties  as 
may  receive  them.  In  regard  to  portability  or  capability  of  being  trans- 
ferred from  place  to  place  in  confined  air,  contagiums  and  infections  are 
alike;  but  they  differ  entirely  in  their  mode  of  propagation.  The  conta- 
giums develop  only  in  the  bodies  of  those  sick,  and  spread  from  individual 
to  individual,  w^hile  the  infections  develop  outside  of  the  human  body  in 
air  containing  certain  impurities  and  at  favorable  temperatures,  and  they 
spread  disease  to  many  simultaneously  or  in  rapid  succession  through  an 
infection  or  poisoning  of  the  atmosphere  without  regard  to  personal  con- 
tact of  one  individual  with  another.  Small-pox,  measles,  and  scarlet  fever 
are  good  examples  of  diseases  produced  by  contagiums;  and  typhus,  plague, 
yellow  fever,  and  erysipelas,  of  those  produced  by  infections.  I  shall  use 
the  word  miasm  to  indicate  any  of  the  products  derived  from  the  decom- 
position of  organic  matter,  whether  animal  or  vegetable,  and  capable  of 
diffusion  in  the  atmosphere.  Those  derived  from  changes  in  animal  mat- 
ter and  animal  excretions  may  be  distinguished  as  idio-miasms,  and  those 
from  vegetable  matter  as  koino-miasras.  Of  course,  most  of  the  contagiums 
and  perhaps  all  of  the  infections  would  be  included  under  the  more  gene- 
ral term  miasm. 

FIRST  GROUP  OF  CONTINUED  FEVERS. 

Simple  Continued  or  Irritative  Fever. — Having  given  you  these 
preliminary  statements  and  definitions,  I  now  invite  your  attention  to  a 
consideration  of  the  most  simple  variety  of  acute  general  diseases,  called 
simple  fever,  irritative  fever,  or  febricula. 

History. — Cases  of  this  variety  of  fever  have  occurred  in  all  ages,  in  all 
climates,  and  among  all  classes  of  people.  This  is  owing  to  the  fact  that 
it  depends  upon  the  action  of  no  one  special  cause,  but  from  any  influence, 
mental  or  physical,  that  is  capable  of  producing  an  abrupt  and  active  dis- 
turbance of  the  properties  and  functions  of  the  system. 

Before  pathological  anatomy  had  made  sufficient  advancement  to  afford 


SYMPTOMS  AND  PEOGXOSIS.  65 

a  foundation  for  distinguishing  one  fever  from  another,  all  such  distinc- 
tions were  founded  entirely  on  the  symptoms  and  tendencies  as  observed 
at  the  bedside  of  the  sick. 

Those  presenting  the  most  active  and  quickly  developed  febrile  phe- 
nomena were  classed  under  the  head  of  Synocha.  Those  presenting  con- 
siderable activity,  yet  slower  in  development  and  of  longer  duration  were 
classed  under  the  word  Synochus.  And  those  of  the  low-est  type  tending 
in  their  progress  to  early  and  dangerous  prostration,  were  classed  as  Ty- 
phus. Under  this  arrangement  the  febricula  or  ephemeral  cases  of  fever 
were  included  with  those  called  Synocha.  But  as  pathological  anatomy 
became  more  generally  and  minutely  studied,  it  was  made  apparent  that 
the  more  protracted  cases  under  the  head  of  Synocha,  nearly  all  of  those 
clafSid  as  Synochus,  with  a  small  number  ranked  as  Typhus,  constituted 
but  one  form  of  fever  presenting  different  degrees  of  severity,  but  the  same 
general  course  and  attended  by  the  same  pathological  lesions.  Conse- 
quently they  were  placed  together  under  the  name  of  Typhoid  fever  ; 
w-hile  the  remaining  grave  cases  continued  to  be  called  Typhus.  Many 
have  carried  this  re-arrangement  so  far  as  to  omit  all  recoo-nition  of  sim- 
pie  continued  or  irritative  fever,  classing  all  the  cases  under  the  heads  of 
typhoid  and  typhus.  Such  is  the  case  in  the  works  of  Bartlett,  Ziemssen 
and  Bartholow.  In  doing  so,  however,  they  ignore  some  of  the  plainest 
facts  of  clinical  experience,  and  place  in  the  same  group  cases  essentially 
different  in  causation,  symptoms  and  pathological  results.  That  cases  of 
well  marked  general  fever  are  frequently  met  with,  which  arise  from  var- 
ious accidental  or  non-specific  causes,  run  a  brief  course,  and  almost  always 
terminate  in  recovery  without  any  special  or  characteristic  structural 
changes,  is  acknowledged  by  a  large  majority  of  writers  and  practitioners 
both  of  this  and  past  generations.*  If  we  include  these  cases  with  those 
classed  as  typhoid,  we  not  only  violate  the  principle  which  constitutes  the 
basis  of  all  classification,  by  grouping  under  one  head  cases  essentially 
dissimilar,  but  we  vitiate  all  the  statistics  of  typhoid  fever  proper,  both  in 
regard  to  the  effects  of  remedial  agents  and  the  ratio  of  mortality.  I  shall 
therefore  continue  to  maintain  the  distinctions  here  indicated,  and  give 
you  a  brief  statement  of  the  symptoms,  causes,  pathological  changes,  and 
irjatment  of  simple  fever. 

Symptoms  and  Progress. — This  form  of  fever  usually  com- 
mences abruptly,  without  any  marked  forming  or  prodromic  stage, 
and  in  most  instances  without  a  noticeable  chill.  In  a  small  proportion  of 
the  cases,  patients  have  complained  of  feelings  of  indisposition  or  lassi- 
tude one  or  two  days  ;  but  the  attack  is  generally  ushered  in  with  pains  in 
the  head,  back  and  limbs;  flushing  or  redness  of  the  face;  increased  heat 
and  dryness  of  the  skin;  a  thin  white  fur  on  the  tongue;  accelerated  and 
full  pulse;  respirations  more  frequent;  urine  less  in  quantity  and  deeper 
color  ;  bowels  inactive  ;  appetite  impaired  ;  considerable  thirst  and  gen- 
eral restlessness.  The  temperature  of  the  body  rises  rapidly,  generally 
reaching  its  climax  in  from  six  to  twenty-four  hours,  at  which  time  it  will 
range  between  40"  and  42^  C.  (102^  and  108°  F.) 

The  temperature  thus  reached,  and  the  assemblage  of  symptoms  enu- 
merated, may  continue  only  a  few  hours,  before  they  commence  notably 
to  abate  coincident  with  the  commencement  of  some  critical  evacuation 
occurring  either  spontaneously  or  induced  by  the  action  of  remedies.  In 
other  cases  they  may  continue,  with  but  little  change,  from  one  to  four  or 
five  days,  when  they  decline  rapidly,  accompanied  by  some  critical  evacu- 

*  See  Aitken's  Science  and  Practice  of  ^[edicine,  Part  I,  pages  560-562. 
0 


66  SIMPLE  COSTTINUED  FEVER. 

ations,  and  convalescence  is  established.  As  this  grade  of  fever  is  one  of 
pure  excitement,  caused  by  some  agent  or  influence  capable  of  exalting 
the  properties  of  the  tissues,  it  must  terminate  either  in  an  earl}^  convales- 
cence, or  in  the  establishment  of  some  local  inflammation,  or  in  such  decline 
in  the  activity  of  febrile  excitement  as  to  impart  a  more  typhoid  character 
to  all  the  symptoms.  It  appears  to  be  impossible,  from  the  nature  of  the 
elements  and  processes  involved,  that  a  fever  of  direct  excitement  or  ex- 
altation of  the  properties  of  living  structures,  such  as  I  have  just  described, 
should  continue  beyond  a  very  limited  period  of  time  without  undergoing 
one  of  these  three  changes  or  destroying  the  life  of  the  patient.  In  the 
great  majority  of  cases,  the  rapid  accumulation  of  the  products  of  tissue 
changes  in  the  blood  caused  by  the  general  diminution  of  the  secretory  and 
eliminative  functions,  so  far  diminishes  the  stimulant  influence  of  that 
fluid,  within  the  first  twenty-four  hours,  that  the  morbid  excitability 
begins  to  decline,  and  soon  reaches  a  point  favorable  for  the  resumption 
of  natural  molecular  changes,  when  the  skin,  kidneys,  and  pulmonary  sur- 
faces resume  active  eliminative  work,  and  the  fever  spontaneously  disap- 
pears. Such  a  result,  as  I  have  already  stated,  may  occur  at  any  time, 
from  three  hours  to  as  many  days;  and  is  often  hastened  by  the  patient's 
taking  freely  of  diluent  drinks,  and  bathing  the  head,  face,  and  hands  in 
cool  water.  When  this  favorable  change  does  not  happen,  by  the  third  or 
fourth  day,  the  lips  become  more  dry;  the  whole  countenance  more  dull; 
the  pains  in  the  head,  back,  and  limbs  less  acute;  the  pulse  softer  but 
more  frequent;  the  mind  more  dull,  and  sometimes  wandering;  the  mouth 
more  dry  and  tongue  more  thickly  coated  with  a  brownish  strip  along  the 
middle  line;  the  urine  remains  scanty;  and  the  bowels  inactive.  In  a 
word,  such  cases  begin  to  show  a  tendency  to  a  lower  grade  of  excite- 
ment, and  an  approximation  towards  the  typhoid  aspect.  Every  day  of 
further  continuance  makes  this  approximation  more  manifest;  especially 
•in  hot  climates,  or  in  the  summer  and  autumn  of  colder  ones,  until  before 
Ihe  end  of  the  second  week  the  whole  tongue  and  mouth  become  dry;  the 
temperature  from  40°  to  41°  C.  (102°  to  106°  F.);  skin. dry;  the  counte- 
nance more  dingy  and  dull;  mind  more  wandering;  and  the  abdomen 
moderately  tympanitic,  with  intestinal  discharges  of  a  thin,  brown  or  gray- 
ish color.  The  common  expression  of  the  attending  physician  is,  that  "the 
case  commenced  as  a  simple  fever  or  bilious  attack,  but  has  run  into  a 
typhoid  condition^  In  temperate  climates  nearly  all  of  these  cases  con- 
valesce before  the  middle  of  the  third  week;  but  in  warm  climates  they 
sometimes  terminate  fatally.  In  the  cold  season  of  the  year  some  of  the 
attacks  of  this  variety  of  fever  become  protracted  in  duration,  and  more 
dangerous,  by  an  early  supervention  of  catarrhal  inflammation  in  the  mu- 
cous membrane  of  the  bronchial  tubes,  not  unfrequently  extending  into 
isolated  lobules  of  the  lungs.* 

Pathological  Anatomy. — As  this  variety  of  fever  rarely  terminates 
fatally,  the  opportunities  for  postmortem  examinations  are  still  more  rare. 
In  the  few  instances  in  which  such  examinations  have  been  made,  the 
pathological  lesions  were  simply  such  as  had  resulted  from  local  compli- 
cations. 

Etiology. — As  I  have  already  remarked,  simple  irritative  fever  has  no  one 
specific  cause;  but  may  be  produced  by  the  action  of  any  cause  or  combina- 
tion of  causes  that  are  capable  of  inducmg,  either  directly  or  indirectly  an 
active  exaltation  or  increase  of  the  elementary  properties  and  functions 
of    the  system.      Careful  observation  has  shown  that    the  most  common 

*?=ee  Adrlress  of  Dr.  Wm  Pepper,  President  of  Section  on  Practical  Med.,  etc.  Transactions  of  tlie 
American  Medical  Association  for  1881. 


TREATMENT.  67 

caiisos  are  exposure  to  extreme  heat,  or  sudden  and  severe  chano-es  of  tem- 
perature; violent  mental  emotions  of  an  exciting  character,  such  as 
sudden  anger  or  great  joy;  and  the  use  of  irritating  ingesta,  as  indi- 
gestible food  and  stimulating  drinks.  A  large  majority  of  the  cases  of 
this  fever  occur  in  childhood  and  youtli,  and  are  chieflv  traceable  to 
the  two  first  named  causes.  Continuous  exposure  to  high  temperature, 
Avhen  not  accompanied  by  a  corresponding  increase  in  the  conversion 
of  free  into  latent  heat  by  active  eliminations  from  the  skin  and  air 
passage?,  causes  the  temperature  of  the  system  to  rise  rapidly  with 
increase  of  susceptibility  and  derangement  of  molecular  movements  in 
the  secreting  organs  and  tissues  generally,  thereby  establishino-  an  active 
febrile  excitement,  or  irritative  grade  of  fever,  with  all  its  usual  symptoms. 
Cases  arising  from  this  cause  are  common  in  India  and  other  tropical 
countries,  and  often  involve  such  sudden  and  extreme  rise  of  temperature 
with  so  great  an  interference  with  the  molecular  changes,  as  to  prove 
rapidly  fatal.  They  are  much  more  rare  in  the  temperate  and  colder 
regions,  but  even  here  cases  are  met  with  every  summer  during  the 
Avaves  of  high  atmospheric  temperature,  and  not  unfrequently  pass  under 
the  names  oi  sioi  fever  and  partial  sun-stroke.  But  in  our  climate  expos- 
ure to  sudden  and  extreme  changes  of  temperature,  by  which  the  elimina- 
tions from  the  skin  and  respiratory  surfaces  are  so  violently  interfered 
with  that  waste  material  of  irritative  quality  is  caused  to  rapidly  accumu- 
late in  the  blood  and  tissues,  where  it  directly  excites  the  properties  of  the 
whole  to  a  febrile  grade  of  activity,  is,  beyond  doubt,  the  most  common 
exciting  cause  of  simple  or  evanescent  fever.  That  sudden  and  severe 
mental  emotions  of  an  exciting  character,  are  capable  of  occasionally 
producing  so  decided  an  influence  over  the  vaso-motor  nervous  functions 
as  to  suddenly  check  secretory  and  eliminative  actions,  and  quicklv  in- 
duce well  marked  febrile  phenomena,  has  been  acknowledged  through  all 
periods  of  medical  history. 

TreatmeiU. — Whatever  may  have  been  the  cause  or  causes  giving  rise 
to  an  attack  of  this  variety  of  fever,  the  sudden  rise  of  temperature  coin- 
cident with  greatly  retarded  excretory  actions  and  consequent  rapid 
accumulation  of  effete  matters  in  the  blood  and  tissues,  which  uniformly 
characterize  it,  present  two  well  defined  indications  for  rational  treatment. 
These  are,  to  reduce  the  excess  of  heat,  and  restore  the  activity  of  the 
excretory  and  eliminative  functions.  If  these  are  successfulh'  accom- 
plished early  in  the  progress  of  any  given  case,  full  convalescence  follows 
and  no  further  treatment  is  needed.  But  in  all  the  more  protracted 
cases,  there  is  a  third  indication,  namely,  to  detect  and  efficiently  coun- 
teract, by  proper  means,  the  beginning  of  any  local  inflammatory  complica- 
tioi's.  It  is  true  that  many  of  the  attacks  of  simple  fever  terminate  spon- 
taneously without  the  aid  of  the  physician,  within  twenty-four  hours,  by 
simple  rest,  abstinence  from  food,  bathing  the  head,  face  and  arms  with 
water,  and  the  free  use  of  diluent  drinks.  It  is  also  true,  that  nearly  all 
of  the  attacks  would  t^riuinate  favorably  by  a  continuance  of  these  same 
simple  remedial  influences  for  several  days  in  succession.  It  is  neither  a 
legitimate  nor  logical  conclusion,  however,  that  because  a  disease  is  nat- 
urally limited  in  duration,  and  very  generally  tends  to  recovery  without 
the  interference  of  art,  therefore,  it  is  not  necessary  or  proper  for  the  phy- 
sician to  interpose  any  treatment.  On  the  contrary,  it  is  clearly  his  duty  to 
study  carefully  the  processes  by  which  nature  efl'ects  a  recovery  of  the  patient 
and  by  the  judicious  and  timely  use  of  such  remedies  as  Avill  aid  the  same 
processes,  not  only  hasten  their  work,  but  render  it  more  certain  and  com- 
plete. To  reduce  the  temperature  of  the  body  and  the  rapidity  of  the 
circulation  down    to   the  standard  favorable  for  the  resumption  of  ac-ivj 


6S  SIMPLE   COK^TINUEDFE TEE. 

secretory  and  elimlafitire  action,  is  tlie  first  stejD  in  the  treatmant.  This  is 
most  readil}^  and  fully  accomplished  by  frequent  sponging  of  the  whole 
surface  with  water  as  cold  as  is  comfortable  to  the  patient,  and  the  internal 
administration  of  some  cardiac  or  vascular  sedative  in  doses  sufficient  to  re- 
duce the  force  and  frequency  of  the  pulse  more  nearly  to  the  natural  standard. 
And  if  the  sedative  can  be  combined  with  some  agents  that  allay  rest- 
lessness and  promote  the  eliminations  from  the  skin  and  kidneys,  and  the 
patient  is  allowed  the  free  use  of  cold  water  for  drink,  the  rational  indica- 
tions for  treatment  will  be  more  fully  met.  For  the  purposes  just  mentioned 
I  have  long  used,  with  much  satisfaction,  the  following  coiubination: 
^       Spiritus  J3:heris  Xitrosi,  50.  c.c. — siss. 

Tincturse  Opii  Camphoratis,  50.  c.c. — iiss. 

Tincturse  Veratri  Viridis,  o.c.  c. — 3i' 

If  3-0U  give  to  an  adult  four  cubic  centimeters  or  an  ordinary  tea  spoon- 
ful in  a  tablespoonful  or  two  of  water,  every  two  or  three  hours,  according 
to  the  intensity  of  the  fever,  you  will  soon  reduce  the  pulse  to  70  or  75 
per  minute,  and  bring  on  general  perspiration,  with  soma  nausea.  As  sooi 
as  these  effects  are  obtained,  you  must  increase  the  interval  between  the 
doses,  aiming  to  so  graduate  the  effect  as  to  hold  the  febrile  action  in  check 
without  carrvino-  the  sedative  effect  of  the  veratrum  viride  far  enouo-h  to 
induce  vomiting. 

Similar  effects  may  be  obtained  by  the  efficient  administration  of  aconite 
and  gelsemiuum,  and  still  more  speedily  by  one  or  two  doses  of  propylamin 
sufficient  to  produce  its  free  sialagogue  and  diaphoretic  effect.  In  most  cases 
no  further  treatment  is  necessary;  the  fever  being  once  subdued  and  gen- 
eral secretory  action  restored,  does  not  return.  If  the  bowels,  however, 
should  be  slow  to  move,  evacuations  may  be  hastened  by  a  mild  saline  lax- 
ative. In  cases  where  the  fever  has  already  continued  twenty-four  hours 
or  more  before  the  physician  is  called,  and  he  finds  the  tongue  much  coated 
and  the  urinary  secretion  very  scanty  and  high  colored,  much  advantage 
may  be  gained  by  giving  at  the  beginning  of  the  treatment,  in  addition  to 
the  frequent  spongings  and  arterial  sedatives,  one  or  two  powders,  each 
containing  nitrate  of  potass,  pulverized,  five  decigrams  (gr.  viii.)  and  calo- 
mel two  decigrams  (gr.  iii.)  rubbed  together  with  a  little  sugar,  and  follow- 
ing in  about  four  hours  with  a  saline  laxative  sufficient  to  cause  two  or 
three  intestinal  evacuations.  But  the  free  use  of  emetics  and  cathartics  at  the 
commencement  of  attacks  of  irritative  fever,  before  the  temperature  and 
high  excitability^  of  the  tissues  have  been  modified  by  the  antipyretic  use 
of  water  externally,  aided  b^'  internal  sedatives,  as  was  customary  in  former 
times,  and  is  still  recommended  by  some  writers,  is  productive  of  more 
harm  than  good.  The  active  determination  they  cause  towards  the  gastric 
and  intestinal  mucous  membranes  often  aids  directly  the  establishment  of 
such  a  degree  of  local  hyperesthesia  as  to  both  protract  the  duration  of 
the  fever,  and  increase  its  disposition  to  assume  a  typhoid  character.  M3' 
own  observations  have  served  to  sustain  the  remark  of  Dr.  Eberle  in  his 
work  on  practical  medicine,  which  was  a  text  boolc  nearly  half  a  century 
since,  to  the  effect  that  he  had  never  seen  a  case  of  simple  continued  fever 
in  which  an  active  emetic  had  been  administered  at  the  beginning  of  the 
attack,  that  reached  final  convalescence  in  less  than  three  weeks.  When 
local  inflammatory  complications  exist  in  connection  with  this  variety  of 
fever,  they  must  be  treated  on  the  same  principle,  and  with  the  same  reme- 
dies as  would  be  required  for  the  same  grade  of  inflammation  unassociated 
with  a  general  fever.  As  the  duration  of  cases  of  simple  fever  under  ju- 
dicious management  is  generally  very  brief,  the  period  of  convalescence  is 
also  short,  and  attended  by  no  special  sequalae. 


INFLUENZA    AND    DENGUE.  69 


LECTUEE  IX. 

Influenza— Its  History,  Symptoms,  Causes,  Prognosis  and  Treatment ;  Dengue— Its  History,  Symp- 
toms, Causes,  Prognosis  and  Treatment. 

GENTLEMEN  :  The  disease  to  which  I  shall  call  your  attention  first 
at  this  hour,  is  known  under  various  names,  as  Influenza,  Epidemic  Brou- 
ciiitis.  Epidemic  Catarrh,  LaGrippe,  etc.  The  first,  which  is  of  Italian  origin, 
I  shall  adopt  as  the  most  familiar  to  the  profession.  Influenza  is  a  general  fe- 
brile disease  usually  abrupt  in  its  access,  irritative  in  its  grade  of  activity,  of 
brief  duration,  but  pretty  unifoimly  accompanied  by  a  grade  of  inflamma- 
tory action  in  the  mucous  membrane  of  the  respiratory  passages. 

Hiatory. — This  disease  has  frequently  prevailed  in  an  epidemic  form, 
and  was  pretty  accurately  described  as  early  as  the  tenth  century.  Itspe- 
riods  of  epidemic  prevalence  have  been  remarkable  for  the  rapidity  of 
their  progress,  the  wide  extent  of  territory  over  which  they  pass,  and  the 
great  numbers  of  people  attacked.  It  has  several  times  prevailed  over 
nearly  all  the  countries  of  Europe  and  Asia.*  Perhaps  the  most  noted  peri- 
ods of  its  prevalence  in  this  country  were  in  1761-2, 1775, 1807, 1831-3, 1847, 
1857  and  1872-4, — at  which  times  it  not  only  extended  its  prevalence  overall 
the  inhabited  parts  of  this  continent,  but  also  over  the  greater  part  of  Europe 
and  Asia.  The  disease  has  generally  been  represented  as  originating  in 
the  northern  part  of  Asia,  and  spreading  from  thence  to  the  southeast  over 
Europe  and  crossing  the  Atlantic  to  America.  For  instance,  the  great 
epidemic  of  1761-2,  is  by  most  writers  described  as  having  originated  in 
Chinese  Tartary,  from  whence  it  spread  over  Russia,  Germany,  Holland 
and  the  British  Islands  ;  and  from  the  latter  southward  through  France  and 
Italy,  to  the  Mediterranean,  and  westward  across  the  Atlantic  to  America, 
which  it  is  rejDresented  to  have  reached  in   October,  1762. 

(.)n  the  other  hand,  however,  Noah  Webster,  in  his  '•'  Brief  History  of 
Epidemic  and  Pestilential  Diseases,"  published  in  London,  1800,  describes 
the  disease  as  extensively  prevalent  in  America  during  the  year  1761,  and 
as  passing  from  thence  to  Europe  in  1762.  The  same  writer  claims  that 
the  disease  passed  from  America  to  Europe  in  three  other  important  epi- 
demics, i.  e.  1698,  1757,  1781.  The  truth  is,  gentlemen,  that  a  careful  ex- 
amination of  the  best  accounts  of  a  large  number  of  the  important  epi- 
demics of  influenza,  shows  no  uniformity  whatever,  either  as  to  their  place 
of  origin,  direction  and  the  extent  of  their  spread,  or  the  rate  of  their  pro- 
gress. The  writers  of  each  country  that  it  invades,  attribute  its  origin  to  some 
neighboring  country  ;  while  in  dift'erent  epidemics  the  spread  has  been  in 
opposite  directions. 

As  I  have  just  stated,  that  of  1762  first  appeared  at  the  northeast  of 
Europe  in  February,  London  in  April,  and  France  in  July;  while  that  of 
1775  was  first  noticed  in  Italy,  from  whence  it  appeared  to  extend  directly 
northward  until  it  reached  the  north  of  Europe;  and  in  the  epidemic  of  1847, 
it  was  prevailing  simultaneously  at  Copenhagen,  London  and  Marsailles. 
Indeed  one  writer  who  claimed  to  have  examined  the  histories  of  all  the 
noted  epidemics  of  this  disease  for  the  three  last  centuries,  came  to  the 
conclusion  that  the  general  course  of  spread  was  from  the  west  to  the  east. 

*  See  Aitken's  Science  and  Practice  of  Medicine,  p.  706. 


70  INFLUENZA. 

The  rapidity  of  its  progress,  or  more  properly,  the  length  of  time  be- 
tween its  appearance  in  one  section  of  a  country  and  another  more  or  less 
distant,  is  very  variable.  Thus  the  epidemic  of  1762,  had  invaded  nearly  the 
whole  of  EurojDe  during  the  first  six  months  of  the  year;  that  of  1830-1- 
2  occupied  more  than  eight  months  to  extend  from  St.  Petersburg  to  the 
south  line  of  Germany;  while  that  of  1847  made  its  appearance  in  all  parts 
of  Europe  within  the  short  period  of  six  weeks.  The  great  epidemics  of 
influenza  to  which  I  have  thus  far  alluded,  have  occurred  at  periods  of  time 
varying  from  ten  to  fifty  years;  and  have  differed  much,  both  in  regard  to 
the  number  of  persons  attacked  and  the  severity  of  the  disease.  They 
have  also  occurred  at  all  seasons  of  the  year,  and  in  all  parts  of  the  globe, 
not  omitting  the  islands  of  the  ocean. 

Syinptoms. — As  a  general  rule  the  attacks  of  influenza  are  sudden  and 
without  any  forming  or  premonitory  stage.  The  first  noticeable  feelings 
of  illness  are  generally  coldness,  varying  in  degree  from  simple  rigors  or 
sensations  of  coldness  in  the  back  and  limbs  to  a  severe  chill  of  half  an 
hour  in  duration.  This  is  accompanied  by  feelings  of  depression,  shrink- 
ing and  paleness  of  the  surface,  variableness  of  respiration  and  pulse,  with 
dull  pains  in  the  head,  back  and  limbs.  This  stage  soon  gives  place  to  a 
steady  and  continuous  grade  of  fever,  characterized  by  heat  and  dryness 
of  the  skin,  some  redness  of  the  face,  congestion  of  the  vessels  of  the  con- 
junctiva, moderate  fullness  and  frequency  of  the  pulse,  some  thirst,  with 
little  or  no  relish  for  food,  bowels  inactive,  urine  diminished  in  quantity  but 
deeper  color,  and  severe  pains  in  the  head,  especially  through  the  frontal, 
^lemporal,  and  orbital  regions,  with  some  pain  in  the  back  and  limbs.  Gen- 
erally, within  twenty-four  hours  from  the  beginning  of  the  attack,  the  mu- 
cous membrane  of  the  respiratory  passages  becomes  severely  congested, 
causing  coryza,  copious  thin  secreiion  from  the  nostrils,  some  soreness  in 
the  fauces,  hoarseness,  harsh  cough,  with  a  sense  of  tightness  or  constric- 
tion in  the  chest,  and  great  sense  of  weakness.  You  have  thus  all  the 
symptoms  of  a  moderate  grade  of  general  irritative  fever  associated  with 
acute  catarrhal  inflammation  of  the  membrane  lining  the  nostrils,  fauces, 
pharynx,  trachea,  larger  bronchial  tubes,  and  sometimes  the  frontal  and 
maxillary  sinuses.  The  symptoms  usually  reach  the  climax  of  severity  dur- 
ing the  second  day,  and  continue  with  but  little  change  in  their  general 
character  from  three  to  seven  days,  terminating  in  either  a  profuse  sweat 
or  a  temporary  diarrhoea,  most  frequently  the  former.  With  these  appar- 
ently critical  evacuations  the  general  febrile  symptoms  disappear,  and  the 
local  catarrhal  irritations  soon  follow,  leaving  the  patient  fully  convales- 
cent, but  weak.  Although  the  pyrexia  in  this  disease  is  continuous,  it 
varies  much  in  intensity  in  different  epidemics,  and  in  different  cases  oc- 
curing  in  the  same  epidemic.  The  temperature  ranges  from  38°  to  40°  C 
(101°  to  104°  F.),  and  may  vary  from  one  to  two  degrees  during  the  same 
twenty-four  hours  ;  the  exacerbation  generally  taking  place  in  the  even- 
ing. 

The  discharge  that  takes  place  from  the  nostrils  and  from  the  membrane 
lining  the  fauces  and  bronchial  tubes,  is,  in  the  early  stage,  thin  and  gen- 
erally copious,  but  after  the  third  day  it  becomes  more  opaque,  less  in 
quantity,  and  more  easily  dislodged.  In  the  most  severe  class  of  cases  the 
catarrhal  inflammation  extends  to  the  membranes  lining  the  frontal  sinuses 
and  antrums,  not  only  adding  much  to  the  pains  in  the  head  and  face,  but 
sometimes  causing,  in  the  advanced  stage,  sudden  and  copious  discharges 
of  a  yellowish  serum,  or  muco-purulent  fluid  through  the  nostrils.  The 
symptoms  and  progress  of  the  disease,  as  I  have  detailed  them  to  you,  cor- 
respond with  my  personal  observations  during  the  severe  epidemics  of 


PROGNOSIS.  71 

1847,  1857  and  1S72-3.  Sporadic  cases  of  influenza,  presentinf^  all  the 
more  characteristic  symptoms  that  I  have  enumerated,  are  met  with  during 
the  cold  seasons  of  every  year.  They  are  most  frequently  seen  during  the 
first  one  or  two  mild  days  following  a  protracted  period  of  severe  cold. 

Prof/nosis. — The  disease  varies  much  in  its  severity  in  different  epidem- 
ics, and  in  difterent  cases  occurring  in  the  same  epidemic.  As  a  general 
rule,  its  prevalence  is  attended  by  only  a  small  ratio  of  mortality.  Most  of 
the  fatal  cases  occur  in  infancy  or  early  childhood,  and  in  old  age  ;  and  are 
largely  due  to  the  supervention  of  pneumonia,  pleurisy,  or  capillary  bron- 
chitis. And  yet  most  Avriters  claim  that  its  prevalence  increases  the  fatal- 
ity of  consumption  and  other  diseases  accompanied  by  exhaustion,  to  such 
an  extent,  that  the  years  of  its  epidemic  prevalence  are  accompanied  by  a 
general  ratio  of  mortality  above  the  average. 

Pathological  A)iatomy. — Though  the  disease  generally  completes  its 
course  in  from  three  to  seven  days,  and  ends  in  the  recovery  of  the  pa- 
tient, yet,  in  all  the  more  severe  epidemics  a  sufficient  number  of  fatal 
cases  "have  occurred  to  afford  ample  opportunities  for  post  mortem  exam- 
inations. The  only  important  pathological  changes  noticed  have  been 
those  of  intense  injection  of  the  vessels  of  the  mucous  membrane  lining 
the  nostrils,  pharynx,  trachea,  and  larger  bronchial  tubes,  causing  redness 
and  tumefaction  of  the  membrane  as  in  other  cases  of  inflammation.  So 
far  the  pathological  changes  belong  to  the  disease  and  correspond  with  the 
severe  catarrhal  symptoms  which  constitute  a  part  of  the  clinical  history 
of  each  case.  But  most  of  the  post  mortems  have  also  proved  the  exist- 
ence of  pneumonic  congestion  and  hepatization,  and  a  few  have  revealed 
app3aranees  of  active  inflammation  in  the  mucous  membrane  of  the  ilium 
and  colon.  These,  however,  are  properly  regarded  as  complications,  very 
liable  to  occur  in  patients  at  either  extreme  of  life — infancy  or  old  age. 

Etiology. — The  causes  of  influenza  have  not  been  reliably  ascertained. 
The  suddenness  with  which  the  disease  is  developed  in  an  epidemic  form, 
the  great  extent  of  territory  over  which  it  prevads,  and  the  large  number 
of  persons  simultaneously  attacked,  render  it  highly  probable  that  its  effi- 
cient cause  or  causes  exist  in  the  atmosphere.  It  is  not  a  contagion  devel- 
oped in  the  bodies  of  the  sick;  and  there  is  no  evidence  that  it  is  ever 
communicated  from  one  individual  to  another.  At  an  early  period.  Dr. 
J.  K.  Mitchell,  of  Philadelphia,  suggested  that  it  originated  from  minute 
cryptogamic  bodies  diffused  in  the  air.  In  1868,  Dr.  J.  H.  Salsbury,  of 
Cleveland,  published  a  paper  claiming  the  discovery  of  a  species  of  infu- 
sorium in  the  nasal  discharges  of  a  considerable  number  of  cases  of  this 
disease,  and  which  he  regarded  as  the  exciting  or  essential  cause.  Other 
microscopists,  however,  have  not  confirmed  the  correctness  of  his  observ- 
ations. 

Schonbein,  after  discovering  the  existence  of  ozone  in  the  atmosphere, 
and  testing  its  irritating  effects  on  the  mucous  membrane  of  the  air  pas- 
sages, claimed  with  much  confidence  that  epidemics  of  influenza  were 
caused  by  an  excess  of  atmospheric  ozone.  Nearly  all  the  older  writers 
attributed  the  disease  to  sudden  and  violent  changes  in  the  temperature, 
moisture  and  electric  conditions  of  the  atmosphere.  On  the  other  hand,  in 
nearly  all  the  more  recent  medical  works,  it  is  merely  suggested  that  the 
theory  of  organic  germs  will  most  easily  explain  the  phenomena  presented 
by  the  history  and  symptoms  of  the  disease,  accompanied,  however,  by  the 
frank  confession  that  there  are  not  a  sufficient  number  of  well  established 
facts  to  justify  an  inference  as  to  the  efficient  cause  or  causes  of  the  dis- 
ease. I  am  not  able  to  see  how  the  theory  of  organic  germs  affords  any 
more  rational  explanation  of  the  origin  and  prevalence  of  the  disease  than 
any  of  the  other  hypotheses. 


72  INFLUENZA. 

It  must  indeed  be,  not  only  a  remarkably  accommodating,  but  really 
ubiquitous  kind  of  organic  germ  that  could  in  one  epidemic  propagate  and 
difi'ase  itself  over  the  whole  of  Europe,  from  the  Mediterranean  Sea  to  the 
north  of  Russia  in  six  weeks;  or  over  our  own  country  from  the  Atlantic 
border  to  the  Rocky  Mountains,  and  from  the  St.  Lawrence  to  the  Gulf  of 
Mexico  in  the  same  length  of  time  ;  and  in  another  be  six  weeks  in  ex- 
tending from  London  to  Edinburgh,  six  months  in  extending  from  Moscow 
to  Vienna,  and  two  years  in  reaching  over  both  Europe  and  America.  Or 
that  could  propagate  itself  and  manifest  its  ravages  almost  simultaneously 
in  all  the  latitudes  or  varieties  of  climate,  soil  and  meteorological  condi- 
tions between  the  equator  and  the  poles.  All  we  know  of  organic  germs 
would  tend  to  place  them  in  the  same  relations  as  living  bodies  of  larger 
size,  which  we  well  know  are  propagated  and  spread,  only  under  certain 
pretty  uniform  conditions,  and  in  accordance  with  fixed  laws. 

From  many  years  of  observation,  coupled  with  the  well  established  fact 
that  cases  of  sporadic  influenza,  presenting  almost  every  symptom  of  the 
cases  of  epidemic  disease,  occur  every  year  during  the  first  forty-eight 
hours  of  warm  atmosphere  following  a  protracted  period  of  intense  cold,  I 
am  strongly  inclined  to  the  opinion  that  the  efficient  causes  of  influenza 
consist  in  such  sudden  and  extreme  atmospheric  changes  as  are  capable  of 
producing  correspondingly  severe  disturbances  of  the  elementary  proper- 
ties and  molecular  movements  of  living  structures.  I  am  the  more  inclined 
to  this  view  from  the  additional  fact,  that  the  epidemic  influenza  sometimes 
attacks  the  horses,  dogs,  and  other  domestic  animals,  as  severely  and  ex- 
tensively, as  it  does  the  human  species.  This  was  true  of  the  remarkable 
epidemic  that  occurred  in  our  country  in  the  autumn  of  1872.  But  this, 
like  many  other  questions  in  etiology,  will  not  be  settled  satisfactorily,  un- 
til continuous  and  reliable  records  concerning  all  appreciable  atmospheric 
conditions  are  kept,  on  a  uniform  plan,  in  many  places,  through  a  series 
of  thirty  or  forty  years,  thereby  furnishing  all  the  data  for  comparing  sev- 
eral epidemic  seasons  with  the  non-epidemic  ones  that  precede  and  follow, 
in  a  sufficient  variety  of  places  to  avoid  mere  coincidences.  Here,  gentle- 
men, is  legitimate  and  very  important  work  for  medical  society  organiza- 
tions, that  you  will  do  well  to  remember  after  you  have  entered  tipon  the 
active  duties  of  your  profession. 

Diagnosis. — This  form  of  general  acute  disease  is  readily  distinguished 
from  all  the  other  members  of  the  class,  by  the  suddenness  of  its  access, 
its  moderate  and  brief  period  of  pyrexia,  and  the  pretty  uniform  associa- 
tion of  these,  with  the  marked  and  severe  catarrhal  or  inflammatory  symp- 
toms manifested  in  the  air  passages. 

Treatment. — As  nothing  is  positively  known  concerning  the  efficient 
cause  or  causes  of  the  disease  under  consideration,  our  indications  for 
treatment  must  be  founded  solely  upon  the  actual  pathological  conditions 
presented  by  the  patient  at  the  time  he  comes  under  the  care  of  the  phy- 
sician, and  the  known  tendencies  of  the  disease.  When  the  physician 
arrives  at  the  bedside  of  the  patient,  the  initial  chilliness  has  ceased,  and 
he  finds  a  moderate  general  fever,  accompanied  by  diminished  eliminations 
from  the  skin  and  kidneys,  severe  headache,  and  an  actively  congested 
condition  of  the  membrane  lining  the  nostrils,  trachea  and  bronchial  tubes, 
clearly  indicating  the  need  of  such  remedial  measures  as  will  lessen  the 
pyrexia,  relieve  the  pains,  actively  promote  all  the  important  excretory 
functions,  and  diminish  the  congestion  of  the  mucous  membrane  of  the 
respiratory  passages.  While  these  four  objects  or  indications  for  imme- 
diate treatment  are  plainly  presented  hy  the  existing  pathological  condi- 
tions of  the    patient,  you    must   remember  the  known   tendency  of  the 


TREATMENT.  73 

clise  se  t)  undue  del>ility,  or  impairment  of  the  nervous  and  muscular 
functions,  and  tlie  frequent  supervention  of  capillary  bronchitis,  lobular 
pneumonia  and  pleurisy,  as  important  complications.  The  former  should 
caution  us  against  resorting  to  measures  for  subduing  the  pyrexia,  of  too 
actively  sedative  or  depletive  character,  and  the  laiter  should  keep  us 
alert  or  watchful  for  the  earliest  symptoms  that  may  indicate  their  exist- 
ence, thit  prompt  measures  may  be  adopced  for  their  relief.  If  you  thus 
comprehend  definitely  the  special  objects  to  be  accomplished  by  thera- 
peutic agencies,  you  will  readily  select  from  the  ample  stores  of  the  mate- 
ria medica  a  variety  of  agents  more  or  less  accurately  adapted  to  accom- 
plish your  purposes.  In  my  own  practice  I  have  found  the  following 
outline  of  treatment  more  satisfactory  in  its  results  than  any  other.  When 
called  during  the  first  or  second  day  to  cases  of  ordinary  severity,  I  have 
generally  ordered  from  four  to  six  powders,  composed  of  Dover's 
powder  and  nitrate  of  potassa,  each  five  decigrams  (gr.  viii),  and  calomel 
one  decigram  (gr.  iss  ),  one  to  be  taken  every  four  hours.  Also  the  fol- 
lowing: 

3       Potassii  Broraidi  20  gm.  3v 

Svrupi  Scillse  Compositi  45  c.  c.  ffiss 

Syrupi  Ipecacuanhne  15  c.  c.         ffss 

Tincturte  Opii  Camphoratis,  00  c.  c.         ff  ii 

Mix,  and  give  four  cubic  centimetres,  or  one  ordinary  teaspoonful, 
mixed  with  a  tablespoonful  of  water  half  way  between  the  powders.  If 
the  attack  is  severe,  the  pulse  active  and  moderately  firm  under  pressure, 
and  the  temperature  under  the  tongue  39°  C  (102°  to  103°  F.)  or  higher.  I 
add  to  the  formu'ae  just  given  from  four  to  six  cubic  centimetres  (ji  to  3iss)  of 
the  tincture  of  veratrum  viride,  and  bathe  the  head,  face  and  hands,  and 
sometimes  the  whole  cutaneous  surface,  frequently  with  slightly  warm 
water.  The  continuance  of  these  remedial  measures  for  twenty-four 
hours,  usually  relieves  the  severe  cephalalgia  and  restlessness,  reduces  the 
temperature,  and  develops  a  pretty  free  action  of  the  skin  and  kidneys, 
with  less  cough  and  tightness  in  the  chest.  I  now  omit  the  further  use  of 
the  powders,  and  follow  them  by  a  laxative  sufficient  to  procure  from  one 
to  three  intestinal  evacuations.  The  liquid  mixture,  however,  may  be 
continued  in  such  doses  as  the  stomach  will  bear  without  nausea,  so  long 
as  the  cough  and  catarrhal  symptoms  continue  troublesome  to  the  patient. 
After  the  bowels  have  been  moved,  I  have  not  generally  found  it  neces- 
sary to  give,  in  addition  to  the  anodyne  and  expectorant  mixture  just 
named,  anything  more  than  from  two  to  three  decigrams  (gr.  iii  to  v)  of 
sulphate  of  quinia  each  mornina:  and  evening-,  and  a  fair  anicjuTit  of  plain 
fool.  Patients  have  generally  convalesced  in  from  three  to  five  days,  and 
have  rarely  presented  any  of  the  more  serious  pulmonary  complications. 
In  some  instances,  however,  mostly  in  persons  beyond  the  middle  period 
of  life,  there  has  appeared  after  the  second  day  such  a  degree  of  general 
weakness,  that  I  have  substituted  in  place  of  the  mixture  containing 
squills,  ipecac,  etc.,  a  combination  of  syrup  of  senega,  fluid  extract  of 
asclepias  tuberosa,  and  camphorated  tincture  of  opium,  equal  quantities  of 
each,  of  which  4  cubic  centimetres,  or  a  teaspoonful  was  given  every  four 
hours,  alternately,  with  one  to  two  decigrams  (gr.  iss  to  iii)  of  sulphate 
of  quinia  in  solution  with  aromatic  sulphuric  acid  0.6  cubic  centimetres 
(10  minims). 

Many  mild  cases  have  been  apparently  cut  short  or  aborted  by  giving  at 
night  a  single  powder  containing  from  four  to  six  decigrams  (gr.  vi  to  x) 
of  Dover's  powder,  the  same  quantity  of  sulphate  of  quinia,  and  two  to  three 
decigrams  (gr.  iii  to  v)  of  calo.nel,  following  it  by  a  laxative  in  the  morning 


74  DENGUE. 

and  2  decigraras  (gr.  iii)  of  quinia  two  or  three  times  a  day  for  three  or 
four  subsequent  days. 

It  is  probable  that  the  same  results  would  be  obtained  by  giving  one 
fair  diaphoretic  dose  of  pilocarpin  in  the  evening  and  following  it  with 
moderate  doses  of  quinia  three  times  a  day  until  the  convalescence  was 
well  established. 

All  patients  should  be  required  to  take  much  rest,  plain,  but  nutritious 
food,  and  good  air,  during  the  period  of  convalescence,  and  until  their 
strength  is  well  restored.  Such  cases  as  present  important  inflammatory 
complications  in  the  pulmonary  or  other  internal  organs,  must  be  treated 
on  the  same  principles  that  govern  the  treatment  of  such  inflammations 
under  other  circumstances. 

DENGUE,  OR  BREAK-BONE  FEVER. 

History. — The  acute  general  febrile  disease  described  by  most  recent 
■writers,  under  the  name  of  Dengut.,  has  been  recognized  as  a  distinct 
variety  of  fever  only  in  modern  times.  It  is  probable,  however,  that 
epidemics  of  this  disease  have  occurred  at  longer  or^  shorter  intervals, 
from  a  remote  period  of  human  history. 

Some  of  them  have  been  described  under  the  names  of  miliary  fever, 
break-bone  fever,  scarlatina  rheumatica,  dandy-fever,  etc.  The  word 
Dengue.,  adopted  by  most  recent  writers,  appears  to  have  no  special  mean- 
ing; and  is  supposed  to  have  been  derived  from  the  fanciful  name 
"(^««f?y/,"  which  had  been  popularly  applied  to  the  fever  in  some  places  on 
account  of  a  peculiarly  stiff  manner  exhibited  by  patients  in  attempting 
to  walk.  Like  the  influenza  which  I  have  just  been  discussing,  dengue 
seldom  prevails  except  in  an  epidemic  form,  and  then  almost  always  in 
warm  climates  embraced  in  the  tropical,  and  southern  half  of  the  temperate 
zone.  It  was  described  by  Dr.  Rush  as  prevailing  in  Philadelphia  in 
1780,  under  the  name  of  break-bone  fever.  It  has  frequently  prevailed 
extensively  throughout  the  East  and  West  India  Islands;  in  the  southern 
part  of  Asia,  Egypt,  along  the  boiders  of  the  Mediterranean  sea,  and  the 
southern  half  of  our  own  country.  The  most  noted  epidemics  of  which 
we  have  full  and  accurate  histories  occurred  in  the  Southern  States  in 
1828  and  1850.  The  first  was  fully  described  by  that  distinguished 
scholar  and  eminent  medical  teacher,  Dr.  S.  H.  Dickson,  then  of 
Charleston,  S.  C,  and  the  second  by  Drs.  Dickson  and  "VVragg,  of  Charleston, 
Dr.  H.  F.  Campbell,  of  Augusta,  Ga.,  and  Dr.  E.  D.  Fenner,  of  New  Orleans. 
You  can  find  a  pretty  full  and  interesting  abstract  of  the  views  of  these 
respective  writers  in  the  report  on  Practical  Medicine  to  the  American 
Medical  Association  in  1851,  by  Dr.  Austin  Flint,  chairman  of  the  com- 
mittee, and  in  the  paper  appended  to  that  rejDort.* 

Since  the  notable  epidemic  of  1850,  the  disease  has  repeatedly  prevailed 
over  more  limited  sections  of  country,  chiefly  in  the  West  Indies  and  in 
the  States  bordering  on  the  Atlantic  and  Gulf  coasts,  but  sometimes  as  far 
north  as  the  Ohio  river.  It  not  only  prevails  chiefly  in  warm  climates,  but 
also  in  the  warm  season  of  the  year.  It  appears  that  its  prevalence  is  fa- 
vored by  the  same  circumstances  that  favor  the  development  of  malarious 
or  periodical  fevers  ;  and  several  writers  have  noted  the  fact  that  it  has 
often,  either  immediately  preceded  or  followed  an  epidemic  of  yellow  fe- 
ver. 

When  the  disease   prevails  in  any  community  it  generally  attacks  large 

*  See  Transactions  of  the  Araetican  Medical  Association,  Vol.  4,  from  p.  173  to  225,  1851. 


SYMPTOMS.  75 

numbers  in  proportion  to  the  poru'ation,  and  so  nearly  simultaneously,  that 
all  must  hav^e  been  influenced  by  a  common  cause.  The  entire  duration  of 
the  epidemic  in  Charleston,  S.  C.  in  Aug-ust  and  September,  1850,  was 
about  six  weeks.  During  the  first  four  of  these  weeks,  not  less  than  seven- 
tenths  of  the  entire  population  of  the  city  were  attacked,  and  Dr.  Wragg 
estimates  that  more  than  10,000  were  sick  at  one  time.  This  wOuld  be 
one-fouith  of  the  whole  population.  It  appears  to  attack  indiscriminately 
all  ages  and  both  sexes.  Perhaps  the  colored  part  of  the  population  was 
less  susceptible  than  the  white. 

iSi/mptorns  and  Progress. — In  some  cases  the  commencement  of  active 
febrile  symptoms,  is  preceded  for  one  or  two  days  by  some  obscure  feel- 
ings of  indisposition,  as  general  lassitude,  dull  pains  in  various  parts  of  the 
body,  sensitiveness  to  cold  or  heat,  and  depression  of  mind. 

But  in  the  larger  proportion  of  cases  the  attack  is  abrupt,  and  attended 
with  chilliness,  but  not  a  full  chill  ;  severe  pains  in  the  head,  back  and 
joints,  especially  those  of  the  extremities  ;  intolerance  of  lig-ht  and  sound; 
skin  hot  and  dry,  face  flushed,  and  tongue  coated  with  a  white  fur.  In  a 
few  hours  the  fever  reaches  its  climax,  when  the  face  and  head  feel  hot 
and  excessively  painful;  the  articular  pains  change  rapidly  from  one  joint  to 
another,  not  omitting  the  smaller  joints  of  the  fingers  and  toes;  the  pulse  firm 
and  frec^uent;  great  restlessness,  and  sometimes  severe  vomiting  of  bilious 
matter,  the  bowels  being  generally  inactive.  This  grade  of  active  fever 
usually  continues  from  two  to  four  days,  when  a  marked  remission  super- 
venes, during  which  all  the  more  severe  symptoms  subside,  leaving  only 
slight  acceleration  of  pulse,  and  some  stiffness  and  soreness  in  the  mus- 
cles of  the  lower  extremities. 

This  remission  may  last  from  twelve  hours  to  two  days,  when  nearly  all 
the  active  febrile  symptoms  return,  but  with  a  little  less  severity  than  at 
first.  The  joints,  however,  become  more  red  and  swollen,  and  in  almost  all 
cases  an  eruption  appears  on  the  skin.  It  most  frec[uently  begins  in  the 
palms  of  the  hands  and  soles  of  the  feet,  as  an  exanthematous  eruption, 
and  from  those  parts  extends  over  the  whole  body,  accompanied  by  much 
heat  and  itching,  which  added  to  ihe  pains  in  the  joints  and  muscular  sore- 
ness, causes  much  restlessness  and  loss  of  sleep.  The  charact'  r  of  the  erup- 
tion varies  much,  in  some  cases  resembling  erythema,  in  others  roseola,  and 
in  others  lichen.  It  also  varies  much  in  amount,  being  in  some  cases  only 
slight  or  altogether  absent.  It  varies  also  in  the  time  of  its  appearance, 
being  sometimes  manifested  before  the  remission  instead  of  coincident 
with  the  second  accessor  relapse,  as  some  writers  have  styled  it.  The  sec- 
ond paroxysm  of  fever  usually  continues  three  days,  but  in  some  cases 
ends  in  forty-eight  hours;  while  in  others  it  has  been  protracted  to  four  or 
five  days.  It  pretty  uniformly  ends  with  a  critical  evacuation.  This  gen- 
erally cotisists  of  a  free  diaphoresis,  but  sometimes  takes  the  form  of  copi- 
ous renal  or  intestinal  evacuations.  You  will  see  that  the  whole  course  of 
the  disease  from  its  access  to  its  final  termination  occupies  from  five  to 
nine  days.  It  thus  varies  much  in  its  duration  and  still  more  in  the  sever- 
ity of  its  symptoms  ;  many  cases  being  so  mild  as  not  to  require  the  at- 
tendance of  a  physician,  while  others  are  accompanied  by  the  most  intense 
suffering  and  followed  by  such  a  degree  of  weakness  as  to  rec[uire  several 
weeks  to  regain  the  usual  health  and  strength. 

Prognosis. — This  disease  is  rarely  if  ever  fatal  in  adult  life,  and  prob- 
ably not  in  children,  unless  it  becomes  complicated  with  convulsions  or 
cholera  morbus.  It  is  remarkable  for  the  rapidity  of  its  spread;  the  large 
numbers  attacked;  the  brief  duration  of  its  prevalence,  and  the  almost 
entire  absence  of  fatality. 


76  DENGUE. 

Erysipelas,  purpura,  and  haemorrhages,  have  been  observed  as  compli- 
cations in  a  few  instances.  Pregnant  women  attacked  with  the  disease 
are  very  liable  to  miscarry.  Relapses  of  the  disease  are  not  uncommon, 
and  all  severe  cases  are  apt  to  be  followed  by  a  slow  and  tedious  conva- 
lescence. 

Etiology. — Of  the  nature  or  identity  of  the  cause  or  causes  of  dengue 
nothing  is  positively  known.  Its  appearance  usually  in  very  warm,  dry 
seasons;  the  suddenness  and  rapidity  with  which  it  attacks  a  large  part 
of  the  population  of  a  city  or  district  of  country;  and  the  brief  period  of 
its  prevalence  as  an  epidemic,  are  circumstances  that  could  hardly  co- 
exist in  regard  to  any  disease  unless  it  was  produced  by  some  modifica- 
tions in  the  condition  or  composition  of  the  atmosphere.  Dr.  E.  D.  Fen- 
ner,  of  New  Orleans,  who  had  good  opportunities  for  studying  the  disease, 
evidently  regarded  it  as  only  a  modification  of  the  ordinary  malarious  or 
periodical  fevers,  endemic  throughout  the  Southern  States.  From  the 
close  similarity  of  circumstances  relating  to  season  of  the  year,  geograph- 
ical limits  of  prevalence,  rapid  spread  without  personal  contact,  and  double 
febrile  course,  sej^arated  by  an  intermission,  more  or  less  complete,  we 
would  be  justified  in  assigning  the  disease  a  place  intermediate  between 
the  malarious  remittent  and  the  yellow  fever,  and  claiming  as  its  cause  some 
atmospheric  agency  similar  in  kind,  but  less  virulent  in  its  efi'ects,  than 
that  which  gives  rise  to  yellow  fever. 

Diagnosis. — As  I  have  already  intimated  to  you,  Dr.  E.  D.  Fenner 
regarded  the  disease  called  dengue  as  simply  a  modification  of  the  ordinary 
endemic  malarious  fevers  of  warm  climates.  He  adduces  many  and  plau- 
sible reasons  in  favor  of  this  view  in  the  paper  appended  to  the  report  of 
the  committee  on  Practical  Medicine,  published  in  the  Transactions  of  the 
American  Medical  Association  for  1851,  to  which  I  have  before  alluded. 
If  we  consider,  however,  only  its  clinical  history  or  symptoms  and  prog- 
ress, we  should  distinguish  it  from  the  intermittent  and  remittent  types  of 
fever,  by  the  less  marked  chill  at  the  access;  by  the  continuance  of  the 
febrile  exacerbation  for  two  or  three  days  instead  of  a  daily  intermission 
or  remission;  by  the  one  long  intermission  and  a  second  exacerbation  of 
equal  length  with  the  first,  accompanied  by  its  swollen  joints  and  cutaneous 
eruptions.  From  relapsing  fever,  which  in  some  respects  it  strongly 
resembles,  it  is  distinguished  by  the  pain  and  swelling  of  the  joints;  the 
peculiar  stiffness  and  soreness  of  the  muscles;  the  eruptions  on  the  surface; 
the  shorter  course  of  the  fever;  and  the  simultaneousness  of  its  attacks  on 
large  numbers  in  a  given  population.  The  same  symptoms  and  facts  in 
its  history,  together  with  its  almost  uniform  tendency  to  recovery,  equally 
distinguish  it  from  the  epidemic  form  of  yellow  fever. 

Treatment. — The  epidemics  of  this  disease,  that  occurred  from  1824  to 
18:i8,  and  from  1847  to  1850,  developed  so  suddenly,  and  the  fever  and 
pains  were  so  intense,  that  most  of  the  earlier  cases  were  treated  with  the 
active  depletive  and  evacuant  measures  then  so  generally  adopted  in  the 
treatment  of  all  acute  diseases.  Blood-letting,  emetics,  cathartics,  ano- 
dynes, calomel,  and  quinine,  were  all  freely  used,  and  each  had  their  zeal- 
ous advocates,  until  it  came  to  be  fully  understood  that  the  disease,  when 
left  entirelv  to  itself,  almost  uniformly  terminated  in  full  convalescence  in 
from  five  to  nine  days. 

Since  the  general  recognition  of  this  important  fact,  the  treatment  pur- 
sued by  far  the  larger  number  of  American  practitioners  is  very  largely 
expectant,  consisting  in  rest,  light  food,  ano(3ynes  to  allay  pain  and  rest- 
lessness, diaphoretics  to  favor  critical  evacuations;  and  during  convales- 
cence mild  tonics  and  more  nourishment.     From  the  well-known  efficacy 


TYPHOID    FEVER.  77 

of  salicylic  acid  in  relieving  rheumatic  pains  when  associated  with  active 
pyrexia  or  high  temperature  of  the  body,  especially  when  used  conjointly 
with  soda  and  diaphoretics,  I  should  expect  much  benefit  from  its  use  in 
the  active  stage  of  the  more  severe  cases  of  dengue.  In  such  cases  I 
would  give  three  decigrams  (gr.  v  )  of  calomel,  to  be  followed  in  five  or 
six  houis  by  a  saline  laxative,  and  the  following  formula: 

I^ 


Acidi  Salicylici 

15  gms. 

3iv. 

Sodii    Bicarbonatis 

10    " 

3iis3. 

GlycerinjB 

30  c.  c. 

fii. 

TincturiB  Phytolaccse 

75    " 

f  fiiss. 

Tinctur^e  Opii  Camphoratis, 

45   " 

f  jiss. 

Mix,  and  give  four  cubic  centimetres,  or  an  ordinary  teaspoonful  every 
two,  three  or  four  hours,  mixed  with  a  little  additional  water  when  taken. 
This  should  be  discontinued  as  soon  as  the  active  febrile  symptoms, 
together  with  the  severe  pains  and  restlessness,  cease.  During  the  inter- 
mission between  the  first  and  second  exacerbations  of  fever,  and  also 
during  the  final  convalescence,  the  patient  should  avoid  active  physical  and 
mental  exercise,  live  on  plain  but  nutritious  food,  and  take  from  one  to  two 
decigrams  (gr.  ii  to  iii)  of  sulphate  quinifB  three  times  a  day.  Of  course, 
the  closes  of  medicines  I  have  mentioned  are  such  as  are  proper  for  adult 
patients.  For  children  the  quantity  must  be  lessened  in  proportion  to 
their  age.  This,  gentlemen,  completes  the  brief  account  I  have  deemed 
desirable  to  give  concerning  a  group  of  general  fevers  characterized  by 
active  exaltation  of  the  properties  and  general  processes  taking  place  in 
the  human  system,  but  brief  in  duration,  tending  very  uniformly  to  recov- 
ery, and  depending  for  their  production  mostly  upon  atmospheric  causes 
that  are  also  transient  or  incapable  of  continuous  propagation. 


LECTURE  X. 


Tj-phoid  Fever— History,  Causes,  Symptoms,  Diagnosis,  Prognosis,  Special  Pathology,  Pathologi- 
cal Anatomy  and  Treatment. 

GENTLEMEN:  I  must  now  call  your  attention  to  one  of  the  most  im- 
portant of  all  the  acute  general  diseases.  It  is  most  important,  from 
the  wide  extent  of  its  prevalence,  being  liable  to  occur  wherever  human 
beings  aggregate  together  in  civilized  and  stationary  communities,  from 
its  protracted  duration,  and  from  the  high  ratio  of  mortality  that  results 
from  it. 

Typhoid  f"ver  has  been  recognized  and  described  under  various  names, 
from  the  remotest  periods  of  medical  history.  Until  the  days  of  M.  Louis, 
of  Paris,  it  had  not  been  separated  from  the  typhus  fever,  but  had,  with 
the  latter,  been  described  under  the  names  of  synochus,  typhus  mitior, 
and  abdominal  typhus. 

In  later  times  it  has  been  called  typhoid  fever,  enteric  fever,  dothin en- 
teritis, common  continued  fever,  pythogenic  fever,  and  sometimes  autum- 
nal bilious  fever.     In  Germany  and  some  other  parts  of  Europe  it  is  still 


78  TYPHOID    FEVER. 

frequently  called  abdominal  typhus,  but  in  this  country  it  is  very  gener- 
ally designated  as  typhoid  or  enteric  fever.  The  latter  name  was  applied 
.  to  the  disease  by  Dr.  George  B.  Wood,  but  is  objectionable,  as  implying  a 
dependence  of  the  fever  on  the  intestinal  lesions,  and  I  shall  adopt  the 
former  as  the  one  most  generally  familiar  to  the  profession  in  this  country, 
and  least  likely  to  suggest  erroneous  pathological  ideas.  As  I  have  al- 
ready intimated,  the  prevalence  of  typhoid  fever  is  not  limited  to  any 
soils,  climates,  topographical  conditions,  seasons  of  the  year  or  classes  of 
people.  It  occasionally  attacks  a  sufficient  number  of  people  in  a  given 
community  in  a  particular  season  to  be  called  an  epidemic,  but  its  preva- 
lence is  generally  strictly  endemic  and  continuous  to  a  greater  or  less  ex- 
tent throughout  the  year. 

I  do  not  mean  by  these  general  expressions  that  this  variety  of  fever 
prevails  equally  at  all  seasons  of  the  year,  or  to  t!io  same  extent  in  all 
localities.  On  the  contrary,  while  in  any  given  community  cases  of  the 
disease  may  be  met  with  every  month  of  the  year,  yet  as  a  general  rule, 
it  is  much  more  prevalent  during  the  last  half  of  summer,  autumn  and 
winter  than  in  the  remaining  seasons.  And  in  relation  to  localities,  it 
prevails  more  in  cities  than  rural  districts;  and  much  more  in  districts 
and  countries  long  peopled  than  in  those  recently  settled  by  civilized 
man.  The  latter  remark  is  more  particularly  applicable  to  such  newly 
settled  countries  as  present  a  soil  and  climate  favorable  for  the  develop- 
ment of  the  group  of  fevers  styled  periodical  or  malarious.  Such  was 
the  condition  of  a  large  part  of  our  own  country. 

The  whole  of  this  great  interior  valley,  extending  from  Lake  Superior 
to  the  Gixlf  of  Mexico,  the  territory  bordering  on  the  gulf  from  tie  Rio 
Grande  river  to  Key  West,  together  with  the  Atlantic  and  Pasittc  slopes, 
presented  at  the  time  of  their  settlement  by  civilized  races  of  men,  a  rich- 
ness of  alluvial  or  tertiary  deposits,  containing  decomposable  vegetable 
matter  in  such  quantity  that  malarial  or  periodical  fevers  took  the  prece- 
dence of  all  other  endemic  febrile  afl'ections,  and  typhoid  fever  was  hardly 
recognized  as  having  an  existence  during  the  first  two  generations.  But 
as  the  settlements  grew  older,  the  population  more  dense,  and  the  vege- 
table matter  in  the  soil  lessened  by  cultivation,  cases  of  typhoid  fever 
began  to  attract  attention,  and  from  year  to  year  became  relatively  more 
prevalent,  until  they  have  become  familiar  in  every  part  of  the  country.* 

JEtiologi/. — Perhaps  there  is  no  topic  embraced  in  the  domain  of  med- 
ical literature  concerning  which  we  have  on  record  a  greater  diversity  of 
opinions,  or  more  directly  contradictory  statements  by  authors  apparently 
equally  entitled  to  our  confidence,  than  concerning  the  efficient  cause  or 
causes  of  typhoid  fever.  Some  few  claim  with  much  positiveness  that  the 
disease  spreads  by  contagion  emanating  from  the  body  of  the  sick,  suffi- 
cient to  infect  the  surrounding  atmosphere.  A  much  greater  number 
deny  th'S,  and  assert  that  the  disease  is  never  communicable  directly  from 
one  individual  to  another  by  personal  contagion.  Until  a  comparatively 
recent  period  much  the  larger  number  of  writers  and  eminent  observers 
simply  claimed  that  the  efficient  cause  of  typhoid  fever  was  a  poison,  or 
class  of  poisons,  produced  by  accixmulations  of  animal  matter  or  excre- 
tions, either  in  the  confined  air  of  dwellings  and  other  buildings,  or  in 
moist  soils,  and  capable  of  impregnating  both  air  and  water.  The  sujd- 
posed  poison  or  poisons  thus  engendered  were  called  idio-miasms,  to  dis- 

*  For  a  more  detailed  account  of  the  development  and  progress  of  typhoid  and  ty^hn*;  fevers,  the 
student  can  consult  the  second  volume  of  Dr.  Daniel  Drake's  work  on  the  Principal  Diseases  of 
the  Interior  Valley  of  North  America,  from  page  361  to  4'10. 


ETIOLOGY.  79 

tincruish  tlicm  from  the  poisonous  products  of  veo^etable  decomposition 
called  koino-iniasins,  or  more  commonly,  maUria.  But  since  the  applica- 
tion of  the  microscope  to  medical  investig-atious,  and  the  discovery  of  va- 
rious disease'produciujcr  germs,  it  has  been  assumed  by  nearly  all  our 
recent  writers  that  the  essential  cause  of  typhoid  fever  is  an  organic  germ 
of  specific  character,  propagated  chiefly,  if  not  exclusively,  from  the  intes- 
tinal evacuations  of  those  sick  with  the  disease.  It  is  not  claimed  that 
such  intestinal  evacuations  are  capable  of  producing  the  disease  when 
freshly  voided,  or  of  infecting  the  atmosphere  around  the  patient  so  as  to 
endanger  nurses  or  friends  in  attendance  on  the  sick;  but  tliat  thev  con- 
tain immature  germs,  capable,  under  given  circumstances,  of  further  devel- 
opment, when  they  become  capable  of  inducing  the  disease  in  others  by 
im]")regnating  either  the  air  of  dwellings,  or  the  drinking  water,  or  even 
milk  from  dairies. 

And  we  are  assured  by  these  authors  that  the  disease  never  originates 
in  any  house  or  locality  until  these  specific  germs  have  been  introduced 
from  some  previous  case  or  cases. 

They  contend  that  the  poison  never  originates  de  novo,  from  any 
amount  or  kind  of  decomposing  animal  excrements  unless  the  specific 
typhoid  germ  be  present.* 

It  is  ray  duty,  however,  to  caution  you  against  receiving  such  positive 
assertions  with  entire  confidence;  and  for  the  simple  reason  that  an  im- 
partial examination  of  all  the  more  carefully  observed  and  recorded  facts, 
do  not  afford  sufficient  positive  evidence  of  their  correctness.  Indeed, 
gentlemen,  we  have  no  direct  or  positive  evidence  that  this  much  talked 
of  "  typhoid  germ''''  has  any  existence  except  in  the  human  imagination; 
for  no  one  has  yet  succeeded  in  isolating,  and  satisfactorily  identifying  it, 
either  with  microscope  or  chemical  apparatus.  I  do  not  claim  that  such 
actual  identification  is  necessary  before  we  are  justified  in  admitting  the 
existence  of  a  poison  or  germ  of  some  kind.  For  when  certain  effects  are 
found  uniformly  to  follow  the  coincidence  of  certain  circumstances  or  con- 
ditions, we  may  logically  infer  that  such  circumstances  or  conditions  give 
rise  1o  the  alleged  effects,  either  directly  by  their  own  action,  or  indirectly 
by  the  evolution  of  some  agent  of  peculiar  or  specific  qualities.  To  make 
such  inference  legitimate,  however,  the  supposed  conditions  must  always 
be  found  either  coincident  with,  or  directly  antecedent  to,  the  alleged 
effects.  Such  coincidence  between  the  local  or  recognizable  conditions 
and  the  prevalence  of  certain  diseases,  such  as  intermittent,  remittent  and 
yellow  fevers,  has  been  traced  with  a  reasonable  degree  of  uniformity; 
and  we  may  feel  fully  convinced  that  the  coincident  circumstances  ac- 
tually evolve,  or  give  origin  to,  the  efficient  cause  of  these  fevers.  We 
may  go  so  far  as  to  give  this  cause  a  name,  calling  it  a  miasm,  or  malaria, 
and  study  the  laws  that  appear  to  govern  its  diffusion. 

But  typhoid  fever  has  not  been  found  to  originate  with  uniformity  from 
the  juxtaposition  of  any  special  conditions  of  the  air  or  earth  or  seasons. 
On  the  contrary,  cases  of  the  disease  are  met  Avith,  as  I  have  already 
stated,  at  all  seasons  of  the  year,  in  all  climatic  zones,  and  among  all 
varieties  of  people.  And  it  is  this  very  great  diversity  of  the  conditions 
under  which  typhoid  fever  has  been  observed,  that  renders  it  so  difficult  to 
trace  it  to  any  one  specific  germ  as  its  essential  cause.  It  is  true,  that 
many  cases  have  been  traced  directly  to  the  influence  of  foul  air  from 
cesspools,  sewers  and  waste-pipes  ;  and  others  to  water  from  wells,  cis- 
terns and  reservoirs,  which  had  been  contaminated  by  excretions.     But  in 

'  •  ^ee  A  Treatise  on  the  Practice'of  Medicine,  by  Roberts  Bartholow,  M.  D.,  etc.,  p.  689  ;  also  Lie 
oermeister,  in  Ziemssen's  Cyclopeedia 


80  TYPHOID    FEVER. 

onK-  a  few  of  these  had  it  been  positively  ascertained  that  the  dejections 
from  typhoid  fever  patients  had  constituted  any  part  of  the  contaminating 
material.  One  of  the  cases  that  has  been  regarded  as  affording  the 
strongest  proof  of  the  propagation  of  the  disease  from  germs  in  the  evacu- 
ations of  a  person  affected  by  the  fever,  was  reported  by  Dr.  Austin  Flint, 
first  in  the  American  Journal  of  Medical  Sciences  in  1845,  subsequently 
in  his  interesting  volume  of  "Clinical  Reports  on  Continued  Fev'er"  in 
1853,  and  still  later  in  the  scraral  editions  of  his  valuable  work  on  the 
Practice  of  Medicine.*  This  case  occurred  in  1843,  in  a  small  village 
called  North  Boston,  in  the  western  part  of  New  York  State.  A  traveler 
from  some  one  of  the  New  England  States,  was  taken  sick  on  his  journey 
westward,  and  on  arriving  at  the  tavern  in  this  little  village  he  was  unable 
to  go  further,  and  after  remaining  a  few  days  he  died.  The  history  of  the 
case  obtained  by  the  physicians  who  saw  it,  rendered  it  reasonably  certain 
that  it  was  one  of  typhoid  fever.  Previous  to  the  arrival  of  the  stranger, 
this  variety  of  fever  had  never  been  recognized  in  the  neighborhood. 

In  twenty-three  days  after  the  arrival  of  the  stranger,  members  of  the 
family  of  the  tavern-keeper  became  sick  with  the  same  disease.  Cases 
soon  followed  in  the  other  families  living  in  close  proximity  to  the  tavern, 
and  in  one  month  forty-three  cases  had  occurred,  constituting  about  one- 
half  of  the  entire  population  of  the  village,  and  ten  of  those  attacked  died. 
The  only  family  in  this  little  community  that  entirely  escaped  the  disease 
was  one  the  members  of  which  had  no  communication  with  the  tavern  or  its 
inmates  on  account  of  personal  enmity.  The  history  of  this  little  isolated 
outbreak  of  typhoid  fever,  so  directly  following  the  introduction  of  the 
disease  by  the  stranger  from  New  England,  was  first  published  by  the 
distinguished  author  I  have  named,  as  furnishing  positive  proof  of  the 
contagiousness  of  the  disease,  he  then  supposing  that  it  had  spi'ead  by 
personal  communication  from  one  individual  to  another.  Subsequent 
investigations,  however,  pretty  clearly  showed  that  all  who  had  been 
attacked  had  been  drinking  water  from  the  well  belonging  to  the  tavern, 
and  that  the  privy^  also  used  in  common,  was  in  close  proximity  to  the 
well.  The  addition  of  these  facts  led  to  the  suf  position  that  the  intestinal 
evacuations  of  the  sick  stranger,  containing  the  typhoid  germs,  were 
thrown  into  the  privy,  from  whence,  after  due  development,  they  perco- 
lated into  the  well  and  contaminated  the  drinking  water  for  the  neighbor- 
hood. As  this  prevalence  of  typhoid  fever  in  North  Boston  in  1843,  is 
acknowledged  to  be  one  affording  the  strongest  proof  of  the  propagation 
of  the  disease  by  means  of  germs  originating  in  the  evacuations  of  typhoid 
fever  patients,  please  note  carefully  the  essential  facts  accompanying  it. 
They  are,  first,  the  arrival  of  a  stranger,  sick  with  the  fever,  in  a  small 
settlement  previously  entirely  exempt  from  the  disease.  Second,  twenty- 
three  days  later  the  disease  attacked  members  of  the  family  in  the  house 
where  the  stranger  had  been  entertained,  and  soon  spread  to  all  the  fami- 
lies in  the  immediate  vicinity,  except  one.  Third,  there  was  a  loell  and  a 
privy  in  close  proximity  to  each  other,  which  were  used  in  common  by  all 
the  families  in  which  the  disease  made  its  appearance.  Fourth,  it  is  sup- 
posed that  the  evacuations  of  the  sick  stranger  were  thrown  into  the  privy. 
Fifth,  all  the  families  using  water  from  the  well  near  the  privy  had  more 
or  less  of  the  fever,  while  the  only  family  among  them  that  did  not  use  the 
water  from  that  well  escaped. 

These  are  the  essential  coincident  facts.  The  inferences  which  have 
been  drawn  from  them   are   that  the   evacuations  from  the  sick  stranger, 

*Pee  a  Treatise  on  the  Principles  and  Practice  of  Medicine,  etc.  By  Austin  Flint  M.  D.,  etc. 
Fifth  Edition,  p.  96i 


ETIOLOGY.  81 

containing;  fever  Ejerms,  were  thrown  into  the  privy;  that  the  germs  there 
tindmo-  a  favorable  medium,  developed  to  the  stag-e  of  activity,  and  then 
percohited  into  the  well  in  sufficient  quantity  to  contaminate  the  water 
and  communicate  the  disease  to  those  using  it.  You  will  see  that  the 
only  part  of  these  inferences  which  are  actually  justified  by  the  facts,  are 
the  deposit  of  the  stranger's  evacuations  in  the  privy  and  the  subsequent 
sickness  of  those  who  used  water  from  the  well  near  by  it.  All  that  is 
said  about  germs  is  mere  assumption,  there  having  been,  no  investigation 
made  for  their  discovery,  and  of  course  none  discovered  either  in  the 
evacuations  of  the  sick  stranger  or  in  the  water  of  the  well.  So  far  as 
the  ascertained  facts  show,  the  coming  and  death  of  the  stranger  may 
have  been  a  mere  coincidence,  without  having-  had  any  influence  whatever 
in  producing  the  subsequent  outbreak  of  fever  in  the  place.  It  would  be 
just  as  legitimate  and  more  nearly  in  consonance  with  other  well-known 
facts,  to  suppose  that  the  contents  of  the  privy  had  been  accumulating 
for  two,  three  or  more  years,  and  each  year  percolating  into  and  saturat- 
ing more  and  more  the  surrounding  soil,  until  in  this  particular  season 
the  percolations  had  reached  the  adjacent  well  in  sufficient  quantity  to 
contamiijate  the  water,  as  to  suppose  the  mere  addition  of  a  few  evacua- 
tions from  this  unfortunate  stranger  had  done  all  the  mischief.  The  ques- 
tion whether  the  coining  of  the  sick  stranger  was  in  this  and  other  parallel 
cases  a  mere  coincident,  or  a  cause  of  the  subsequent  outbreak  of  fever, 
can  be  properly  answered  only  by  a  close  adherence  to  the  acknowledged 
rules  of  evidence,  or  the  well-known  principles  of  inductive  reasoning. 
If  on  examining  the  I'ecorded  histories  of  the  various  outbreaks  of  ty- 
phoid fever  during  the  last  half  century,  we  should  find  that  in  eight 
out  of  every  ten  of  such  outbreaks  one  or  more  cases  of  the  disease  had 
been  imported  or  received  into  each  locality  at  a  reasonable  time  prior  to 
the  occurrence  of  the  first  cases,  we  wouhl  be  justified  in  claiming  that 
the  efficient  cause  was  in  some  way  furnished  by  the  cases  arriving  before 
the  local  development  of  the  disease. 

On  the  other  hand,  if  the  recorded  histories  show  no  positive  proof  of 
the  arrival  of  either  patients  or  their  excretions  prior  to  the  local  devel- 
opment of  the  disease  in  nine  out  ot"  every  ten  of  the  outbreaks  on 
record,  then  certainly  the  proof  of  such  preceding  importation  in  the 
tenth  case  can  be  properly  regarded  only  as  an  accidental  coincident.  If 
we  examine  the  collection  of  facts  concerning  the  development  and  pro- 
gress of  the  typhoid  outbreaks  in  this  country,  from  the  appearance  of 
the  "spotted  fever"  epidemic  at  Medfield,  in  the  Connecticut  River  Val- 
ley in  1806.  to  1850,  contained  in  the  second  volume  of  the  valuable  work 
on  the  Principal  Diseases  of  the  Interior  Valley  of  North  America,  by  Dr. 
Daniel  Drake,  we  shall  find  these  occurring  at  different  times,  in  every 
variety  of  locality,  from  the  coast  of  New  Enp;land  to  the  Mississippi 
river,  and  from  the  Great  Lakes  to  the  gulf;  in  cities  and  sparsely  popu- 
lated rural  districts;  among  all  classes  of  the  people,  and  at  all  seasons 
of  the  year. 

And  certainh"  not  in  more  than  one  instance  out  of  ten,  is  there  any 
mention  of  evidence  that  the  outbreaks  were  preceded  by  cases  of  the 
disease  arriving  from  other  localities.  The  brief  histories  of  Dr.  Drake 
are  well  supplemented  by  reports  on  the  topography  and  epidemics  of 
different  States,  contained  in  the  annual  volumss  of  transactions  of  the 
American  Medical  Association,  from  184:4  to  1870. 

Nearly  all  of  these  reports  embrace  accounts  of  the  prevalence  of 
typhoid  fever  in  different  parts  of  the  country,  mostly  from  intelligent 
members  of  the  profession,  who  described  what  came  directly  under  their 

6 


82  TYPHOID    FEVER. 

own  observation  ;  and  many  of  them  in  localities  where  the  disease  liad 
never  before  prevailed,  and  where,  from  the  sparseness  of  the  population 
and  comparative  isolation,  the  questions  of  spontaneous  origin  or  of 
importation  of  germs,  could  be  investigated  much  more  successfully  than 
in  large  cities,  or  the  older  and  more  densely  populated  rural  districts  of 
European  countries.  In  examining  these,  together  with  the  reports  on 
practical  medicine  and  hygiene  in  the  same  volumes,  we  find  but  few  in- 
stances in  which  the  first  development  of  the  fever  was  traceable  to  any 
jDossible  connection  with  previous  cases,  either  in  the  same  locality  or  from 
other  places.  In  a  much  larger  number  of  instances,  the  question  of 
sources  from  which  some  infection  might  have  been  received  was  not 
critically  investigated,  but  none  were  detected  or  mentioned.  While  in  a 
considerable  number  of  instances,  the  origin  of  the  disease  spontaneously, 
from  local  causes  free  from  the  prior  introduction  of  any  cases  or  infectious 
germs  from  without,  was  so  clearly  established  as  to  leave  no  reasonable 
doubt  in  the  mind  of  any  impartial, ')bserver.* 

In  addition  to  the  instances  of  spontaneous  or  local  origin  of  this  variety 
of  fever  given  in  the  volumes  to  which  we  have  alluded,  a  score  of  other 
instances  could  be  collected  from  the  pages  of  our  periodical  literature, 
where  it  occurred  in  jails,  manufacturing  establishments,  boarding  schools 
and  private  houses,  under  circumstances  precluding  all  probability  of  its 
having  had  any  connection  with  preceding  cases  or  infection  introduced 
from  without.  Two  such  instances  have  come  under  my  own  observation; 
and  during  an  active  practice  of  more  than  forty  years  I  have  met  with 
many  single  cases  of  well-marked  typho'd  fever:  some  in  the  country,  oth- 
ers in  the  city,  which  passed  through  the  regular  ordinary  course  of  the 
disease,  each  surrounded  by  family  and  friends;  the  urinary  and  foecal 
discharges  being  promptly  removed,  and  without  disinfection  thrown 
■directly  into  the  common  privy-vault,  without  their  having  been  either 
preceded  or  followed  by  any  other  cases  on  the  same  premises  during  a 
period  of  at  least  fiiteen  years.  In  many  of  these  cases  the  patients  had 
iHot  been  off  from  their  own  premises  for  many  months,  neither  had  any 
other  case  of  that  disease  been  on  the  premises  for  years  previous.  For 
thirty  years  past  I  have  been  an  active  member  of  the  medical  staff  of  the 
Mercy  Hospital  in  this  city.  Apart  of  the  medical  wards  have  been  under 
my  care  all  that  period  of  time,  and  typhoid  fever  has  been  one  of  the 
most  common  forms  of  disease  under  treatment.  The  patients  laboring 
under  that  fever  have  been  received  into  the  same  wards  with  other 
patients,  and  their  evacuations  disposed  of  in  the  same  manner;  yet,  in  not  a 
single  instance  has  the  disease  been  communicated  to  the  other  patients.  It 
is  true  that  the  wards  have  been  kept  clean  and  well  ventilated,  but  no 
more  so  for  typhoid  fever  patients  than  for  all  others.  My  exjDorience  in 
this  respect  is  in  direct  accordance  with  that  of  many  of  the  most  experi- 
enced and  careful  observers  in  this  country. j 

From  the  foregoing  facts  and  references  you  will  see  that  the  positive 
assertions  of  Dr.  Budd,J  Dr.  Liebermeister,||  and  others,  to  the  eifect  that 
typhoid  fever  never  originated  in  any  person  or  place  without  the  pres- 

*  See  an  account  of  the  typhoid  fever,  etc.,  that  prevailed  on  Capo  Ann  in  1833,  by  Joseph  Rey- 
nolds, M.  D.,  of  Gloucester,  Mass. .in  Transactions  of  the  Amer.  Med.  Association,  Vol.  Ill,  p.  137,  1850. 
Also  case  related  by  Dr.  Ilartz,  on  p.  229. 

See  Transactions  of  tlie  same  Association, Vol.  V,  pp.  308-334— Vol.  VI,  p.  356.  Also  Vol.  13,  1860, 
pp.  -232-231. 

fDr.  George  B.  Wood,  of  Philadelphia,  in  the  fifth  edition  of  his  Treatise  on  the  Practice  of  Med- 
icine, page  3.51.  uses  the  following  emphatic  lansuage:  "But  against  the  opinion  of  its  ordinary 
contagif)Usnes3  is  the  fact,  that  it  is  constantlj^  springing  up  in  isolated  cases,  without  any  pomhle 
communication,  and  that,  in  such  instances,  it  is  very  seldom,  if  ever,  imparted  to  others." 

t  .-ee  Flint's  Practice,  page  963. 

II  See  Ztem-isen's  Cyclopaedia  of  Practice,  Vol,  I.  from  page  50  to  51  i  elusive. 


ETIOLOGY.  83 

ence  of  the  specific  fever  germs  furnished  by  the  excretions  of  those 
suffering  from  the  same  general  fever,  are  not  sustained  by  the  facts  con- 
nected with,  the  prevalence  of  that  disease  in  this  country.  If  you  scan 
the  statements  of  writers  and  observers  more  closely,  you  will  find  them 
all  freely  admitting  that  there  is  no  evidence  of  infection  or  communica- 
tion of  the  disease  from  any  kind  of  contact  with  the  excretions  of  typhoid 
fever  patients  when  freshly  voided.  It  is  only  when  such  excretions  have 
been  kept  in  privy  vaults,  moist  soils,  or  other  places  favorable  for  further 
decomposition,  that  the  organic  germs  they  are  supposed  to  contain  be- 
come developed  into  an  active  infection,  capable  of  comraunicatino-  the 
disease  either  by  inhalation  with  the  air,  or  by  suspension  in  drinking 
water,  etc.  Direct  microsco2:)ic  examinations  of  the  intestinal  follicles, 
mesenteric  glands  and  spleen,  of  typhoid  fever  cases,  have  been  made  by 
Von  Recklinghausen,  Klein,  Fischel,  Eberth,  SokolofF  and  Klebs,  result- 
ing in  the  discovery  of  micrococci,  bacilli,  or  bacteria,  in  about  one-third  of 
the  number  of  cases  examined;  but  nothing  was  discovered  tending  to 
show  that  these  organic  bodies  had  any  agency  in  producing  the  fever  from 
which  the  patients  had  died.  There  is,  therefore,  no  proof  of  the  exist- 
ence of  a  special  fever  germ,  or  specific  organic  poison,  either  in  the  fresh 
evacuations  of  typhoid  fever  patients,  or  in  the  diseased  structures  of  those 
who  have  died  from  the  gravity  of  the  fever.  Consequently  the  very 
general  assumption  that  the  essential  cause  of  typhoid  fever  is  a  specific 
organic  germ,  capable  of  being  propagated  in  the  evacuations  from  those 
sick  with  the  disease,  must  be  regarded  at  present  as  a  mere  theoretical 
dogma. 

A  careful  adherence  to  well  ascertained  facts  concerning  the  etiologv 
of  the  fever  under  consideration  will  require  us  to  accept  the  three  follow- 
ing propositions  :  First,  that  cases  of  typhoid  fever  originate  and 
multiply  in  dwellings  or  buildings  of  any  kind,  in  which  from  either  over- 
crowding the  number  of  the  occupants  or  the  neglect  of  ventilation  and 
cleanliness,  the  air,  furniture  and  walls  become  strongly  impregnated  with 
the  organic  matter  exhaled  from  the  skin  and  lungs  of  the  occupants.* 

So  true  is  this  that  the  annual  returns  of  mortality  statistics  for  every 
densely  populated  city  in  our  country  show  the  highest  ratio  of  mortality 
from  this  disease,  in  the  crowded  tenement  houses,  manufacturing  estab- 
lishments, and  small  dwellings  of  the  poor. 

Second,  that  the  more  the  soil  of  any  given  locality  becomes  impregna- 
ted with  the  intestinal  and  urinary  excretions  by  the  progressive  increase 
of  the  density  of  the  population,  provided  the  two  conditions  of  drainage 
and  water  supply  remain  the  same,  the  more  frequent  and  severe  will  be 
the  cases  of  typhoid  fever  occurring  among  the  inhabitants  of  such 
locality. 

This  proposition  has  been  so  fully  illustrated  by  the  progress  of  settle- 
ment and  increase  of  population  in  our  country  that  its  truth  is  established 
beyond  controversy.  In  addition  to  this,  the  great  number  of  outbreaks 
of  the  fever,  which  have  been  traced  directly  to  the  use  of  water  impreg- 
nated with  the  percolations  through  the  soil  from  privies,  cesspools,  house 
drains,  etc.,  leave  no  room  for  doubt  as  to  the  influence  of  this  agency  in 
producing  the  disease. f 

*  For  a  most  interesting  and  valuable  discussion  of  the  amount  of  organic  matter  escaping  from 
the  lungs  and  skin  in  a  given  time,  and  the  readiness  with  which  the  air  of  unventilated  rooms  may- 
become  contaminated  from  this  source,  see  the  Report  on  Public  Hygiene  by  the  late  Dr.  Joseph  M. 
Smith,  of  New  York,  in  the  Transactions  of  the  American  Medical  "Association,  Vol.  Ill 
p.  -223,  ia50. 

t  An  important  fact  bearing  upon  this  subject  was  stated  by  Dr.  L.  S.  .^rcMu^t^y,  of  Danville, 
Ken  ucky,  in  an  address  delivered  before  the  Kentuckv  State  Medical  Societv,  in  April,  ISSl,  a-id 
published  in  the  Medical  News  and  Abstract  f  ^r  June,"l881.    He  says,  "  twenty  years  ago  the  dis- 


84  TYPHOID    FEVER. 

Third,  cases  of  genuine  typhoid  fever  have  occurred,  and  are  still  oc- 
curring occasionally,  in  almost  every  civilized  community  in  persons  who 
have  had  no  traceable  communication  with  previous  cases  of  that  disease, 
or  with  any  of  the  recognized  or  even  suspected  sources  of  infection.  I 
have  met  with  many  isolated  cases  03curring  in  members  of  families  liv- 
ing in  houses  in  wliich  a  case  of  the  disease  had  not  been  known  to  occur 
for  ten  years  previously,  neither  did  any  others  follow  for  ten  years  after. 
Yet  these  individual  cases  were  surrounded  and  nursed  by  their  respec- 
tive families,  and  their  evacuations  emptied  into  the  ordinary  water- 
closets  belonging  to  the  premises.  Most  of  these  cases  appeared  to 
originate  from  causes  directly  personal  to  the  individuals  affected,  such  as 
protracted  mental  depression  and  anxiety,  excessive  mental  or  physical 
work,  and  abrupt  changes  from  active  out-door  occupations  to  passive  in- 
door work.  Assuming  that  typhoid  fever  is  a  specific  disease,  character- 
ized by  a  definite  course,  and  accompanied  by  special  or  peculiar  patho- 
logical and  anatomical  changes,  maiiy  writers  have  claimed  that  it  must 
have  a  single  specific  and  essential  cause,  and  consequently  that  all  other 
causes  apparently  influencing  the  prevalence  of  the  disease  were  only 
predisposing  agencies.  Probably  no  fact  is  better  established  than  that 
the  disease  under  consideration  generally  originates  from  the  use  of  air  or 
water  impregnated  with  some  one  or  more  of  the  products  derived  from 
the  decomposition  of  organic  mitter.  It  does  not  follow,  however,  that 
such  product  of  organic  changes  must  necessarily  be  formed  outside  of 
the  human  body. 

On  the  contrary,  there  are  many  facts  that  indicate  the  possibility  of 
such  modifications  in  the  processes  of  disintegration  of  living  structures  as 
are  capable  of  evolving  septic  or  other  poisonous  material,  which  like  all 
other  products  of  tissue  changes,  are  returned  into  the  blood,  where  they 
are  capable  of  acting  on  the  general  properties  and  inducing  general 
febrile  disturbances  of  the  same  character  as  when  an  organic  poison  is 
received  from  without.  It  is  well  known  that  some  of  the  general  acute 
disea-es  which  ordinarily  manifest  no  tendency  to  communicate  from  in- 
dividual to  individual  by  personal  contagion,  in  some  rare  instances  have 
manifested  this  disposition  in  the  most  decisive  manner.  Several  instances 
are  on  record  of  this  kind  in  relation  to  typhoid  fever;  which  can  be  ex- 
plained in  no  other  way  than  by  admitting  that  a  disease  ordinarily  pro- 
duced by  causes  received  from  without  may  also  originate  from  similar,  if 
not  identical,  causes  developed  from  pei'verted  molecular  changes  within 
the  living  body.  That  protracted  mental  depression  and  anxiety,  coupled 
with  deficiency  of  sleep,  is  capable  of  modifying  all  the  properties  and 
molecular  movements  concerned  in  the  processes  of  nutrition,  disintegra- 
tion, and  secretion  must  be  admitted  by  all  experienced  observers. 

So,  too,  protracted  and  severe  physical  labor,  by  which  the  waste  of  tissues 
is  made  to  exceed  the  supply  or  repair,  may  not  on'y  cause  tissues  to  be- 
come so  deficient  in  tissue  material  as  to  derange  or  pervert  the  move- 
ments of  atoms,  and  consequently  cause  the  formation  of  morbid  products; 
but  may  also  cause  the  ordinary  products  of  waste  to  accumulate  in  the 
blood  faster  than  the  excretory  organs  can  eliminate  them,  until  such  ac- 
cumulation becomes  a  cause  of  disturbance.     Still  more,  may  similar  per- 

casc  ("typhoid  fever)  prevailed  in  epidemic  form  throushout  the  villnscs  and  farming  dis'rie's  of 
this  stale  almost  every  season  with  frightful  severiiy.  Now  we  rarely  eneouuter  typhoid  fever  ex- 
cept in  isrjlated  eases  in  which  the  disease  wiis  contracted  elsewhere  and  brou.ulit  home  in  the 
formal  i  \  i-  sia;rc."  The  reasons  for  this  change  he  gives  as  follows  :  "  Formerly  wells  with  free  sub- 
soil (•oiiiiiiuiiiiatiuii  ucre  the  sources  of  drinking  water;  now  cisterns  are  almost  universal  sourc  s 
(if  watci  siipiily  ill  K'liilucky.  The  geological  formation  is  admirably  adapted  to  the  construction 
of  cisterns,  ancl  tiie  cemented  cisterns  of  this  State  are  practically  sealed  bottles  into  wliich  the 
water  pourj  through  filters." 


ETIOLOGY.  85 

versions  of  molocular  movemoiits  in  the  processes  of  disintof^ration  and 
elimination  tal<e  j)lace  in  those  persons  who  in  the  early  period  of  adult  life 
change  suddeidy  from  active  open  air  occupations  in  rural  districts  to  the 
more  confined  indoor  employments  of  our  large  cities. 

Such  persons  seldom  get  sick  during  the  first  few  weeks  after  they  change 
residence,  but  more  particularly  after  from  four  to  six  months.  The 
teiulency  of  typhoid  fever  to  attack  persons  who  had  resided  in  Paris  less 
than  one  year,  much  more  frequently  than  older  residents,  was  noticed  by 
yi.  Louis;  and  the  same  tendency  has  been  observed  in  many  other  cities 
since.  During  the  whole  of  my  residence  here  I  have  not  failed  to  observe 
that  an  undue  proportion  of  those  young  persons  of  both  sexes  Avho 
change  their  residence  from  the  country  to  the  city  in  the  winter  or  spriiig 
have  an  attack  of  typhoid  fever  in  the  latter  part  of  the  following  sum- 
mer or  autumn,  and  those  who  make  the  change  in  the  autumn  are  more 
liable  to  have  the  fever  in  the  following  spring  or  early  summer.  Among 
the  predisposing  causes  of  this  variety  of  fever  are  generally  ermmerated 
age  and  season  of  the  year. 

Statistics  show  that  far  the  larger  number  of  cases  occur  between  the 
ages  of  -15  and  30  years,  and  in  about  an  equal  ratio  in  the  sexes.  The 
next  period  of  life  most  amenable  to  attacks,  is  from  10  to  15,  years,  but 
no  period  of  life  is  entirely  exempt. 

In  regard  to  the  influence  of  seasons  of  the  year,  it  must  be  remarked 
that  particular  epidemics  and  certain  strictly  local  outbreaks  in  particu- 
lar houses  or  buildings,  have  occuired  at  all  seasons  of  the  year,  yet  it  is  cer- 
tain that  tlie  ordinary  endemic  prevalence  of  the  disease  is  much  greater 
in  the  autumnal  months,  than  in  any  other.  Generally  in  this  city  the 
attacks  are  observed  to  commence  being  more  frequent  the  last  half  of 
August,  and  to  reach  the  climax  of  their  frequency  in  October;  then  gradu- 
ally declining  through  November  and  December,  reaching  nearly  the 
minimum  in  January.  In  most  years  a  slight  increase  takes  place  during 
the  months  of  February  and  March,  to  be  followed  by  a  decline  through 
April,  and  an  actual  minimum  of  prevalence  through  May  and  June. 
As  a  rule,  a  wet  spring  followed  by  a  warm  and  dry  summer  is  succeeded 
by  an  unusual  pevalence  of  the  disease  in  the  autumn.* 

But  I  have  already  occupied  your  attention  on  the  subject  of  the  etiol- 
ogy of  this  fever  longer  than  I  had  intended.  If,  however,  I  have  suc- 
ceeded in  impressing  your  minds  with  the  importance  of  adhering  to  well- 
ascertained  facts,  and  avoiding  hasty  and  positive  conclusions  until  all  the 
facts  have  been  ascertained,  and  each  allowed  its  proper  influence,  the 
hour  will  have  been  spent  profitably,  both  for  yourselves,  and  the  com- 
munities you  are  preparing  to  serve. 

*  The  present  year.  1881,  presents  some  peculiarities  The  winter  w  is  protracted  later  than 
usual  with  a  great  excess  of  snow.  The  melting  of  the  snow  not  only  caused  a  full  saturation  of 
the  soil,  but  unusual  floods  over  a  large  part  of  the  country  during  March  and  April.  This  was 
foil  wed  by  entire  dryness  during  May  and  June;  and  the  latter  part  of  the  last  named  month,  a 
H  severe  grade  of  typhoid  fever  began  to  prevail  in  many  parts  of  the  city,  and  has  continued  with 
but  little  abatement  to  the  present  time  time,  July  20th,  1881.  The  health  department  of  the  city 
reports  2-1  deaths  from  typhoid  fever,  and  3  from  typho-malarial  fever,  in  June,  which  is  a  very 
much  greater  mortality  than  usually  takes  place  in  that  month  from  the  same  diseases.  In  June 
of  the  preceding  year,  1880,  the  number  of  deaths  from  the  same  fevers  was  only  9. 


86  TYPHOID    FEVER. 


LECTURE  XL 

Typhoid   Fever  Continued— Symptoms,  Diagnosis,  Prognosis,  Special    Pathology,  Pathological 
Anatomy,  and  Treatment. 

GENTLEMEN:  An  unmixed  case  of  typhoid  fever  presents  four  stiges 
or  periods  of  progress  requiring  the  attention  of  the  physician,  namely, 
the  prodromic,  or  forming  stage,  the  stage  of  active  progress,  the  stage  of 
defervescence  or  decline,  and  tiie  period  of  convalescence.  Those  who 
believe  in  the  origin  of  the  disease  exclusively  from  a  specific  fever  poison, 
speak  also  of  a  period  of  incubation,  the  length  of  which,  however,  is  made 
to  vary  from  five  or  seven  days  to  three  or  four  weeks.  It  is  hardly  nec- 
essary, after  the  statements  made  in  my  previous  lecture  concerning  ti.e 
causes  of  typhoid  fever,  that  I  should  characterize  the  claim  of  a  period  of 
incubation  as  entirely  hypothetical. 

The  forming  stage  varies  in  different  cases  from  five  to  fil'teen  days,  the 
average  being  about  one  week.  The  second,  or  active  stage,  usually 
extends  from  two  to  three  weeks,  and  the  third,  or  declining  stage,  from 
five  to  nine  days,  making  the  average  duration  of  the  disease  from  the 
beginning  of  the  symptoms  to  the  establishment  of  convalescence  about 
four  weeks,  or  three  weeks  from  the  time  the  patient  takes  his  bed.  I 
have  seen  cases  terminate  in  two  weeks,  and  I  have  seen  others  continue 
six,  seven,  and  some  even  eight  weeks,  before  convalescence  was  fairly 
established. 

Sympt07ns. — The  symptoms  of  the  forming  stage  are  chiefly  feelings  of 
languor,  weariness,  indisposition  to  mental  or  physical  exercise,  morbid 
sensations  of  heat  and  cold,  indifference  or  loss  of  appetite,  a  mawkish  or 
unpleasant  taste  in  the  mouth,  especially  in  the  morning  after  sleep,  a 
numb  and  unsteady  feeling  in  the  head,  especially  on  rising  from  the  bed 
or  chair,  and  in  many  instances  a  dull,  steady  pain  in  the  head,  back,  and 
limbs.  The  expression  of  countenance  is  goierally  dull;  the  face  some- 
times flushed  and  at  others  a  leaden  paleness;  lips  dryer  than  natural,  and 
tongue  usually  coated  with  a  dull  or  dirty  white  covering  over  the  middle 
and  posterior  part,  but  sometimes  remaining  clean  and  moist  through  the 
whole  of  this  stage.  The  skin  is  generally  dryer  than  natural,  and  in- 
creased one  or  two  degrees  above  the  natural  temperature;  the  urinary 
secretion  slightly  diminished,  and  bowels  often  failing  to  move  each  day, 
though  easily  moved  by  laxatives,  and  sometimes  loose.  The  forecroing 
symptoms  usually  commence  so  gradually  that  the  patient  finds  it  difficmlt, 
often,  to  specify  the  first  day  he  began  to  feel  unwell.  They  increase, 
however,  from  day  to  day,  especially  the  dullness  and  aching  in  the  head; 
the  weariness  and  unsteadiness  of  gait  in  attempting  to  exercise;  and  in 
from  five  to  seven  days,  as  a  general  rule,  the  patient  feels  obliged  to  re- 
main at  rest  or  take  to  his  bed,  which  marks  the  beginning  of  the  second, 
or  more  active  stage  of  the  fever.  It  is  rare  that  an  unmixed  case  of  ty- . 
phoid  fever  is  ushered  in  by  an  abrupt  and  well-marked  chill,  but  it  is 
very  common  during  the  latter  part  of  the  forming  stage  and  the  first 
two  or  three  days  of  the  active  progress,  for  the  patient  to  complain  of 
coldness  in  undressing  or  in  getting  in  or  out  of  bed,  and  when  questioned 
by  the  physician  he  often  calls  these  momentary  feelings  of  coldness, 
chills.     Many  patients  during  the  forming  stage  intei'pret  their  dullness 


SYMPTOMS.  87 

and  feelings  of  indisposition  as  indications  of  "  biliousness,"  and  con- 
soquently  take  active  physic  to  correct  it,  without  consulting  a  physician. 
Instead  of  affording  relief,  however,  such  evacuants  generally  operate  more 
freely  than  usual,  and  almost  invariably  hasten  the  time  the  patient  is 
obliged  to  take  his  bed,  and  cause  a  continued  looseness  of  the  bowels 
much  earlier  than  would  otherwise  have  occurred.  It  is  generally  at  the 
beginning  of  the  second  stage,  when  the  patient  is  no  longer  able  to  be 
out  of  bed,  that  your  aid  as  physicians  will  be  required.  At  that  time,  in 
addition  to  the  symptoms  already  described,  you  will  find  the  face  more 
flushed;  the  lips  more  dry;  the  skin  generally  more  dry  and  hot;  more 
decided  pains  in  the  head,  with  the  addition  of  dizziness  on  attempting  to 
get  up;  some  thirst,  with  more  decided  coating  upon  the  tongue;  repug- 
nance to  food;  the  mind  more  dull,  with  inclination  to  drowsiness,  yet 
somewhat  restless;  urine  scanty,  and  bowels  inactive,  except  in  cases  in 
which  active  physic  had  been  given  in  the  forming  stage.  In  such  you 
will  often  find  slight  tympanites,  with  gurgling  on  pressure,  and  from 
three  lo  five  or  six  intestinal  evacuations  in  the  twenty-four  hours,  even 
on  the  first  days  of  the  patient's  confinement  to  bed.  The  pulse  usually 
ranges  between  85  and  100  per  minute,  and  the  temperature  in  the  axilla 
about  38"  C.  (100.5°  F.)  in  the  morning,  and  39°  C.  (102.5°  F.)  in  the 
evening.  If  not  materially  modified  by  treatment,  the  assemblage  of 
symptoms  just  enumerated  will  continue,  steadily  becoming  more  pro- 
nounced from  day  to  day,  until  at  the  end  of  the  first  week  after  confine- 
ment to  the  bed,  the  temperature  has  advanced  to  39°. 4  C.  (103°F.)  in 
the  morning,  and  to  89°.9  C.  or  40°.5  C.  (101°  F.  or  105°F.,  in  the  even- 
ing. The  patient  will  complain  less  of  pains  and  restlessness,  but  appear 
more  drowsy;  the  whole  face  more  suffused  with  redness;  less  moisture' 
in  the  mouth,  and  a  strip  over  the  middle  of  the  tongue  dry,  and  brownish 
color,  while  the  tip  and  edges  are  red;  mind  often  wandering,  especially 
at  night;  pulse  from  95  to  110,  and  more  soft;  respirations  slightly  in- 
creased in  frequency,  with  harsh  respiratory  murmur,  indicating  dryness 
of  the  respiratory  mucous  membrane;  more  frequent  intestinal  discharges, 
generally  reddish-brown  and  thin,  though  sometimes  lighter,  or  ash-gray 
color;  abdomen  more  convex  and  tympanitic;  occasional  epistaxes,  or  hem- 
orrhage from  the  nose;  and  in  some  cases,  small,  slightly  oval  red  spots 
appear  about  this  time  on  the  chest  and  abdomen.  The  pyrexia,  or  essen- 
tial symptoms  of  the  fever,  are  generally  at  the  climax  of  intensity  as  the 
patient  enters  upon  the  second  week  of  his  confinement,  and  they  con- 
tinue with  but  little  variation  through  that  week.  The  mental  dullness 
and  delirium  may  increase  some;  the  whole  surface  of  the  tongue  appear 
more  dry  and  brown;  some  sordes  may  appear  on  the  exposed  part  of  the 
teeth  and  edges  of  the  lips;  the  abdomen  more  decidedly  tympanitic,  and 
intestinal  discharges  more  frequent  and  more  thin  and  brown,  containing 
small  white  flakes,  and  sometimes  small  masses  of  mucus  with  specks  of 
blood  adherent  to  them;  more  rose-colored  spots  appear  and  disappear 
over  the  chest  and  abdomen;  more  frequent  epistaxes,  and  more  dry 
bronchial  rales.  The  morning  temperature  during  the  whole  of  this 
second  week  is  generally  between  39°  and  40°  C.  (102.5°  and  104°  F.), 
and  the  afternoon  and  evening  temperature  from  one  to  two  degrees 
higher. 

The  pulse  may  vary  from  100  to  120  per  minute,  soft  and  weak;  respi- 
rations from  18  to  22  per  minute,  with  occasional  cough,  and  imperfect 
inflation  of  the  posterior,  and  lower  part  of  the  lungs.  In  cases  tending 
towards  a  favorable  termination,  as  the  patient  enters  the  third  week  of 
his  confinement  in  bed,  the  disparity  between  the  morning  and  evening, 


88  TYPHOID    FEVER. 

temperature  becomes  greater,  the  former  gradually  decliniug;  to  37°  or 
38"  C.  (99°  or  100.5°  F.),  while  the  latter,  though  more  unsteady,  will  still 
often  reach  40.5°  C.  (105°  F.)  During  this  third  week  the  flush  leaves 
the  face;  the  lips  cease  to  gather  sordes;  the  mouth  is  less  dry;  the  coat- 
ing on  the  tongue  breaks  up,  and  the  edges  become  moist;  some  moist- 
ture  appears  on  the  skin,  especially  in  the  mornings;  the  bronchial  rales 
are  less  dry;  the  abdomen  is  less  tympanitic,  and  the  intestinal  discharges 
less  frequent,  and  sometimes  quite  natural;  delirium  ceases,  and  the  pe- 
riods of  sleep  are  more  pe  feet.  At  the  end  of  this  week,  or  during  the 
first  half  of  the  fourth,  the  temperature  returns  permanently  to  the  natu- 
ral standard,  the  abdominal  tympanites  ceases,  and  convalescence  is  es- 
tablished. Such  is  the  usual  course  of  typhoid  fever,  when  of  average  se- 
verity. Many  cases  run  a  milder  course,  and  convalesce  during  the  third 
week,  while  others  are  more  severe,  and  do  not  reach  a  final  convales- 
cence until  the  end  of  the  fourth,  or  even  during  the  fifth  week  after  the 
patient  takes  to  his  bed.  But  in  all  the  cases,  the  important  symptoms 
are  the  same  in  kind,  only  differing  much  in  the  degree  of  severity. 
When  the  fever  is  of  that  grave  character,  which  tends  inherently 
towards  a  fatal  result,  the  symptoms  are  much  the  same  as  I  have  just  de- 
scribed, until  about  the  end  of  the  second  week,  at  which  time  the  patient 
becomes  more  constantly  delirious;  muscular  movements  more  unsteady 
and  sometimes  tremulous;  hearing  more  dull;  temperature  higher;  pulse 
more  frequent  and  feeble;  respirations  shorter  and  more  frequent,  with 
increase  of  bronchial  rales,  and  commencing  dullness  on  percussion  over 
the  posterior  part  of  the  chest;  whole  mouth  dry,  coat  flakes  oft'  from  the 
surface  of  the  tongue,  leaving  it  red,  dry,  and  often  fissured,  with  difficulty 
of  protrusion;  abdomen  more  decidedly  tympanitic  and  intestinal  dis- 
charges very  thin,  reddish  brown,  offensive,  and  often  mixed  with  some 
blood,  varying  from  three  to  six  or  eight  in  the  twenty-four  hours. 
Near  the  end  of  the  third  week,  in  the  most  severe,  and  during  the 
fourth  in  those  a  little  less  so,  the  patient  becomes  entirely  prostrate  or 
exhausted.  His  countenance  becomes  pale  and  haggard;  his  chin  be- 
gins to  drop,  leaving  his  mouth  open,  except  when  strongly  aroused;  deg- 
lutition difficult;  his  skin  relaxed  and  moistened  Avith  a  clammy  sweat; 
extremities  cool  and  of  a  leaden  hue;  pulse  very  frequent  and  feeble; 
sphincters  relaxed,  permitting  both  urine  and  feces  to  be  discharged  in- 
voluntarily; or  the  urine  tc  be  retained  until  the  bladder  becomes  over- 
distended,  and  then  dribbles  in  the  bed.  When  these  signs  of  extreme 
exhaustion  have  supervened,  the  patient  may  linger  one,  two  or  three 
days,  when  death  from  asthenia  supervenes;  although,  I  have  seen  a  few 
cases  recover  after  all  these  more  dangerous  symptoms,  had  become  well 
marked. 

In  a  very  few  of  the  more  dangerous  cases  of  tjqohoid  fever,  instead  of 
somnolency,  stupor,  muttering  delirium  and  coma,  the  patient  manifests  a 
morbid  vigilance  that  admits  of  no  sleep  either  night  or  day.  The  ex- 
pression of  countenance  is  that  of  anxiety  and  apprehension;  the  pulse  is 
small  and  very  frequent,  respirations  hurried,  the  hands  tremble,  the  skin 
is  most  of  the  time  wet  with  perspiration,  and  yet  the  bodily  temperature 
is  high— from  40°  to  41°  C.  (104.5°  to  106°  F.)  These  cases  are  always 
dangerous,  as  the  nervous  excitement  and  loss  of  sleep  rajDidly  exhaust 
the  strength  of  the  patient. 

Throughout  the  first  and  second  stages  of  tyjohoid  fever  of  all  grades  of 
severity,  there  is  considerable  thirst,  but  either  indifference,  or  positive 
repugnance  to  food,  with  more  or  less  impairment  of  all  the  special  senses. 
Hearing,  especially  is  so  impaired  during  the  second  and  third  weeks,  that 


SYMPTOMS.  89 

in  some  cases  the  patients  appear  quite  deaf.  Vision  is  less  affected,  yet 
somewhat  impaired,  as  are  also  the  senses  of  smell,  taste  and  touch. 
Such,  g-eiitlemen,  are  the  chief  symptoms  presented  during  the  progress 
of  typical  or  uncomplicated  cases  of  typhoid  fever.  If  I  should  leave  you, 
however,  with  the  impression  that  the  forming  stage  and  first  week  of  con- 
finement in  all  the  cases  of  this  disease  corresponded  in  the  symptoms 
with  the  detail  just  given,  you  would  be  very  poorly  prepared  to  appre- 
ciate the  variations  in  different  cases  that  you  will  certainly  meet  at  the 
bedside  of  the  sick.  The  untypical,  or  complicated  cases  of  this  fever 
may  be  arranged  in  three  groups  for  convenience  of  description,  namely, 
those  cases  presenting  in  the  forming  stage  unusual  symptoms  of  gastro- 
intestinal irritation;  those  accompanied  by  inflammatory  action  in  the  air- 
passagc'S  and  puhnonary  structures;  and  such  as  present  at  the  beginning 
chills,  with  decided  exacer'oations  of  fever,  so  well  marked  as  to  resemble 
the  early  stage  of  a  genuine  remittent.  Of  those  constituting  the  first 
group,  I  have  seen  some  commence  suddenly  with  all  the  phenomena  of 
an  ordinary  attack  of  cholera  morbus.  After  vomiting  and  purging 
severely  from  two  to  eight  or  ten  hours,  the  former  ceases,  and  the  latter 
is  reduced  to  simple  diarrhosal  discharges  of  a  grayish,  or  turbid  appear- 
ance, and  a  slow,  febrile  reaction  takes  place,  causing  the  face  to  become 
flushed,  the  lips  and  mouth  dry,  the  skin  moderately  hot,  the  mind  and 
countenance  dull,  pulse  small  and  increased  in  frequency,  with  considera- 
ble thirst  and  some  drowsiness;  and  at  thy  end  of  furty-eight  hours,  instead 
of  convalescence,  as  is  usually  the  case  after  a  simple  attack  of  ordinary 
cholera  morbus,  the  patient  presants  all  the  phenomena  belonging  to  the 
first  part  of  the  active  stage  of  typhoid  fever.  I  have  seen  a  much  larger 
number  of  cases  commence  with  more  or  less  active  diarrhoea,  without 
vomiting. 

At  first  the  discharges  will  be  simply  thin  fecal  matter,  of  light  yellow  or 
grayish  color,  accompanied  by  little  or  no  pain,  and  not  more  than  three  or 
four  in  the  day.  Each  day.  however,  they  become  more  watery  and  frequent, 
the  patient  feels  dull  and  weak,  his  lips  are  dry,  appetite  poor,  mind  listless, 
but  he  often  continues  to  attend  to  his  usual  work  for  several  days,  but 
is  finally  compelled  to  take  his  bed,  at  which  time  you  will  find  him  with 
all  the  usual  phenomena  of  the  active  stage  of  tyj^hoid  fever,  except  those 
pertaining  to  the  alimentary  canal  will  be  unusually  prominent.  The 
cases  belonging  to  this  group,  generally  occur  during  the  warmest  part  of 
summer,  and  appear  to  be  modified  in  the  forming  stage  by  the  causes 
that  usually  favor  attacks  of  cholera  morbus  and  ordinary  summer  diar- 
rhoea. On  the  other  hand,  cases  belonging  to  the  second  group  of  untypi- 
cal attacks,  are  met  with  chiefly  during  the  cold  season  of  the  vear,  more 
especially  late  in  the  autumn,  and  early  in  the  spring,  when  there  is  much 
wet,  with  a  predominance  of  cold.  Every  season  some  of  these  cases  are 
met  with,  and  are  found  by  the  physician,  after  the  patient  has  taken  to 
his  bed,  with  the  following  history:  For  a  period  varying  from  three  to 
six  days,  the  patient  had  been  unusually  sensitive  to  impressions  either  of 
heat  or  cold,  with  many  of  the  symptoms  of  catarrhal  irritation  of  the  air 
passages,  such  as  dull  pain  through  the  temples,  stuffing  of  the  nostrils, 
slight  soreness  in  the  chest,  with  some  cough,  and  some  general  soreness 
of  the  muscular  structures  on  the  back  and  extremities.  The  headache 
increased  from  day  to  day,  the  general  feelings  of  lassitude  and  weari- 
ness became  more  marked,  accompanied  by  more  sense  of  heat  and  flush- 
ing of  the  face  in  the  afternoon,  and  less  feeling  of  ability  to  get  up  and 
go  about  in  the  morning.  When  the  physician  is  called  he  finds  the 
patient  presenting  the  general  symptoms  I  have  mentioned,  which  he  is 


90  TYPHOID    FEVER. 

assured  have  all  come  from  a  "  bad  cold."  On  close  examination,  how- 
ever, he  finds  more  dullness  of  expression,  more  general  dryness  of  the 
skin,  flush  of  the  face,  coating  of  the  tongue;  a  quicker,  softer  pulse;  and 
higher  temperature  than  usually  accompanies  an  ordinary  cold.  Exam- 
ination of  the  chest  and  air  passages  shows  evidence  of  a  congested  and 
rather  dry  condition  of  the  nasal  and  bronchial  mucous  membrane,  with 
occasional  harsh  cough.  The  urine  is  less  than  natural,  and  the  bowels 
quiet  unless  they  have  been  disturLed  by  physic,  in  which  case  they  will 
have  exhibited  a  tendency  to  looseness. 

You  will  perceive  that  these  symptoms  differ  from  those  of  an  ordinary 
cold  by  presenting  a  steadily  increasing  temperature,  and  dryness  of  the 
air  passages,  at  a  time  when  the  feverishness  of  a  catarrhal  attack  should 
have  disappeared,  and  the  secretion  from  the  raucous  membrane  be 
free  and  more  or  less  opaque.  Yet  this  fact  is  often  overlooked,  and  the 
patient  treated  for  a  catarrhal  attack  or  a  sub-acute  bronchitis,  until  an- 
other week  has  passed,  when  the  typhoid  symptoms  become  so  prominent 
as  to  compel  a  recognition.  This  group  of  cases  are  not  only  complicated 
from  the  beginning  by  a  low  grade  of  inflammation  in  the  respiratory 
mucous  membranes,  but  a  limited  area  of  pneumonia  is  also  very  apt  to 
supervene  towards  the  end  of  the  first  or  during  the  second  week  after  the 
patient  takes  to  his  bed.  You  should  remember  this  fact,  and  pay  special 
attention  to  the  physical  signs  elicited  by  an  examination  of  the  chest  from 
day  to  day,  for  the  pneumonic  inflammation  in  many  of  these  cases  is  not 
accompanied  by  the  ordinary  bloody  expector.itioM,  nor  by  so  much  pain 
as  to  attract  the  attention  of  patients.  The  tliir  1  group  of  untypical  cases, 
embracing  those  commencing  with  distinct  chills  and  daily  exacerbations 
of  fever,  are  very  numerous  throughout  the  whole  interior  valley  of  this 
continent,  from  the  great  lakes  to  the  Mexican  Gulf,  though  becoming 
gradually  less  so  from  year  to  year.  If  you  examine  the  facts  collected 
by  Dr.  Daniel  Drake,  and  those  given  in  the  various  reports  contained  in 
the  earlier  volumes  of  Transactions  of  the  American  Medical  Association, 
to  which  I  referred  in  the  lecture  of  yesterday,  you  will  find  much  the  larger 
number  of  the  cases  referred  to  described  as  commencing  with  a  chill  and 
followed,  for  the  first  two  or  three  days,  by  well-marked  exacerbations  and 
remissions. 

The  same  phenomena  accompanied  the  development  of  three  out  of 
every  four  cases  of  typhoid  fever  coming  under  my  observation  during  the 
first  ten  years  of  my  residence  in  this  city,  namely,  from  1849  to  1860. 
This  fact  led  many  of  the  older  practitioners  then  living  in  the  city,  who 
had  been  accustomed  to  meet  only  genuine  intermittents  and  remittents 
during  an  earlier  period  in  the  settlement  of  this  part  of  the  country,  to 
persistently  deny  the  existence  of  any  cases  of  real  t^'phoid  fever  here. 
They  claimed  that  all  such  cases  as  I  have  included  in  this  group,  were 
true  malarious  or  periodical  fevers,  with  a  tendency  to  "run  into  a  typho  d 
condition."  And  I  have  known  many  instances  in  which  the  attending 
physician  repeated  and  increased  his  doses  of  quinine  to  "break  up,"  ur 
abort,  the  fever,  until  Liebermeister  and  all  his  followers  were  fairly  out- 
done in  the  quantities  of  the  anti-periodic  (or,  in  more  modern  phrase, 
anti-pyretic,)  given  to  the  patient  within  a  limited  time.  Nevertheless, 
the  cases  of  fever  continued  their  usual  course,  each  day  bringing  the 
typhoid  phenomena  more  prominent,  until  some  of  them  proved  iatal,  and 
post  mortem  examinations  showed  all  the  characteristic  intestinal  and 
other  lesions  as  perfect  as  in  any  cases  ever  described  by  M.  Louis  in 
Paris.  Although  this  variety  of  cases  is  relatively  much  less  frequent 
than  thirty  or  forty  years  since,  they  are  still  more  or  less  prevalent  every 


DIAGNOSIS.  91 

year,  especially  during  the  latter  part  of  summer  and  autumn.  And  prac- 
titioners are  still  frequently  deceived  as  to  their  nature  when  first  called 
to  attend  them.  It  is  not  three  weeks  since  I  was  called  to  see  a  case  in 
consultation^  in  the  southern  part  of  the  city,  which  at  the  time  of  my  visit 
presented  all  the  characteristics  of  a  well-marked  case  of  enteric  typhoid 
fever  about  the  middle  of  the  second  week  of  its  progress.  Yet  the 
patient  had  suffered  from  so  decided  a  chill  and  exacerbation  of  fever, 
regularly  each  day  for  the  first  three  days  of  sickness,  that  the  attending 
physician  felt  compelled  to  reg  u'd  it  as  a  genuine  malarious  fever,  and  to 
commence  the  treatment  in  accordance  with  that  supposition.  To  recog- 
nize the  true  character  of  these  cases  in  the  beginning-,  requires  the  clo.-e 
and  patient  attention  of  the  physician  to  the  entire  series  of  symptoins 
presented  by  tVie  patient  during  the  first  forty-eight  hours,  and  the  preced- 
ing forming  stage.  If  such  attention  is  given,  it  will  be  observed  that 
though  the  initial  chili  is  well  marked,  the  temperature  during  the  hot 
stage  neither  rises  so  rapidly  nor  attains  so  high  a  figure  on  the  thermom- 
eter, as  in  the  hot  stage  of  a  remittent  fever.  It  is  not  accompanied  by 
the  same  degree  of  active  thirst,  restlessness,  epigastric  distress  or  vomit- 
ing, as  at  the  climax  of  the  paroxysm  in  the  latter.  Neither  is  the  decline 
of  the  paroxysm  so  rapid,  nor  does  tlie  temperature  of  the  patient  return 
so  near  to  the  natural  standard  during  the  remission;  and  when  there  is  a 
coat  on  the  tongue,  it  is  much  thicker  towards  the  back  part  and  along  the 
median  lijie,  than  at  the  beginning  of  uncomplicated  cases  of  periodical 
fever.  If  to  these  we  add  the  greater  dullness  of  expression,  and  less 
activity  of  thought  and  speech,  we  shall  seldom  fail  to  recognize  the  true 
typhoid  character  of  these  cases  as  soon  as  they  come  under  our  care. 
From  the  detailed  description  I  have  now  given  you  of  the  difierent  stages 
and  varieties  of  typhoid  fever,  drawn  directly  from  clinical  observation  at 
the  bedside,  you  will  not  fail  to  recognize  the  fact  that  while  cases  present 
a  wide  difference  in  the  degree  of  severity,  and  considerable  diversity  in 
the  order  of  symptoms  at  the  beginning,  there  is  in  all,  both  a  universal  dis- 
turbance of  the  general  processes  and  functions  of  the  body,  and  a  recog- 
nizable sameness  in  the  character  and   tendencies  of  such  disturbance. 

Diagnosis. — There  can  be  but  little  difficulty  in  arriving  at  a  correct 
diagnosis  in  all  typical  or  unmixed  cases  of  typhoid  fever.  The  long  and 
gradually  increasing  feelings  of  indisposition  before  the  patient  is  com- 
pelled to  take  his  bed,  and  the  gradual  increase  of  temperature  and  oth  t 
febrile  symptoms  through  the  first  week  of  confinement,  are  so  different 
from  the  abrupt  beginning,  and  rapid  rise  of  temperature,  in  the  general  fe- 
vers I  have  already  described,  that  it  would  hardly  be  possible  to  mistake 
one  for  the  other.  The  same  circumstances  place  it  in  still  stronger  contrast 
with  the  sudden  access,  high  excitement,  and  rapid  increase  of  temperature 
that  characterize  the  first  stage  of  fevers  of  the  eruptive  order;  and  in  fact 
of  all  other  acute  general  diseases  except  typhus.  In  the  middle  and  lat- 
ter stages  of  the  disease,  the  addition  of  the  fully  developed  abdominal 
tympanites,  gurgling  on  pressure,  thin  passages,  and  generally  blunted 
sensibilities,  render  the  contrast  between  it,  and  the  other  general  fevers 
more  striking  even  than  in  the  first  stage.  The  untypical  cases  are  far 
more  likely  to  be  confounded  with  sub-acute  bronchitis  or  pneumonitis; 
or  similar  grades  of  inflammation  affecting  the  mucous  membrane  of  the 
stomach  and  intestines,  on  the  one  hand;  and  with  remittent  fever  on  the 
other.  But  the  more  important  symptoms  on  which  we  must  rely  for  cor- 
rect diagnosis  in  these  cases,  were  sufficiently  indicated,  when  T  was  giv- 
ing the  detail  of  symptoms,  and  need  not  be  repeated  here.  There  have 
been  some  cases  of  sub-acute  meningitis  in  children,  of  cerebritis  in  adults, 


92  TYPHOID    FEVER. 

and  of  acute  granular  or  miliary  tuberculosis,  that  were  mistaken  for  ty- 
phoid fever.  It  was  only  yesterday  that  I  saw  a  case  of  the  latter  variety, 
in  the  person  of  a  young  girl  of  13  years,  who  was  represented  to  have  just 
jjassed  through  a  period  of  three  weeks  confinement  with  what  was  sup- 
posed to  be  typhoid  fever,  but  which  was  only  the  acute  stage  of  tubercu- 
losis, as  the  whole  upper  part  of  the  left  lung  is  now  giving  all  the  physi- 
cal signs  of  purulent  softening  or  degeneration.  Such  cases  can  always 
be  distinguished  from  the  general  fever  by  proper  attention  to  the  phj-si- 
cal  sig'us  of  incipient  tuberculosis,  and  the  absence  of  the  characteristic 
alidominal  symptoms  of  the  typhoid  disease.  The  cases  of  sub-acute  men- 
ingitis in  children,  always  present  conditions  and  changes  in  the  pupils 
of  the  eyes,  and  nervous  startings,  very  different  from  anything  ac- 
comjianj'ing  the  early  stage  of  typhoid  fever;  and  though  the  bowels  are 
often  loose  in  such  cases,  the  character  of  the  discharges  are  very  change- 
able in  color  and  quantity,  and  the  abdomen  lank,  as  if  empty;  a  condi- 
tion 1  have  never  seen  in  the  general  typhoid  disease.  Some  of  the  cases 
of  cerebritis  certainly  present  a  train  of  symptoms  closely  resembling  the 
fever  under  consideration.  A  case  of  this  kind  occurred  in  the  practise 
of  the  late  professor  James  McNaughton  of  x^lbany,  in  the  person  of  a 
young  man  who  died  from  what  had  been  regarded  as  a  protracted  ty2Dhoid 
fever,  but  which  the  post  mortem  examination  showed  to  have  been  a  case 
of  cerebritis,  terminating  in  suppuration,  and  a  well  formed  abscess  in  the 
central  part  of  one  of  the  cerebral  hemispheres.  The  case  was  reported 
with  great  candor  and  minuteness,  more  than  twenty  years  since,  by  the 
distinguished  professor,  I  have  just  named.  In  all  the  cases  of  cerebritis 
that  have  come  under  my  observation,  the  pain  in  the  head  has  been  more 
circumscribed,  penetrating,  and  fixed  to  one  place,  and  the  patient  has 
exhibited  much  greater  aversion  to  free  movements  of  the  head,  than  in 
the  general  fever.  Again,  in  the  inflammation  of  the  interior  ^oortions  of 
the  brain,  the  abdomen  is  not  only  empty  and  free  from  tjanpanites,  Vmt 
generally  the  bowels  are  very  costive,  thus  presenting  conditions  just  the 
reverse  of  those  found  in  the  general  typhoid  disease. 

Prognosis. — As  I  have  already  remarked,,  typhoid  fever  is  limited  in  its 
duration,  and  its  general  tendency  is  to  the  recovery  of  the  patient,  es- 
pecially if  placed  under  favorable  hygienic  regulations;  and  yet  the  ex- 
ceptions to  this  favorable  tendency  are  sufficiently  numerous  to  cause  a 
high  ratio  of  mortality.  Its  severity,  and  the  consequent  mortality,  differs 
much  in  different  seasons  of  its  prevalence  and  at  different  periods  of  life. 

A  large  part  of  the  statistics  concerning  the  ratio  of  mortality  have 
been  collected  from  hospital  records,  and  undoubtedly  give  a  much  higher 
ratio  of  deaths  than  takes  place  in  private  practice,  under  ordinary  cir- 
cumstances. For  instance,  of  over  18,000  cases,  collected  from  the  more 
important  public  hospitals  of  London,  Glasgow,  Paris  and  Strasbourg,  by 
Dr.  Murchison,  over  18  per  cent,  or  1  in  5.  -4  died.  Of  1,420  cases  men- 
tioned by  Dr.  Liebermeister,  as  treated  in  the  hospital  in  Basle,  an  aver- 
age of  15  per  cent,  or  1  in  6.6,  proved  fatal.  Dr.  James  Jackson,  of 
Boston,  in  an  interesting  Report  on  Typhoid  Fever,  gives  303  cases 
treated  in  the  Massachusetts  General  Hospital  between  the  years  1828 
and  1835,  of  whom  nearly  13  per  cent,  or  1  in  7  died.  Of  73  cases  given 
by  Dr.  Austin  Flint,  24  per  cent.,  or  1  in  4  terminated  in  death.  Dr. 
George  B.  Wood  states,  that  of  the  whole  numljer  treated  by  him  in  the 
Pennsylvania  Hospital  of  Philadelphia  from  1850  to  1854,  less  than  6  per 
cent.,  or  1  in  17  died.  In  the  general  hospitals  of  New  York,  such  re- 
ports and  statistics  as  have  come  under  my  observation,  lead  to  the  infer- 
ence that  the  average  mortality  resulting  from  typhoid  fever  cases  is  from 


PEOGNOsrSo  93 

1  in  5  to  1  in  7,  or  from  15  to  20  per  cent.  During  the  thirty  years  from 
1850  to  1880,  there  have  been  treated  in  the  wards  of  the  Mercy  Hospital, 
under  my  car.e,  520  cases  of  well  marked  typhoid  fever,  attended  by  a 
mortality  of  1  in  16,  or  G.2  per  cent.  Daring  the  first  ten  years  men- 
tioned it  was  the  only  general  hospital  in  this  city,  and  as  it  then  occupied, 
the  greater  part  of  the  time,  a  building  on  Wabash  Avenue,  neither  con- 
structed for,  nor  well  adapted  to,  hospital  purposes,  its  capacity  was  over- 
crowded by  fever  cases  from  the  poorest  classes  of  society.  Still  the 
highest  ratio  of  mortality  reached  in  any  one  year  was  1  in  9,  or  11  ])er 
cent.  On  the  other  hand,  since  the  completion  of  the  present  ample 
hospital  building  in  1869,  several  years  have  passed  without  a  singe 
death  from  this  disease  in  the  wards  under  my  care.  There  are  two 
reasons  why  the  Hospital  Statistics  show  a  high  ratio  of  mortality  from 
this  disease. 

First,  in  this  country  especially,  most  of  the  patients  admitted  into  the 
general  hospitals  are  from  the  poorer  classes  of  society,  and  have  been 
living  in  the  midst  of  bad  sanitary  conditions. 

Second,  they  are  seldom  brought  to  the  hospital  until  they  have  reached 
the  middle  period  in  the  progress  of  the  disease,  and  sometimes  so  late  as 
to  admit  of  no  treatment,  being  really  in  a  moribund  condition.  I  am 
aware  that  Dr.  Budd  has  estimated  that  the  average  number  of  cases  of 
t3'phoid  fever  occurring  annually  in  Great  Britain  is  110,000,  giving  an 
annual  mortality  of  20,000,  or  1  in  7. 

But  from  my  own  experience,  and  from  what  I  have  seen  in  the  practice 
of  others,  I  am  satisfied  that  the  ratio  of  mortality  from  typhoid  fever 
under  judicious  management  in  private  practice  does  iiot  exceed  one  i;i 
from  twenty  to  twenty-five,  or  from  four  to  five  per  cent.  The  resulcs  are 
not  only  influenced  by  the  different  degrees  of  severity  in  different  years, 
but  also  by  the  age  of  the  patient.  Far  the  greater  number  of  cases  occur 
between  the  ages  of  fifteen  and  thirtv  years,  and  the  younger  the  patients 
the  less  is  the  ratio  of  mortality.  But  few  cases  occur  after  forty  years 
of  age,  and  a  very  high  ratio  of  mortality  results.  Sex  appears  to  exert 
but  little  influence  over  either  the  number  attacked  or  the  ratio  of  deaths. 
Those  accustomed  to  the  habitual  or  excessive  use  of  alcoholic  drinks 
yield  a  very  high  ratio  of  mortality.* 

If  the  temperature  of  the  patient  is  maintained  at  or  above  40.5"  C. 
(105°  F.)  during  the  last  half  of  the  second  week  of  confinement,  it  indi- 
cates a  great  degree  of  danger.  If  a  similar  high  temperature  is  contin- 
ued both  morning  and  evening  during  the  third  week  of  confinement,  it  is 
of  still  more  unfavorable  augury.  But  a  high  temperature  found  only  at 
evening,  while  it  recedes  to  37.2°  or  38.3°  C.  (99°  or  101°  F.)  in  the 
morning,  either  in  the  last  part  of  the  second,  or  during  the  third  week, 
indicates  a  favorable  result.  My  own  clinical  experience  has  led  me  to 
attach  much  less  importance  to  the  mere  degree  of  temperature  in  typhoid 
fever,  than  is  indicated  in  the  works  of  most  recent  writers.  I  am  certain 
that  the  condition  of  the  kidneys,  abdominal  viscera,  and  lungs,  afford  a 
much  more  reliable  guide  for  our  prognosis  than  the  temperature.  If  the 
kidneys  fail  to  eliminate  a  full  amount  of  urea  and  urates,  either  with  or 
without  the  appearance  of  much  albumen  in  the  urine,  even  though  the 
temperature  of  the  body  may  be  low,  there  is  great  danger  attending  the 
fvirther  progress  of  the  case.  The  same  is  true  if  at  any  time  after  the 
middle  of  the  second  week  the  abdomen  becomes  largely  distended  with 
tympanites;  the  intestinal  discharges  frequent  and  somewhat  mixed  with 

*  Liebermeister  states  that  of  nineteen  habitual  drunkards  having  typhoid  fever  In  the  hos- 
rital  at  Basle,  seven,  or  more  than  one-third,  died. 


94  TYI'HOID    FEVER. 

blood,  or  unusually  offensive;  the   spleen  enlarged;  with   a  soft,  frequent 
and  wavy  pulse. 

If,  instead  of  a  simple  admixture  of  blood  with  the  intestinal  discharges 
a  genuine  intestinal  hemorrhage  occurs,  it  indicates  great  danger  of  an 
early  fatal  result.  And  ^9e9y6»ra^^o?i  of  the  intestine,  which  sometimes 
occurs  in  the  advanced  stages  of  the  disease,  or  even  during  convalescence, 
is  pretty  uniformly  followed  speedily  by  general  peritonitis,  vomiting, 
collapse  and  death.  The  number  of  cases  in  which  the  hypostatic  en- 
gorgement of  the  lower  and  posterior  part  of  the  lungs,  coupled  with 
extensive  congestion  of  the  capillary  bronchial  tubes,  so  far  interferes 
with  the  oxygenation  and  decarbonization  of  the  blood,  that  the  latter 
fails  to  sustain  the  functions  of  the  nervous  centres;  the  patient  becomes 
very  drowsy;  pulse  and  heart's  action  weak;  cutaneous  capillary  circula- 
tion feeble;  and  the  sphincters  of  rectum  and  bladder  relaxed,  allowing 
more  or  less  involuntary  discharges,  and  finally  death,  is  greater  than  you 
would  infer  from  most  of  the  works  on  practice  within  your  reach.  The 
fatal  result  in  many  of  these  cases  is  attributed  to  cardiac  weakness,  and 
alcoholic  remedies  are  resorted  to  with  the  idea  of  strengthening  the 
heart;  while  in  truth  they  only  increase  the  deficiency  of  blood  oxygena- 
tion, still  further  anaesthetize  the  nervous  centers,  and  hasten  the  fatal 
result. 


LECTUKE  XII. 

Tjrptoid  Fever  Continued— Its  special  Pathology,  Pathological  Anatomy,  and  Treatment. 

GENTLEMEN  :  After  what  I  have  stated  to  you  in  the  lecture  on  the 
general  pathology  of  all  idiopathic  fevers,  it  is  not  necessary  that  I  dis- 
cuss at  any  considerable  length  the  special  pathology  of  any  one  member 
of  the  class.  I  then  endeavored  to  trace  the  starting  point  of  all  fevers  to 
an  active  disturbance  of  those  general  properties  of  living  organized  mat- 
ter, that  control  atomic  or  molecular  changes,  and  impart  the  capacity  to 
receive  organic  impressions;  in  other  words,  to  those  general  elementary 
properties  that  I  have  designated  as  susceptibility  and  vital  affinity.  The 
essential  pathology  of  typhoid  fever  consists  in  such  an  impairment  of  these 
properties  as  to  lessen  the  impressions  of  all  the  natural  excitors  of  organic 
life,  such  as  oxygen,  light,  heat,  food,  and  mental  activity,  and  to  impair  the 
regularity  and  activity  of  those  atomic  changes  concerned  in  the  processes 
of  nutrition,  disintegration,  secretion,  and  elimination.  In  consequence 
of  such  impairment  of  the  general  properties,  there  necessarily  follows 
corresponding  impairment  of  nerve  sensibility,  of  the  generation  of  nerve 
force,  and  of  the  performance  of  all  the  jorimary  functions  of  the  body. 
The  slow  but  steady  increase  of  heat  through  the  forming  stage  and  first 
week  of  confinement,  is  evidently  owing  much  more  to  a  diminution  of 
those  processes  by  which  free  heat  is  rendered  latent,  than  to  any  increase 
in  the  rapidity  of  tissue  changes  causing  increased  heat  production.  The 
impairment  of  the  vital  affinity  on  which  the  secrating  structures  depend  for 
tiieir  ability  to  elect  from  the  blq^d  the  elements  necessary  to  form  their 
respective  secretions,  rationally  accounts  for  the  general  diminution  of  se- 


ITS    SPECIAL    PATHOLOGY.  95 

cretions,  and  the  constant  tendency  to  the  accumulation  of  effete  matter  in 
the  blood,  and  the  steadily  iiicreasincr  deterioration  in  the  quality  of  that 
fluid.  The  same  change  in  the  force  of  affinity  also  lessens  the  tonicity 
of  the  tissues,  favors  passive  cong-estions,  hypostatic  infiltrations,  asthenic 
inflammation,  svith  softening  or  ulceration,  and  fatty  degeneration.  You 
thus  perceive  that  tvphoid  fever,  instead  of  being  a  disease  of  excitement, 
of  increased  molecular  activity  from  exaltation  of  the  general  properties, 
is  one  of  true  debility,  both  in  regard  to  the  strength  or  integrity  of 
structures,  and  the  activity  of  the  various  functions  and  processes.  This 
view  of  the  nature  of  the  morbid  processes  constituting  the  essential 
pathology  of  this  variety  of  fever,  is  in  harmony  with  the  nature  of  the 
causes  known  to  favor  its  development,  and  also  with  the  morbid  anatomy 
or  pathological  changes  in  the  solids  and  fluids  presented  in  post  niortetii 
examinations.  It  matters  not  whether  the  disease  is  produced  by  the 
direct  influence  of  the  impure  air  of  over-crowded  dwellings,  damp  and 
unventilated  places,  impure  water  from  soils  impregnated  with  decompo- 
sable org;anic  matter;  excessive  physical  labor,  and  protracted  mental  de- 
pression and  anxiety;  or  from  some  specific  poison  which  may  have  gained 
access  to  the  blood,  it  is  evident  that  all  these  agencies  have  the  tendency 
to  depress  or  impair  the  properties  and  functions  of  the  living  body. 

Pathological  Anatomy. — The  changes  in  the  fluids  and  solids  of  the 
human  body  during  the  p  ogress  of  a  typical  case  of  typhoid  fever  of  or- 
dinary severity,  aft'ord  a  very  interesting  field  for  study.  The  secretions 
and  eliminations  constituting  one  class  of  the  fluids,  are  very  generally 
diminished  in  quantity,  as  indicated  by  the  unnatural  dryness  of  the  cuta- 
neous and  pulmonary  surfaces,  and  the  actually  smaller  quantity  of  saliva, 
gastric  juice,  and  urine,  secreted  each  day  during  the  active  progress  of 
disease.  The  pulraonaty  and  cutaneous  exhalations  vary  much,  both  in 
quantity  and  quality,  in  different  cases  and  in  different  stages  of  the  same 
case.  But  the  nature  and  extent  of  these  changes,  and  their  relations  to 
the  progress  of  the  general  disease,  have  not  been  accurately  ascertained. 
The  systematic  and  thorough  investigation  of  these,  with  the  aid  of  both 
analytical  chemistry  and  the  microscope,  is  worthy  of  yoi;r  future  atten- 
tion. The  renal  secretion  has  already  been  investigated  with  much  care 
and  success.  It  has  been  ascertained  that  the  quantity  of  urine  voided  in 
the  twenty-four  hours  begins  to  diminish  during  the  forming  stage,  and 
continues  to  decrease  during  the  first  week  of  confinement.  In  cases 
tending  to  recovery  it  increases  during  the  second  week,  and  returns  nearly 
or  quite  to  the  natural  quantity  during  the  third. 

In  cases  of  more  than  average  severity,  and  in  those  tending  toward  a 
fatal  termination  the  quantity  of  urine  voided  is  apt  to  vary  much  from 
day  to  clay  during  the  second  and  third  weeks  after  the  patient  is  confined 
to  his  bed.  Sometimes  the  urinary  secretion  is  so  nearly  suppressed  as  to 
cause  a  speedily  fatal  result.  A  man  was  brought  into  the  Mercy  Hospital 
only  a  few  days  since,  in  the  third  week  of  what  appeared  to  be  a  case  of 
ordinary  typhoid  fever.  The  mind  of  the  patient  was  dull  and  incapable 
of  giving  any  reliable  history  of  his  case.  At  the  end  of  twenty-four 
hours  it  was  ascertained  that  he  had  two  or  three  intestinal  evacuations, 
but  had  passed  little  or  no  urine,  and  during  the  following  night  he  had 
general  convulsions  and  died.  Alterations  in  the  constituents  of  the 
urine  are  also  of  much  importance.  The  specific  gravity  is  generally  in- 
creased in  proportion  to  the  diminution  in  the  quantity  of  urine.  The 
quantity  of  chloride  of  sodium  is  decidedly  diminished.  The  sulphuric 
and  phosphoric  acids  are  found  to  remain  nearly  the  same  as  in  health. 
But  the  urea,  uric  acid   and  colored  pigment  are  decidedly  increased,  not 


96  TYPHOID    FEVER. 

only  relatively  to  tlie  quantity  of  urine,  but  absolutely  above  the  usual 
quantit}'  of  these  ingredients  in  health.  The  increase  of  urea  and  uric 
acid  is  most  marked  during  the  first  two  weeks  from  the  initial  symptoms. 
During  the  third  w^eek  it  is  more  variable,  being  sometimes  above  and  at 
others  below  the  natural  standard.  The  latter  is  almost  always  the  case 
during-  the  period  of  convalescence.  Neither  the  absolute  quantity  of 
urine  voided,  nor  the  relative  proportion  of  its  several  constituents,  have 
been  found  to  bear  any  fixed  or  uniform  relation  to  the  deg-ree  of  pyrexia 
or  fever  heat.  So  true  is  this,  that  in  many  of  the  most  dangerous  cases 
when,  during  the  third  or  fourth  weeks  the  temperature  has  risen  to  40°  or 
41°  C.  (104:°  or  106°  F.),  the  amount  of  urea  excreted  in  a  given  time  has 
been  found  so  much  below  the  natural  standard  as  to  cause  just  fears  of 
uremic  poisoning  from  its  retention  in  the  blood.  During  the  first  two 
weeks  of  typhoid  fever  the  urine  gives  a  stronger  acid  reaction  than  in 
health.  This  is  caused  by  the  greater  concentration  from  diminution  of 
the  waterj^  element,  and  not  from  an  increase  in  the  quantity  of  acids,  for 
the  most  reliable  analyses  show  the  total  amount  of  acids  eliminated  in  the 
twenty- four  hours,  to  be  less  than  in  health.  In  the  third  and  fourth  weeks 
of  the  more  dangerous  cases,  the  urine  gives  a  decided  alkaline  reaction 
from  the  presence  of  a  fixed  alkali. 

Besides  the  foregoing  changes  in  the  natural  constituents  of  the  urine, 
albumen  has  been  found  in  some  part  of  the  progress  of  about  one-third 
of  the  cases  examined.  In  a  large  majority  of  these  cases,  the  presence 
of  albumen  was  only  temporary,  while  in  a  smaller  number  it  continued 
and  was  associated  with  renal  epithelium,  tubular  casts  and  blood  cor- 
puscles. And  in  a  verv  small  number  these  elements  remained  after  com- 
plete convalescence  from  the  fever,  and  constituted  the  beginning  of 
Bright's  disease.  The  secretion  of  bile  is  generally  diminished,  as  shown 
by  examination  of  the  intestinal  discharges,  though  seldom  suppressed. 
Dr.  Hoifman,  who  took  special  pains  to  investigate  the  quantity  and  qual- 
ity of  this  secretion,  found  it  to  be  thin  and  much  less  colored  in  one-fourth 
ol  the  cases  examined.*  I  am  not  aware  of  any  special  investigations 
concerning  the  composition  and  properties  of  the  salivary,  gastric,  and 
pancreatic  secretions  in  continued  fever.  The  general  indications  are 
that  they  are  decidedly  diminished  in  quantity  during  all  the  active  or 
advancing  stage  of  the  disease.  The  only  source  from  which  an 
increase  of  secretion  or  exudation  takes  place  in  nearly  all  the 
cases  of  tj'^phoid  fever,  is  the  mucous  membrane  of  the  ilium  and  colon. 
The  intestinal  evacuations  are  very  notably  increased,  as  I  have  stated  in 
detailing  the  symptoms,  during  all  the  middle  and  later  stages  of  the  dis- 
ease, and  in  some  cases  from  the  beginning.  Such  increase,  however,  is 
not  from  an  increase  of  the  natural  secretions  from  the  various  glandular 
structures  contained  in  the  mucous  membrane,  but  an  exudation  from  the 
locally  diseased  glands,  and  consists  mostly  of  the  water  or  serum  of  the 
blood  holding  in  suspension  some  mucous,  epithelium  cells,  the  debris  of 
food  and  foecal  matter,  sometimes  blood  corpuscles,  and  various  saline  in- 
gredients. The  exudation  comes  chiefly  from  the  aggregated  glands  of 
Payer  and  the  solitary  glands  of  Brunner  in  various  stages  of  asthenic  in- 
flammation. 

And  though  most  of  the  pathologists  of  the  present  day,  represent  the 
so-called  typhoid  fever  germs  as  existing  in  the  intestinal  evacuations  of 
patients  laboring  under  that  disease,  yet  no  one  has  thus  far  been  able  to 
identify  any    such    germs   as    peculiar  to  the   discharges    in  this  vaiiety 

*  See  Ziemssen's  Cyclopcedia,  Vol,  I,  p.  106, 


PATHOLOGICAL    ANATOMY.  97 

of  fevor.  Tbo  blood  itself  undergoes  important  changes  during  the  pro- 
gress of  this  disease.  During  the  period  intervening  between  1850  and 
ISGO,  I  made  a  careful  and  somc^what  extended  investigation  of  the  blood 
at  different  stages,  of  both  typhoid  and  periodical  fevers. 

1  took  from  the  arms  of  several  typical  cases  of  typhoid  fever  in  the 
wards  of  the  Mercy  Hospital  under  my  care,  sufficient  blood  for  full  chemi- 
cal and  microscopical  analysis,  in  the  first,  second,  and  third  weeks  in  the  pro- 
gress of  the  disease.  I  also  examined  specimens  of  blood  taken  from  the 
cavities  of  the  heart  in  some  cases   resulting  fatally. 

It  is  not  pro;;er  to  occupy  your  time  here  with  the  detail  of  these  inves- 
tigations. 1  will  state  the  results  as  follows:  To  ordinary  inspection  the 
blood  taken  during  the  first  week  was  a  shade  darker  color,  than  healthy 
venous  blood;  that  during  the  second,  a  little  darker  than  the  first;  that 
t.ikeu  during  the  third  week  in  bad  cases,  and  that  found  in  the  right  cav- 
ities of  the  heart  after  death,  was  much  darker  in  hue  than  either  of  the 
previous  specimens.  That  taken  during  the  third  week  from  cases  tending 
to  recovery,  had  not  changed  perceptibly  in  color,  from  that  taken  earlier 
in  the  progress  of  the  disease.  All  the  specimens  coagulated  more  slowly 
than  healthy  blood;  the  clot  formed  was  larger,  softer  and  more  easily  torn 
tlian  patural.  This  diminished  coagulability  and  tenacity  of  the  fibrin 
became  more  marked,  as  the  disease  advanced;  and  in  some  of  the  fatal 
cases  the  blood  remained  fluid  after  death,  very  dark  color,  with  a  film  of 
oil  over  the  surface.  The  clot  was  not  only  slow  in  forming,  but  contract- 
ed very  little  after  it  had  formed,  and  was  easily  lacerated  or  broken  to 
pieces.  The  small  amount  of  serum  that  separated  from  the  clot  looked 
more  turbid  than  the  serum  of  healthy  blood.  Examinations  with  the 
microscope  showed  no  marked  changes  except  that  the  red  corpuscles  ap- 
peared less  disposed  to  adhere  together  in  rows,  and  some  of  them  were 
corrugated  and  irregular  in  outline  as  if  commencing  to  disintegrate  ; 
there  was  very  little,  if  any,  increase  in  the  number  of  white  corpuscles  ; 
here  and  there  a  fat  granule  with  many  specks  or  shreds  of  what  appeared  to 
be  the  debfis  of  disintegrated  corpuscles  were  seen,  more  especially  in  the 
specimens  of  blood  from  the  advanced  stage  of  severe  cases  ;  and  there 
was  more  or  less  haematin  or  red  coloring  matter  in  the  serum.  Careful 
quantitive  analysis  showed  a  progressive,  though  moderate,  diminution  in 
the  relative  proportion  of  albumen,  red  corpuscles,  and  chlorides,  as  the 
disease  advanced.  On  the  other  hand,  the  white  corpuscles,  fatty  and  ex- 
tractive matters,  were  moderately  increased,  while  the  fibrin  varied  from  2.2 
to  2.8  parts  in  1000,  which  is  nearly  the  same  as  in  healthy  blood.  From 
these  investigations  it  appears  that  the  nutritive  and  formative  constituents 
of  the  blood  undergo  a  progressive  moderate  diminution  in  their  relative 
proportion  as  the  fever  advances  through  its  several  stages,  and  the  pro- 
ducts of  tissue  disintegration  increase.  If  there  are  any  exceptions  to  this 
rule,  it  is  in  the  apparent  increase  in  the  number  of  white  corpuscles  and 
the  continuance  of  the  natural  proportion  of  fibrin.  I  think  further  in- 
vestigations will  show  that  the  increase  of  the  former  is  derived  altogether 
from  the  lymph  in  the  lymphatic  vessels  returning  matter  from  the  organized 
tissues,  and  the  proportion  of  fibrin  will  be  found  to  vary  in  strict  accord- 
ance with  the  variations  in  the  quantity  of  urea  and  uric  acid  excreted  from 
the  kidneys.  So  long  as  the  quantity  of  urea  continues  large,  the  fibrin 
in  the  blood  will  be  found  at  or  slightly  below  the  natural  standard,  and 
vice  versa.  As  you  will  have  seen  by  the  detail  I  have  given,  the  quality 
of  the  more  important  organic  constituents  of  the  blood,  is  impaired  to  a 
much  greater  (Jiegree  in  typhoid  fever,  than  the  quantity  or  relative  pro- 
portion of  each.    Ever  since   the  analyses    of   M.  M.  Andral  and  Gavarett, 

7 


98  TYPHOID    FEVEE. 

authors  have  represented  the  fibrin  of  the  blood  as  particularly  deficient  in 
both  typhoid  and  typhus,* 

These  distinguished  investigators  in  separating  the  fibrin  from  the  other 
constituents  of  the  blood,  practiced  the  very  common  method  of  stirring 
the  freshly  drawn  blood  with  a  bundle  of  rods  for  the  purpose  of  entan- 
gling the  fibrin  on  them  as  it  solidifies.  This  mode  is  sufficient  when  the 
fibrin  coagulates  with  its  natural  degree  of  readiness  and  tenacity.  But 
I  found  in  the  advanced  stage  of  bad  cases  of  typhoid  fever,  these  proper- 
ties of  the  fibrin  so  impaired  that  very  little  could  be  gathered  upon  the 
rods  by  diligent  stirring  for  an  hour.  The  same  blood,  however,  when 
allowed  to  stand  at  rest  three  hours  or  more  presented  a  large,  soft  clot, 
which,  when  enclosed  in  clean,  firm  linen  cloth,  and  washed  under  a 
stream  of  water  until  all  the  corpuscles  were  removed,  as  practiced 
by  Dr.  Bence  Jones,  of  London,  gave  a  proportion  of  fibrin  eqtial  to  2.3 
per  1000.  These  facts  have  led  me  to  think,  the  very  prevalent  idea, 
that  the  quantity  of  fibrin  in  the  blood  of  patients  affected  with  the 
lower  grades  of  continued  fever  is  very  deficient  is  not  altogether  correct. 
Turning  from  the  fluids  to  the  various  organized  structures  of  the  body,  we 
can  find  some  appreciable  changes  resulting  from  protracted  and  fatal 
cases  of  typhoid  fever,  in  nearly  all  of  them.  In  the  nervous,  muscular, 
vascular,  and  secreting  structures  generally,  a  critical  examination  aided 
by  the  microscope,  shows  some  degree  of  softening  or  impairment  of  the 
tonicity  and  tenacity  of  the  textures  accompanied  by  more  or  less  fatty  de- 
generation. These  general  degenerative  changes  and  impairments  of  tex- 
ture, are  attributed  by  most  writers  and  teachers  to  the  influence  of  the 
protracted  high  temperature,  and  not  to  anything  belonging  to  the  essen- 
tial pathology  of  this  variety  of  fever.  So  far  as  a  high  temperature  im- 
pairs the  force  of  vital  affinity  and  thereby  retards  the  molecular  changes 
in  the  several  tissues,  it  aids  in  the  work  of  cell  and  granule  degeneration. 

But  you  must  keep  in  mind  the  fact  that  impairment  of  the  property 
called  vital  affinity  is  an  essential  and  primary  part  of  the  pathology  of 
this  fever,  and  its  steady  increase  during  the  progress  of  protracted  and 
fatal  cases,  is  abundantly  sufficient  to  cause  the  general  impairments 
of  textures  without  regard  to  the  direct  influence  of  heat,  especially  when 
aided  by  the  imperfectly  oxygenated  and  decarbonized  condition  of  the 
blood  existing  in  the  middle  and  later  stages  of  all  those  cases  in  which 
the  capacity  of  the  lungs  is  diminished  both  by  congestion  of  the  bron- 
chial membrane  and  hypostatic  engorgement  of  the  more  dependent  portion 
of  the  lungs. 

I  have  no  doubt  but  the  primary  impairment  of  the  vital  affinity,  the  in- 
creased temperature,  and  the  imperfect  oxygenation  of  the  blood  all  co- 
-operate  in  producing  the  very  general  softening  and  molecular  degenera- 
tion, that  is  found  in  nearly  all  the  organized  tissues  of  the  body  after 
death  from  typhoid  fever.  You  will  find  these  general  changes,  in  mak- 
ing: ordinary  post  mortem  examinations,  most  noticeable  in  the  dark 
color  and  passively  engorged  condition  of  the  posterior  portion  of  the 
lungs,  the  softened  condition  of  the  muscular  structure  of  the  heart;  and 
the  enlarged  and  softened  state  of  the  spleen  and  liver.  But  the  special 
pathological  changes  of  structure,  universally  regarded  as  character- 
istic of  this  fever,  are  found  in  the  aggregated  and  solitary  glands  in  the 
mucous  membrane  of  the  ilium; — the  glands  of  the  mesentery;  and  the 
spleen. 

The  aggregated   glands  of  Payer,  or  elliptical  plates,  as  they  are  often 

*  See  Flint's  Practice,  5th  Ed.,  p.  951. 


i 


PATHOLOGICAL    ANATOMY.  99 

called,  evidently  become  red  and  tumefied  early  in  the  progress  of  the 
disease.  And  after  death,  they  are  found  in  all  stages  of  morbid  change, 
from  simple  redness  and  swelling  sufficient  to  make  their  outline  easily 
recoo-nized,  to  complete  destruction  by  softening  and  ulceration  until  only 
an  open  ulcer,  with  abrupt  margins,  and  the  muscular  fibres  of  the  middle 
coat  of  the  intestine  at  the  bottom,  occupies  the  place  where  the  gland  had 
been.  The  solitary  glands  of  Brunner  are  generally  much  enlarged,  but  not 
often  ulcerated.  The  glands  in  the  mesentery  opposite  the  changes  in  the 
mucous  membrane,  are  also  found  increased  in  vascularity,  enlarged,  soft- 
ened, and  sometimes  reduced  to  a  pulpy  or  creamy  consistence.  All  these 
chanofes  are  found  in  the  greatest  degree  of  progress  in  the  lower  part  of 
the  ilium  and  at  its  junction  with  the  colon,  diminishing  as  we  ascend  the 
intestine  until  at  the  distance  of  three  metres  (ten  feet)they  are  absent  alto- 
gether. If  you  examine  these  fresh  specimens  of  the  lower  section  of  the 
ilium,  which  have  been  laid  open  to  expose  fully  the  mucous  membrane,  from 
the  ilio-colic  junction  upward  for  a  distance  of  one  metre,  or  about  three  feet, 
with  portions  of  the  mesentery  attached,  containing  several  mesenteric 
glands  in  various  stages  of  enlargement,  from  the  size  of  a  pea  to  that  of 
a  hickory  nut,  you  will  have  a  better  knowledge  of  these  morbid  changes 
than  1  could  impart  by  any  mere  verbal  description.  Beginning  at  the 
upper  part  you  see  several  of  the  elliptical  plates  of  Payer  merely  reddened 
and  elevated  by  swelling,  enough  to  make  their  outline  easily  recognized. 
A  little  lower,  there  are  others  more  elevated,  with  small  excavations  on 
the  surface,  indicating  the  commencement  of  ulceration.  Around  aud  be- 
tween these  you  see  quite  a  number  of  single,  round,  elevated  bodies  near 
the  size  of  small  peas,  which  are  the  inflamed  and  enlarged  glands  of 
Brunner.  Still  lower,  or  nearer  to  the  junction  with  the  colon,  you  see 
not  the  glandular  structures  elevated  and  undergoing  the  process  of  soft- 
ening, but  in  their  place  open  oval-shaped  ulcers,  with  abrupt  and  some- 
what irregular  margins,  and  between  them  the  mucous  membrane,  gener- 
ally redder  than  natural.  Some  of  the  adjacent  enlarged  mesenteric 
glands  I  have  laid  open  by  an  incision,  and  you  see  their  interior  present- 
ing evidences  of  increased  vascularity  and  in  various  stages  of  softening 
with  some  caseous  degeneration. 

There  is  another  shorter  section  of  the  lower  part  of  the  ilium,  not  fresh, 
but  selected  from  the  wet  preparations  in  the  museum,  in  which  you  see 
a  large  ulcer  occupying  the  place  of  one  of  the  elliptical  plates,  with  a 
complete  perforation  of  the  muscular  and  peritoneal  coats.  It  was  taken 
from  a  patient  who  was  brought  into  the  hospital  in  a  state  of  collapse 
preceded  by  all  the  characteristic  symptoms  of  sudden  perforation,  general 
peritonitis,  and  death.  The  constancy  with  which  these  intestinal  glands 
are  found  diseased  in  making  post  mortem  examinations  of  typhoid  fever 
patients,  has  led  some  pathologists  to  regard  them  as  the  essential  and 
primary  seat  of  the  disease. 

The  well  ascertained  facts,  however,  that  the  extent  of  the  disease  in 
these  glandular  structures  bears  no  uniform  relation  to  the  severity  and 
danger  of  the  general  fever,  and  that  the  earlier  the  patient  dies  from 
some  unusual  malignity  of  the  fever,  the  less  are  the  appearances  of  dis- 
ease in  the  intestines  and  mesentery,  show  the  latter  to  be  consequences 
or  results  of  the  general  morbid  actions  set  up  throughout  the  system. 
And  as  a  rule,  the  more  protracted  the  course  of  the  fever,  the  more  ex- 
tensive will  be  the  ulceration  of  the  aggregated  glands  in  the  ilium,  the 
enlargement  and  softening  of  the  mesenteric  glands  and  spleen,  and  the 
molecular  degenerations  of  the  muscular  and  nervous  structures  generally. 
You  will  not  fail  to  perceive  from  the  detailed  descrijDtion  I  have  given, 


100  TYPHOID    FEVER. 

that  the  entire  series  of  changes  taking  place  during  the  progress  of  the 
general  fever  are  in  the  direction  of  impairment  of  tonicity,  passive  con- 
gestions, molecular  degenerations,  softening  of  texture,  and  ulcerations 
in  the  glands  of  the  intestinal  mucous  membrane'  Wherever  inflammatory 
action  is  set  up,  whether  in  the  alimentary  canal,  the  lungs,  or  the  brain, 
it  assumes  a  purely  asthenic  character,  leading  directly  to  tumefaction, 
softening,  vilceration  or  gangrene.  Nowhere  do  we  find  plastic  exuda- 
tions or  indurations  of  structure.  In  a  few  instances,  small  gray  depos- 
its, looking  much  like  miliary  tubercles,  have  been  observed  in  the  tume- 
fied glands  of  the  ilium.  By  some  they  have  been  called  typhus  depos- 
its, but  their  presence  does  not  appear  to  alter  in  any  way  the  usual 
tendency  to  softening  and  ulceration  of  these  glands,  and  it  is  doubtful 
whether  they  possess  any  pathological  significance. 

Treatment. — From  the  facts  and  considerations  I  have  now  presented 
to  you  concerning  the  causes,  clinical  history,  and  special  pathology  of 
this  important  general  disease,  we  may  see  clearly  several  important  in- 
dications to  be  fulfilled,  or  objects  to  be  accomplished,  in  its  treatment. 

First,  it  is  desirable  to  suspend  as  far  as  practicable  the  further  action 
upon  the  patient,  of  all  the  causes  that  may  have  contributed  to  the 
development  of  the  disease. 

Second,  to  restore  the  natural  condition  of  the  general  properties  of  the 
tissues,  and  thereby  retard  or  arrest  those  perverted  molecular  movements 
which  constitute  the  disturbances  of  nutrition,  secretion,  excretion,  etc. 

Third,  to  promote  the  action  of  certain  excretory  organs  and  thereby 
prevent  deterioration  of  the  blood  by  the  accumulation  of  the  products  of 
tissue  changes  or  waste  matter. 

Fourth,  to  counteract  the  development  of  important  local  diseases, 
either  in  the  head,  chest  or  abdomen. 

Fifth,  to  sustain  the  patient  with  nourishment  suitably  adjusted,  both 
in  quality  and  quantity,  to  the  difi"erent  stages  of  the  disease. 

These  several  objects,  gentlemen,  are  not  to  receive  your  attention  in 
consecutive  order  of  time,  as  I  have  named  them,  but  as  distinct  objects 
to  be  accomplished  in  the  management  of  all  general  acute  diseases.  They 
should  be  clearly  before  your  minds  at  every  visit  to  the  bedside  of  j^our 
patient,  from  the  beginning  to  the  end  of  your  attendance. 

To  fulfill  properly  the  first  indication  named  requires  both  a  proper 
regulation  of  all  the  hygienic  surroundings  of  the  patient,  and,  so  far  as 
the  present  state  of  medical  knowledge  will  permit,  the  administration  of 
such  remedies  as  will  either  neutralize  or  expel  the  specific  fever  poison 
from  the  system,  if  such  poison  exists.  To  secure  for  your  patient  an 
abundance  of  fresh,  pure  air,  at  a  comfortable  temperature;  to  secure  a 
high  degree  of  cleanliness  by  suitable  changes  of  shirts  and  bed-clothes, 
and  frequent  ablutions;  and  to  have  all  evacuations  from  the  kidneys  and 
bowels  promptly  removed  from  the  room;  are  matters  of  the  highest  im- 
portance, and  should  not  be  overlooked  for  a  single  day  in  any  stage  of 
the  disease.  Unfortunately  you  will  meet  with  a  large  proportion  of  your 
cases  of  typhoid  fever  among  the  laboring  classes,  occupying  small,  badly 
ventilated  bed-rooms;  and  in  large  towns  and  cities,  especially,  in  tene- 
ment houses  or  small  buildings  on  narrow  streets  and  alleys,  and  some- 
times in  damp  basements.  In  many  such  cases  a  proper  supply  of  fresh 
and  pure  air  is  not  to  be  obtained,  and  you  will  be  obliged  to  have  them 
removed  from  their  homes  or  treat  them  under  the  disadvantage  of  an  in- 
sufficient degree  of  ventilation.  Many  of  this  same  class  of  patients  will  have 
an  inadequate  supply  of  shirts  and  sheets  to  permit  the  changes  necessary 
for  insuring  a  healthful  degree  of  cleanliness;  and  not  a  few  of  them  will 


TKEATMENT.  101 

persist  in  keeping  on  two  or  three  coarse  woolen  shirts  all  saturated  with 
the  cutaneous  eliminations  for  a  week  or  more,  even  if  they  have  a  plen- 
tiful supply.  It  is  your  duty,  however,  in  all  cases,  to  exercise  your 
influence  in  procuring  for  those  under  your  care  the  best  degree  of  ven- 
tilation and  cleanliness  that  the  circumstances  will  permit.  By  so  doing 
vou  will  remove  as  far  as  practicable  the  further  action  of  those  influences 
that  are  generally  recognized  as  predisposing  causes.  If  we  admit  the 
existence  of  a  specific  fever  poison  in  the  blood,  as  the  essential  or  direct 
excitinp-  cause,  to  suspend  its  further  action  requires  the  use  of  such 
remedies  as  will  either  neutralize  the  poison  or  cause  its  elimination.  As 
we  have  no  reliable  knowledge,  however,  concerning  the  nature  and  prop- 
erties of  this  supposed  poison,  we  have  no  guide  for  the  selection  of 
remedies  to  act  upon  it.  Bat,  in  consequence  of  the  known  deficiency  of 
the  chlorine  salts  in  the  blood  and  its  defective  arterialization,  as  shown 
by  the  early  and  marked  deficiency  of  these  constituents  in  the  urine  and 
the  darker  color  of  the  blood,  we  may  give  the  chlorate  of  potassium  in 
solution,  acidulated  with  the  hydrochloric  acid,  for  the  purpose  of  supply- 
ins:  these  deficiencies,  and  the  free  chlorine  which  the  solution  contains 
will  constitute  as  efficient  an  antiseptic  for  destroying  organic  germs  in 
the  blood  as  any  we  could  administer  with  propriety.  Ever  since  the  in- 
genious experiments  of  M.  Bernard,  by  which  it  was  demonstrated  that 
the  capacity  of  the  blood  for  taking  up  oxygen  was  increased  by  the  ad- 
dition of  the  chlorates  and  other  salines,  I  have  used  the  chlorate  of  potassium 
in  dilute  acidulated  solution,  in  the  early  stage  of  typhoid  fever,  and  with 
marked  benefit.  Whether  the  benefit  obtained,  is  owing  to  the  action  of 
the  free  chlorine  on  the  supposed  fever  poison,  or  to  the  increased  amount 
of  oxygen  taken  up  from  the  air-cells  of  the  lungs  by  the  addition  of  the 
chlorate  of  potassium  to  the  serum  of  the  blood,  or  to  both,  I  do  not  know.* 

That  increasing  the  chlorate  of  potassium  in  the  blood  increases  the 
oxygenation  of  that  fluid,  I  have  demonstrated  many  times,  clinically,  by 
giving  it  to  children  affected  with  cyanosis  from  congenital  defects  in  the 
heart. 

That  an  abundant  supply  of  pure  air,  not  only  increases  the  oxygena- 
tion of  the  blood  and  resists  the  impairment  of  the  quality  of  its  constitu- 
ents, but  also  greatly  improves  nervous  sensibility  and  promotes  the  nat- 
ural molecular  changes  in  all  the  structures  of  the  body,  and  thereby 
greatly  increases  the  tendency  to  recovery  from  attacks  of  typhoid  and 
other  low  forms  of  fever,  has  been  abundantly  proved  by  clinical  obser- 
vation. I  think  it  was  the  uniform  experience  of  members  of  the  medical 
staff  of  the  army  during  the  late  war  for  maintaining  the  Union,  that 
whenever  they  were  obliged  to  treat  their  fever  patients  in  tents,  or  simply 
under  canvas,  a  very  much  larger  ratio  of  recoveries  took  place  than  when 
they  were  treated  in  the  wards  of  their  best  regulated  hospital  buildings. 

*  From  the  recent  investigations  of  >I.  Pasteur,  concerning  the  efifects  of  simple  dilution  and 
exposure  to  the  oxygen  of  the  air,  of  infectious  organic  poisons,  in  lessening  their  virulence  and 
finally  rendering  them  wholly  inactive,  we  derive  additional  proof  that  oxygen,  is  not  only  an  ex- 
citor  of  organic  life,  but  also  "one  of  the  most  efficient  germicides  or  antiseptics. 


102  TYPHOID   FEVER. 


LECTUEE    XIII. 


Typhoid  Fever  continued— Treatment. 


GENTLEMEN  :  At  the  close  of  the  lecture  yesterday,  1  was  directing 
your  attention  to  the  several  indications  to  be  fulfilled,  or  objects  to 
be  accomplished,  in  the  treatment  of  typhoid  fever.  1  had  named  five 
such  distinct  and  important  objects,  and  had  explained  as  fully  as  neces- 
sary the  best  means  for  accomplishing  the  first  of  the  series  then  men- 
tioned. The  second,  was  to  restore  the  general  properties  of  the  tissues 
to  their  natural  condition,  and  thereby  retard  or  arrest  those  perverted 
molecular  movements  which  constitute  the  disturbances  of  nutrition,  se- 
cretion, excretion  and  calorification,  on  which  the. prominent  symptoms  of 
the  disease  depend.  As  I  endeavored  more  fully  to  explain,  when  speak- 
ing of  the  causes  and  pathology  of  the  fever  under  consideration,  the 
properties  of  the  blood  and  tissues  are  impaired  from  the  beginning  to  the 
end  of  the  disease. 

This  impairment  is  the  result  of  such  cause  or  causes  as  exert  a  de- 
pressing influence  on  the  properties  and  functions,  and  hence  the  first 
step  in  the  fulfillment  of  this  second  indication  is,  to  remove  the  further 
action  of  all  such  causes  by  the  same  means  described  in  the  closing  part 
of  the  previous  lecture. 

And,  if  as  then  indicated,  you  can  from  the  beginning  of  the  disease 
have  the  patients  supplied  with  an  abundance  of  fresh,  pure  air  ;  suffi- 
ciently sponged  over  with  water  daily,  to  preserve  cleanliness  and  promote 
healthy  exhalations  from  the  cutaneous  surface  ;  and  supplied  with  proper 
nourishment,  in  proper  quantities,  twenty-nine  out  of  every  thirty  will 
recover  without  medication  of  any  kind.  But  as  stated  yesterday,  a  large 
proportion  of  our  typhoid  fever  patients  are  found  in  such  condition  and 
with  such  surroundings,  that  the  healthful  influences  just  mentioned  can- 
not be  secured  to  the  extent  necessary  for  safe  reliance,  and  other  means 
must  be  found  for  directly  or  indirectly  increasing  the  susceptibility  and 
vital  affinity  throughout  the  tissues  of  the  body.  Of  tho^e  agents  which 
act  directly  as  excitors  of  vital  affinity,  and  thereby  promote  the  natural 
molecular  changes,  none  are  probablv  more  efficient  than  oxygen,  the 
mineral  acids,  the  chlorine  salts — more  especially  the  chlorate  of  ptjtassium 
— chloride  of  sodium,  bichloride  of  mercury,  iodine,  and  cold  water. 
The  practical  application  of  any  one  of  these  general  excitors  must  be 
determined  by  collateral  circumstances.  For  instance,  the  direct  adminis- 
tration of  oxygen  is  inconvenient,  on  account  of  its  bulk  in  the  gaseous 
form,  and  the  impracticability  of  trusting  its  admitiistration  to  nurses  and 
ordinary  attendants  on  the  sick.  But  so  far  as  you  can  increase  the  quan- 
tity and  purity  of  the  air  of  the  sick  room,  and  by  administering  judi- 
ciously the  chlorate  of  potassium  or  chloride  of  sodium,  increase  the  capac- 
ity of  the  blood  to  take  up  the  oxygen  from  the  air-cells  of  the  lungs,  in 
the  same  proportion  you  will  increase  the  quantity  of  oxygen  circulating 
with  the  arterial  blood  and  exerting  its  natural  vivifying  influence  on  the 
properties  and  functions  of  the  system. 

The  amount  of  the  chlorate  of  potassium  given,  must  be  so  limited  as  not 
to  endanger   undue  action  on  the  mucous   memurane   of  the   intestmes. 


TREATMENT.  103 

And  the  sam?.  remark  applies  with  still  more  force  to  the  use  of  the 
chloride  of  sodium  and  the  bichloride  of  meriiury,  but  less  to  iodine,  if 
given  in  the  form  of  aqueous  solution  or  tincture.  If  you  have  properly 
studied  the  nftture  and  action  of  remedies,  you  will  notice  that  the  agents 
I  hav'B  just  mentioned,  are  not  only  ganeral  excitors  of  tissue  properties, 
and  promoters  of  blood  arterialization,  but  also  actively  antiseptic,  and 
therefore  well  calculated  to  destroy  any  organic  fes'er  poison  that  might 
ex  St  in  the  blood.  If  any  among  you  have  become  imbued  with  the  pop- 
ular idea  that  all  merecurials  merely  act  on  the  liver  and  some  other  gland- 
ular organs,  and  depress  the  powwrs  of  life  by  impairing  the  plasticity  of 
the  blood,  you  will  be  surprised  to  hear  me  mention  the  bichloride  of 
mercury  as  one  of  the  leading  agents  for  promoting  the  general  properties 
of  the  tissues  and  preserving  the  blood  from  deterioration.  It  is  now 
nearly  forty  years  since,  while  listening- to  a  clinical  lecture  by  the  late  Dr. 
Valentine  Mott,  I  heard  that  most  eminent  of  surgeons  recommend  for  a 
delicate,  pale  looking  girl,  with  irritable  scrofulous  ophthalmia,  a  combina- 
tion of  the  bichloride  of  mercury,  with  tincture  of  cinchona  bark,  to  be 
taken  internally  three  times  a  day.  And  truth  compels  me  to  say,  gentle- 
men, that  through  all  the  changes  of  medical  fashions  and  prejudices, 
from  that  time  to  the  present,  I  have  derived  more  benefit  from  the  use 
of  small  doses  of  this  preparation  of  mercury,  given  in  conjunction  with 
some  of  the  preparations  of  cinchona,  in  the  treatment  of  depressed,  de- 
praved and  cachectic  conditions  of  the  system,  than  from  all  the  prepara- 
tions of  iron,  cod-liver  oil,  and  so-called  alcoholic  stimulants,  to  be  found 
in  the  list  of  remedial  agents.  And  strangely  enough,  at  this  late  day, 
direct  experimental  investigations  have  proved  that  small  doses  of  the  bi- 
chloride taken  internally  actually  increase  the  number  of  red  corpuscl-'S  in 
the  blood  and  promote  its  plasticity.  Nevertheless,  its  practical  value  in 
the  treatment  of  typhoid  fever  is  limited  mostly  to  the  early  stage,  on 
account  of  its  tendency  to  increase  the  intestinal  evacuations.  The  same 
is  true  in  regard  to  the  use  of  the  mild  chloride  or  calomel.  Iodine  has 
long  been  known  and  used  as  a  general  alterative  and  tonic  of  great  value 
in  the  treatment  of  chronic  affections  of  a  general  or  constitutional  nature, 
and  as  an  efficient  antiseptic;  but  its  use  has  not  until  very  recently  been 
extended  to  the  treatment  of  the  general  acute  diseases  or  fevers.  At  the 
present  time,  however,  both  iodine  and  mercury  are  being  urged  as  spe- 
cific remedies  for  the  cure  of  typhoid  fever.  The  revival  of  this  idea  in 
relation  to  the  specific  curative  effects  of  mercury,  especially  in  the  form  of 
ten-grain  doses  of  calomel,  repeated  once  or  twice  in  the  twenty-four  hours 
during  the  early  stage  of  the  disease,  we  owe,  as  we  do  the  revival  of  many 
other  extravagances,  to  the  profession  in  G-ermany.  I  say  revival  of  the 
rdea,  because  it  is  no  more  novel  or  original  at  this  time  than  is  the  use  of 
large  antipyretic  doses  of  quinine,  or  the  refrigeration  with  cold  water. 
The  last  named  method  was  thorou^^hly  tested  and  strongly  recommended 
by  Dr.  Currie,  of  London,  a  century  since;  and  as  I  have  stated  in  a  pre- 
vious lecture,  quinine  has  been  given  in  quantities  sufficient  for  the  most  effi- 
cient antipyretic  effect  during  the  first  and  second  weeks  of  typhoid  fever, 
by  the  physicians  of  the  south  and  west  during  the  earlier  periods  of  the 
prevalence  of  that  variety  of  fever  in  those  sections  of  our  country.  And 
during  the  same  period,  namely,  from  1835  to  1850,  mercurials  in  the 
form  of  calomel  and  blue  mass,  were  tried  with  equal  thoroughness,  in  all 
doses  from  one  to  twenty  grains,  and  repeated  from  one  to  six  times  in 
the  twenty-four  hours.  I  have  myself  seen,  during  that  early  part  of 
my  professional  life,  more  than  a  score  of  cases  of  typhoid  fever  pretty 
fully  salivated  from  the  calomel  administered  daring  the  first  week  or  ten 


104  TYPHOID    FEVER. 

days  of  their  progress.  Most  certainly,  if  there  had  been  any  specific 
curative  power  possessed  by  either  quinine  or  mercurials  in  the  treatment 
of  any  variety  of  continued  fevers,  it  should  have  been  so  fully  demon- 
strated by  the  practices  of  half  a  century  ago  in  this  country,  that  their 
use  would  have  become  as  firmly  established  and  universal  as  is  the  use 
of  quinine  in  the  treatment  of  intermittents.  The  demonstrations,  how- 
ever, were  all  in  the  opposite  direction  so  strongly,  that  even  the  most 
conservative  among  us  at  that  time,  were  rapidly  forced  from  large  doses  to 
small  ones,  and  from  small  ones  to  none  at  ail.  And  to  complete  the  history, 
I  only  need  say  we  passed  from  no  active  medicines,  or  simple  expectancy^ 
to  positive  efforts  at  stimulation,  and  from  food  and  so-called  stimulants, 
we  are  now  gracefully  invited  back  to  the  fullest  doses  of  active  medica- 
tion. It  is  only  necessary  now,  gentlemen,  that  some  one  occupying  a 
prominent  position  in  Germany,  or  some  other  European  State,  should 
publish  a  score  or  two  of  cases  in  which  the  treatment  was  commenced 
with  an  emetic  or  emeto-cathartic  or  a  moderate  venesection,  accompanied 
by  such  a  statement  of  the  ratio  of  mortality  as  to  show  better  results  than 
had  been  obtained  by  some  other  methods  of  treatment,  and  the  cycle  of 
medical  progress  will  be  complete,  and  therapeutics  in  relation  to  contin- 
ued fevers  will  stand  very  nearly  in  the  same  position  as  half  a  century 
ago.  The  principal  difference  will  consist  in  the  lact,  that  somewhere  in  our 
professional  progress  around  the  circle,  we  have  unconsciously  ceased  to 
group  our  remedies  under  the  names  of  evacuants,  alteratives,  and  anti- 
periodics,  and  now  call  them  either  specific  remedies,  antipyretics,  or 
paraciticides. 

The  third  object  to  be  kept  constantly  in  view  while  directing  the  treat- 
ment of  typhoid  fever,  is,  to  so  far  promote  the  action  of  the  more  impor- 
tant excretory  and  eliminating  organs  as  to  prevent  the  deterioration  of 
the  blood  by  the  accumialation  of  the  products  of  tissue  changes,  includ- 
ing waste  matter  and  heat.  The  organs  or  structures  through  which  the 
greater  part  of  the  waste  matter  derived  from  ordinary  tissue  changes,  is 
eliminated  from  the  blood  and  cast  out  of  the  system,  are  the  kiunevs, 
lungs  and  skin.  These  organs  not  only  eliminate  the  greater  part  of  the 
natural  waste  material,  but  they  also  eliminate  most  of  the  foreign  and 
disturbing  elements  that  find  their  way  into  the  blood  from  without,  and 
also  do  much  to  regulate  the  temperature  of  the  body,  by  the  quantity  and 
iorm  of  the  matter  that  passes  from  the  lungs  and  skin.  As  the  functions 
of  these  several  organs  are  especially  liable  to  be  impaired  during  the  first 
two  weeks,  as  I  pointed  out  to  you  in  describing  the  symptoms  and  prog- 
ress of  the  fever,  you  cannot  be  too  vigilant  in  observing  their  condition 
and  in  adopting  such  measures  as  will  increase  their  activity  when  nec- 
essary. 

Aside  from  keeping  the  air  of  the  sick  room  pure  and  at  a  proper  tem- 
perature, there  is  probably  no  measure  better  calculated  to  promote  nat- 
ural exhalations  from  both  skin  and  lungs,  than  frequent  spongings  of  the 
surface  with  water  of  such  temperature  as  is  most  agreeable  to  the  patient. 
It  lessens  the  frequency  and  increases  the  fullness  of  respiratory  move- 
ments, while  it  reduces  the  temperature  and  promotes  the  exhalations 
from  the  cutaneous  surface.  The  latter,  together  with  the  action  of  the 
kidneys,  may  be  also  materially  increased  by  the  administration  of  proper 
medicines. 

In  selecting  medicines  to  promote  the  action  of  the  skin  and  kidneys, 
care  must  be  taken  to  choose  those  diuretics  and  diaphoretics  that  are  not 
liable  to  disturb  the  bowels. 

Perhaps  none  are  better  adapted  to  the  early  part  of  the  progress  of 


TREATMENT.  105 

typhoid  fever  than  the  nitrous  ether,  the  liquor  ammonige  acetatis,  an  J  the 
digitalis,  either  separately  or  in  combination. 

The  fourth  important  object  which  should  constantly  engage  the  atten- 
tion of  the  practitioner  while  managing  this  variety  of  fever,  is,  to  counter- 
act the  development  or  retard  the  progress  of  serious  local  diseases,  either 
in  the  head,  chest  or  abdomen. 

Both  clinical  experience  and  post  mortem  examinations  show  that  much 
the  larger  number  of  deaths  resultitig  from  this  fever  are  determined  by  the 
nature  and  extent  of  the  local  lesions  which  develop  in  some  of  the 
most  important  organs  during  the  progress  of  the  general  disease.  Con- 
sequently much  of  your  success  at  the  bedside  will  depend  upon  the  readi- 
ness with  which  you  detect  the  existence  of  complications  and  the  skill  you 
exhibit  in  palliating  or  removing  them.  Nor  is  this  all ;  for  when  cases  come 
under  your  care  early,  an  accurate  knowledge  of  the  natural  tendencies  to 
develop  certain  local  affections,  and  a  careful  examination  of  the  relative 
susceptibility  of  the  different  groups  of  organs  in  each  patient,  in  connec- 
tion with  the  season  of  the  year  and  special  sanitary  surroundings,  will  en- 
able you  sometimes  to  so  order  your  remedial  measures  as  to  prevent  seri- 
ous complications  that  would  otherwise  occur.  A  careful  analysis  of  past 
cliiiical  experiences,  aided  by  the  results  of  post  m,ortem  examinations,  has 
satisfied  me  that  we  have  one  of  three  leading  sources  of  danger  to  encoun- 
ter in  all  severe  cases  of  typhoid  fever,  and  in  some  all  the  three  are  pre- 
sented in  the  same  patient. 

One  of  these  consists  in  impairment  of  the  functions  of  the  brain  and  im- 
portant nervous  centres,  more  especially  those  centres  that  govern  the  ac- 
tion of  the  vaso-motor,  cardiac,  and  respiratory  nerves.  That  the  functions 
of  the  whole  nervous  apparatus  are  disturbed,  and  in  many  instances  pro- 
foundly impaired,  is  readily  seen  by  the  symptoms,  and  is  acknowledged 
by  all  writers.  And  yet  it  has  seemed  to  me  that  very  few  have  fully  ap- 
preciated the  importance  of  that  impairment  of  the  vaso-motor  influence  by 
which  the  tonicity  and  action  of  all  the  smaller  vessels  is  impaired;  passive 
and  hypostatic  congestions  and  exudations  encouraged,  especially  in  the 
more  vascular  and  distensible  structures  like  the  lungs,  spleen,  and  mu- 
cous membranes;  or  of  the  impairment  of  the  closely  associated  centres  gov- 
erning the  action  of  the  heart,  lungs,  and  sphincters  of  the  rectum  and  blad- 
der, by  which  the  muscular  force  of  the  heart  grows  weakpr,  the  respira- 
tory movements  less  steady  and  efficient,  the  sphincters  weakened,  and  ul- 
timately paralyzed  or  relaxed,  as  the  disease  progresses  through  its  succes- 
sive stages.  It  is  this  progressive  impairment  of  the  motion  of  the  blood 
in  the  smaller  vessels  and  capillaries,  co-operating  with  the  general  impair- 
ment of  vital  affinity,  that  not  onlv  favors  passive  engorgements  and  exuda- 
tions, but  also  that  softening  of  texture  and  fatty  molecular  degeneration 
described  when  speaking  of  the  morbid  anatomy  of  the  fever. 

It  is  in  these  morbid  and  degenerative  processes  that  much  of  the  water 
drank  by  the  patient  is  used  up,  instead  of  re-appearing  in  the  cutaneous 
and  renal  secretions.  And  it  is  by  these  same  processes  and  absorption 
of  the  water  that  the  excess  of  heat  is  evolved  and  the  high  temperature 
maintained  ;  the  latter  being  an  effect  and  not  the  cause  of  the  morbid 
changes  in  the  tissues. 

If  I  am  correct  in  the  expression  of  these  views,  then  certainly  you  can- 
not be  too  vigilant  in  selecting,  or  too  careful  in  adjusting  such  remedies 
as  will  maintain  the  sensibility  and  functional  activity  of  the  several  nerv- 
ous centres  to  which  I  have  just  alluded.  During  the  early  stage  of  the 
disease  you  can  accomplish  this  purpose  best  indirectly  by  the  same  agents 
that  increase   the  oxygenation  and  decarbonization  of  the  blood,  increase 


106  TYPHOID    FEVER. 

nerve  sensibility,  and  remove  the  further  action  of  the  predisposing  and 
exciting  causes  of  fever,  as  I  more  fully  stated  when  speaking  of  the 
means  for  accomplishing  the  first  and  second  objects  enumerated.  But 
when  the  first  stage  has  passed  and  the  symptoms  of  special  failure  in  these 
important  nervous  functions  are  becoming  more  prominent,  you  must  find 
some  remedies  that  will  more  directly  and  efficiently  sustain  them.  For 
this  purpose  I  have  found  nothing  in  the  materia  medica  equal  in  effici- 
ency to  strychnia  and  the  mineral  acids.  I  commenced  the  use  of  strych- 
nia in  the  treatment  of  the  advanced  stage  of  bad  cases  of  typhoid  fever 
as  early  as  1850.  At  first  its  use  was  limited  to  such  cases  as  began  to 
show  loss  of  action  in  the  muscular  coat  of  the  bladder  or  diminished  con- 
trol over  the  sphincters  of  tlie  body;  but  further  experience  showed  that  by 
commencing  its  use  earlier  and  continuing  it  in  doses  sufficient  to  act  as  a 
nerve- and  muscular  tonic,  the  more  extreme  and  dangerous  failures  of 
innervation,  as  indicated  by  loss  of  control  over  the  action  of  the  bladder 
and  rectum,  very  rarely  took  place.  I  usually  give  it  in  solution  with 
nitric  acid,  and  when  too  much  looseness  of  the  bowels  exists,  I  add  tinc- 
ture of  opium  in  proper  proportion  to  the  mixture.  Direct  inflammation 
in  the  nervous  centres  or  their  membranous  coverings  I  have  seen  in  but 
few  cases  of  typhoid  fever.  One  such  case  occurred  in  the  wards  of  the 
Mercy  Hospital  a  few  weeks  since,  and  proved  fatal.  The  best  means  for 
combatting  it  are,  local  bleeding  by  leeches,  cold  applications  to  the  head 
continuously,  and  later,  the  application  of  blisters  to  the  neck  and  mastoid 
spaces.  The  internal  administration  of  iodide  of  potassium  and  digitalis 
may  also  be  used  more  freely  than  in  uncomplicated  cases  of  the  general 
fever. 

In  those  cases  where  cerebral  symptoms  are  developed  from  the  reten- 
tion of  urea,  relief  can  be  obtained  only  by  promoting  the  elimination  of 
the  retained  poison  from  the  blood  by  such  means  as  will  increase  the  ac- 
tion of  the  skin  and  kidneys. 

The  local  affections  of  importance  most  liable  to  occur  in  the  chest,  are 
extensive  hj^postatic  or  passive  engorgement  of  the  lower  and  posterior  por- 
tion of  the  lungs;  capillary  bronchitis,  broncho-pneumonia,  and  softening 
or  degenerative  changes  in  the  muscular  structure  of  the  heart.  When 
either  of  the  three  first  named  pathological  conditions  are  sufficiently  ex- 
tensive to  greatly  lessen  the  amount  of  air  reaching  the  air-cells  of  the 
lungs,  it  adds  very  much  to  the  danger  of  a  fatal  result. 

The  hy2;)Ostatic  engorgement  of  the  lungs,  and  muscular  weakness  of  the 
heart,  are  to  be  counteracted  by  the  same  means  that  increase  general  ton- 
icity and  innervation,  as  I  have  already  indicated  when  speaking  of  the 
means  for  sustaining  the  general  properties  of  the  tissues,  and  for  main- 
taining the  sensibility  of  the  nervous  centres.  It  is  in  this  variety  of  cases, 
and  especially  in  those  characterized  by  cardiac  weakness,  that  most  wri- 
ters and  teachers  advise  the  free  use  of  alcoholic  remedies,  in  the  form  of 
wine,  brandy,  and  whisky.  But  no  fact  in  therapeutics  has  been  better 
established  by  direct  experimental  investigations,  than  that  alcohol  when 
introduced  into  the  blood,  both  diminishes  the  interchange  of  carbonic  acid 
gas  and  oxygen  in  the  capillaries  and  air-cells  of  the  lungs,  and  the  sensi- 
bility of  the  nervous  structures  generally.  Inasmuch  as  the  blood  in  the 
class  of  patients  now  under  consideration  is  already  darker  in  color  and 
less  coagulable  than  natural,  ami  the  capacity  of  the  lungs  for  air  dimin- 
ished in  proportion  to  the  amount  of  hypostatic  infiltration,  while  the  gen- 
eral sensibility  of  the  nervous  systems,  both  cerebro-spinal  and  vaso-motor, 
is  blunted  in  a  marked  degree,  it  is  extremely  difficult  to  see  a  rational 
basis  for  the  administration  of  alcohol  in  any  form. 


TREATMENT.  107 

The  general  idea  apiieais  to  be,  that  it  directly  strengthens  and  sustains 
the  muscular  force  of  the  heart.  But  do  carefully  observed  clinical  facts, 
or  the  results  of  clinical  experience  sustain  this  idea?  I  have  embraced 
every  fair  opportunity  for  studying  this  question  practically  that  has  oc- 
cuired  to  me  during  the  last  thirty-five  years;  and  with  due  deference  to 
the  opinions  of  others,  and  a  full  tense  of  my  own  responsibility,  I  must 
answer  it  in  the  negat.ve.  Neither  by  cardiac  auscultation,  nor  by  the 
disciplined  sense  of  touch,  nor  by  the  sphygmograph,  have  I  been  able  to 
detect  in  a  single  case  an  actual  increase  of  cardiac  force.  When  a  fair 
dose  of  wine  or  brandy  is  first  given  it  often  causes  the  heart  to  give  from 
five  to  ten  beats  more  per  minute  than  before,  and  the  sphygraographic 
line  will  both  rise  and  fall  more  abruptly,  but  with  less  ifteadiness  or  uni- 
formity. This  apparent  excitation,  which  generally  continues  not  more 
than  ten,  or  at  the  longest,  fifteen  minutes,  is  evidently  caused  by  the  direct 
irritative  action  of  the  alcohol  on  the  gastric  branches  of  the  pneumogas- 
tric  nerve,  and  is  evidence  of  mere  temporary  disturbance  or  purturba- 
tion  instead  of  increased  strength.  In  from  twenty  to  thirty  minutes,  or 
so  soon  as  the  alcohol  has  had  time  for  absorption  and  circulation  through 
the  svstem,  it  begins  to  show  its  true  anaesthetic  effects  on  both  the  cere- 
bro-spinal  and  vaso-motor  nerves,  by  calming  the  patient's  restlessness, 
lessening  subsultus  if  it  exists,  slightly  lessening  the  frequency  of  respira- 
tion and  circulation,  and  increasing  the  disposition  to  sleep.  But  these 
apparently  favorable  effects  are  accompanied  by  impairment  of  the  vaso- 
motor influence  over  tlie  whole  vascular  system,  as  indicated  by  relaxation 
of  the  cutaneous  capillaries,  lessening  of  urinary  secretion  with  more  fre- 
quent appearance  of  albumen  in  it,  softness  or  compressibility  of  the  pulse, 
and  diminished  cardiac  impulse.  And  if  the  doses  are  repeated  at  inter- 
vals of  one  or  two  hours,  so  as  to  keep  the  effects  uniform;  the  patient  con- 
tinues the  same  general  aspect  of  quietude,  but  the  tone  of  the  vascular 
system  becomes  steadily  more  impaired,  as  indicated  by  increasing  weak- 
ness of  pulse,  undue  sweating,  scantiness  of  urine,  increasing  size  of  the 
spleen,  more  hypostatic  engorgement  of  the  lungs,  with  general  sxib-rau- 
cous  rhonchus,  and  but  feeble  efforts  to  expand  the  chest,  and  more  drow- 
siness or  mental  inditt'erence;  until,  in  fiom  one -to  two  weeks  after  the 
treatment  is  begun,  in  many  cases  the  combined  influence  of  the  anaesthetic 
effect  of  the  alcohol  and  the  imperfect  oxygenation  of  the  blood  from 
passive  pulmonary  obstruction,  so  far  suspends  the  sensibility  of  the  ex- 
cito-motor  nerve  centres  that  the  sphincters  of  the  bladder  and  rectum 
relax,  the  discharges  becomes  involuntary,  and  the  patient  dies.  The 
death  in  such  cases  is  not  from  simple  asthenia  or  exhaustion,  as  is  gener- 
ally supposed.  For  if  we  compare  the  amount  of  nourishment  taken  in 
the  form  of  milk,  beef  tea,  eggs,  etc.,  with  the  amount  of  discharges  from 
day  to  day,  we  will  find  that  the  patient  has  taken  and  retained  a  sufficient 
supply  to  prevent  any  dangerous  degree  of  exhaustion.  But  the  fatal 
result  is  traceable  directly  to  progressive  enfeeblement  of  respiration  and 
capillary  circulation  from  failure  of  the  influence  of  the  vaso-motor  and 
excito-motor  nervous  systems,  causing  loss  of  tonicitv  in  all  the  tissues 
and  special  passive  engorgements  in  the  more  vascular  and  distensile 
structures  like  the  lungs  and  spleen.  This  final  failure  of  nervous  force 
or  innervation,  and  of  capillary  and  molecular  changes,  is  undoubtedly 
owing  to  the  impairment  of  tlie  quality  of  the  blood  and  properties  of  the 
tissues  which  I  have  already  explained  as  constituting  the  essential 
pathology  of  the  disease.  What  I  claim  in  regard  to  alcoholic  remedies,  is, 
that  by  the  aucesthetic  efi"ect  of  the  alcohol  they  contain,  they  directly  in- 
crease  the   impairment  of  nerve-force,  and  by   its  well  known  effect  in 


108  TYPHOID    FEVER. 

lessening  the  interchange  of  waste  carbonic  acid  gas  for  oxygen  in  the  air- 
ceils  of  the  lungs,  they  increase  the  blood  degeneration  and  still  further 
lessen  its  power  to  excite  or  sustain  either  nerve-sensibility  or  molecular 
movements.  I  might  illustrate  these  effects  by  the  relation  of  a  large 
number  of  clinical  cases  from  my  note-books,  but  I  will  trespass  upon 
your  time  for  a  brief  narration  of  only  two,  as  specimens. 

The  first,  occurred  nearly  thirty  years  since,  in  the  person  of  a  j'oung 
man  in  a  boarding  house  on  Michigan  Avenue,  between  Lake  and  South 
Water  streets,  a  section  of  the  city  then  occupied  entirely  by  residences. 
I  was  first  called  in  consultation  with  the  attending  physician,  who  related 
to  me  the  history  of  the  case,which  corresponded  in  all  respects  with  the 
history  of  a  t^q^ical  case  of  typhoid  fever  of  average  degree  of  severity,  it 
being  at  the  time  of  my  visit  at  the  commencement  of  the  third  week  after 
the  patient  had  taken  to  his  bed.  I  found  him  lying  on  his  back;  face 
dingy, pale;  lips  a  little  retracted  and  edges  slightly  purplish,  or  of  leaden 
hue;  a  little  sordes  on  the  exposed  part  of  the  teeth;  expression  of  face 
dull  and  relaxed;  tongue  covered  over  the  middle  and  back  part  with  a 
thick,  moist  coat,  but  more  red  and  dry  at  the  tip  and  edges;  the  cutaneous 
surface  was  generally  moist,  cool  and  of  leaden  hue  over  the  extremities, 
but  above  the  natural  temperature  over  the  chest  and  abdomen  (clinical 
thermometers  were  not  then  in  use),  the  latter  moderately  tympanitic  and 
gurgling  on  pressure;  pulse  110  per  minute,  ver}^  soft  and  weak;  respira- 
tions 22  per  minute,  the  expansion  of  chest  by  inspiration  very  imjoerfect 
with  short  expiratory  act  and  sudden  fall  of  the  abdominal  muscles,  and 
copious  sub-mucous  rales  over  the  whole  anterior  and  lateral  parts  of  the 
chest,  with  decided  dullness  posteriorly.  The  urine  was  sc:^nty,  but  was 
not  tested  for  albumen;  the  intestinal  evacuations  occurred  from  three  to 
six  times  in  the  twenty-four  hours,  were  thin,  greyish  yellow,  containing 
white  flakes,  and  during  the  last  twenty-four  hours  had  been  only  partially 
controlled  by  the  patient.  The  hearing  was  dull  and  the  mi)id  very  tor- 
pid or  inactive,  but  not  delirious.  The  symptoms  that  had  alarmed  both 
the  friends  and  the  attending  physician,  were  the  rapidly  increasing  pass- 
ive engorgement  of  the  lungs,  with  the  plain  indications  of  imperfect  oxy- 
genation of  the  blood,'  feebleness  of  the  pulse,  and  impairment  of  the 
action  of  the  sphincters  of  the  rectum  and  bladder.  The  patient  had  been 
fed  principally  with  beef  tea  and  other  animal  broths  during  the  first  week, 
with  only  a  little  wine,  but  during  the  last  preceding  five  or  six  days,  to 
these  had  been  added  a  liberal  supply  of  egg-nog  and  milk  punch,  cont.iin- 
ing  whisky.  And  as  the  respiration  and  circulation  became  weaker  or 
less  efficient,  the  latter  was  increased  until  during  twenty-four  hours  pre- 
ceding my  visit  he  had  consumed  nearly  a  tablespoonful  of  whisky  every 
hour.  As  the  whole  aspect  of  the  case  strongly  indicated  deficient  oxy- 
genation and  decarbonization  of  the  blood,  and  the  experiments  of  Dr. 
Prout  had  fully  demonstrated  the  fact  that  the  presence  of  alcohol  in  the 
blood  directly  diminished  the  absorption  of  the  oxygen  and  the  elimina- 
tion of  carbonic  acid  gas  from  the  air-cells  of  the  lungs,  I  suggested  to 
the  attending  physician  the  propriety  of  omitting  the  further  use  of  the 
whisky  and  all  other  alcoholic  remedies,  and  trust  the  case  to  simple 
nourishment,  small  doses  of  quinine,  and  an  emulsion  of  oil  of  turpentine 
and  laudanum  sufficient  to  keep  the  intestinal  discharges  within  proper 
limits.  He,  at  once,  rather  warmly  protested  that  the  "stimulants,"  as  he 
called  the  wine  and  whiskey,  had  been  the  efficient  means  of  keeping  the 
patient  alive  for  several  days  past,  and  that  their  withdraival  now  would 
be  followed  by  certain,  and  speedily  fatal,  prostration.  And  as  I  ex- 
pressed an  earnest  desire  to  see  the    experiment  tried,    he    unexpectedly 


TREATMENT.  109 

withdrew  from  further  attendance,  and  left  the  case  with  all  its  responsi- 
bilities, in  my  hands.  Nothino-  daunted  by  this,  however,  I  ordered  the 
patient  to  be  fed  regularly  every  hour  with  two  or  three  tablespoonfuls  of 
well  prepared  porridge,  or  gruel  made  of  sweet-milk  and  wheat  fiour, 
alt3rnating  every  third  dose  w^ith  an  equal  quantity  of  beef-tea,  seasoned 
with  chlorateof})Otassium  instead  of  common  salt,  and  for  medicine,  directed 
sulphate  of  quinine  0.130  grams  (gr.  ii)  every  four  hours,  alternated  with 
o:l  of  turpentine  and  tincture  of  opium,  each  0.5  cubic  centimetre  (8  min- 
ims), ill  the  form  of  an  emulsion  and  immediately  stopped  all  further  use  of 
alcoliolic  liquids.  I  had  not  then  learned  the  value  of  stychnia  and  the  min- 
eral acids  in  such  cases,  or  1  would  have  given  them  instead  of  the  quinine. 
As  this  was  the  first  time  that  I  had  ever  come  so  directly  in  practical  con- 
tact with  the  question  whether  alcohol  is  a  supporting  or  non-supportino- 
agent  in  the  advanced  stage  of  typhoid  fever,  you  may  be  certain,  gentle- 
men, that  I  watched  the  patient  during  the  next  forty-eight  hours  with  an 
uncomfortable  degree  of  anxiety.  At  each  of  mv  frequent  visits  I  ap- 
proached the  patient  with  trepidation,  lest  the  predicted  sinking  and  col- 
lapse might  meet  me  there.  But  they  never  came.  On  the  contrary,  at 
the  end  of  twelve  hours,  I  could  detect  some  improvement,  both  in  the 
inspirations  and  the  strength  of  the  pulse.  This  improvement  continued 
very  slow  but  steady,  and  was  sufficient  at  the  end  of  forty-eight  hours  to 
relieve  me  of  any  further  oppressive  anxiety.  In  about  eight  days,  being 
the  early  part  of  the  fourth  week  of  confinement,  convalescence  had  fairly 
commenced,  and  the  patient  made  a  good  recovery. 

The  other  case,  the  essential  features  of  which  I  will  relate  in  as  few 
words  as  possible,  came  under  my  observation  only  a  few  weeks  since. 
The  patient  was  a  young  man  who  had  passed  through  a  protracted  course 
of  typhoid  fever,  partially  convalesced,  and  relapsed,  with  all  the  typhoid 
and  enteric  symptoms  severe.  I  was  called  to  see  the'^^':^,ient  in  consulta- 
tion about  eight  days  after  the  commencement  of  the  relapse.  Found  him 
considerably  emaciated;  face  pale;  expression  dull;  a  little  s  )rdes  along 
the  edges  of  the  lips  and  teeth;  some  coating  on  the  back  part  of  the 
tongue,  but  the  mouth  generally  moist;  the  skin  generally  over  the  trunk 
and  extremities  most  of  the  time  moist,  with  brief  spells  of  more  profuse 
sweating,  and  feebleness  of  capillary  circulation;  the  pulse  soft,  weak,  and 
from  100  to  110  beats  per  minute;  respirations  variable,  but  averaging 
about  20  per  minute,  and  attended  by  less  than  the  normal  degree  of  ex- 
pansion of  the  chest  with  eacli  inspiration;  resonance  on  percussion  fair 
over  the  anterior  part  of  the  chest,  but  much  diminished  posteriorly;  a 
mixture  of  dry  and  moist  sounds  detected  over  nearly  all  parts  of  the  chest 
by  auscultation,  with  a  predominance  of  the  sub-mucous  rhonchus.  Both 
hypochondriac  regions  were  full;  in  the  left  there  was  considerable  en- 
largement of  the  spleen,  as  shown  by  increased  area  of  dullness  by  percus- 
sion and  by  detecting  its  edge  projecting  a  little  below  the  margin  of  the 
ribs  by  the  touch.  The  urine  was  much  less  than  natural,  and  was  stated  to 
have  been  much  of  the  time  moderately  albuminous  since  the  relapse. 
The  intestinal  evacuations  were  near  the  color  and  consistence  of  cream, 
pretty  copious,  and  numbered  from  three  to  six  in  the  twenty-four  hours, 
but  no  tympanitic  distension  of  the  abdomen. 

The  hearing  was  slightly  impaired;  the  mind  torpid  or  inactive,  slightly 
wandering  at  times,  but  easily  aroused,  yet  difficult  to  maintain  conversa- 
tion or  connected  thought.  The  temperature  in  the  axilla  had  varied 
during  the  preceding  twenty-four  hours  from  39°  to  40°  C.  (102.5°  to 
104°  F.)  The  extent  of  passive  infiltration  or  obstruction  in  the  lungs, 
the  enlargement  of  the  spleen,  the   quantity  and  quality  of  the  intestinal 


110  TYPHOID    FEVER. 

discharges,  the  small  quantity  and  albuminous  character  of  the  urine,  and 
feebleness  of  the  circulation,  taken  in  connection  with  the  degree  of  ema- 
ciation and  the  duration  of  his  sickness,  rendered  the  prognosis  very  un- 
favorable. The  patient  had  been  diligently  supported  by  nourishment 
consisting  of  milk,  beaf-tea  and  eggs,  vrith  which  he  also  took  15  c.  centi- 
metres, or  half  an  ounce  of  brandy  every  two  hours,  making  180  c.  centi- 
metres (jvi)  in  the  twenty-four  hours.  He  had  taken  it  nearly  at  the  same 
rate  during  the  seven  or  eight  days  since  the  relapse.  He  was  also  tak- 
ing two-grain  doses  of  quinine  every  four  hours,  with  an  emulsion  of  tur- 
pentine and  laudanum  between  to  control  the  intestinal  discharges,  and  a 
solution  of  acetate  of  potash  to  increase  the  action  of  the  kidneys.  As  the 
treatment  bad  been  instituted  and  thus  far  carried  on  by  two  excellent 
physicians,  whose  opinions  were  entitled  to  full  respect,  I  did  not  feel  dis- 
posed to  abruptly  demand  a  change  in  regard  to  the  use  of  the  brandy,  more 
especially  as  the  previous  consulting  physician  was  not  able  to  be  present. 
I  consequently  suggested  no  changes,  either  in  medicine  or  nourishment, 
except  the  addition  of  strychnia  and  nitric  acid,  in  moderate  doses,  every 
four  hours,  in  hope  of  improving  the  sensibility  and  tone  of  the  nervous 
and  muscular  structures.  The  case  progressed  for  three  or  four  days  with 
no  marked  changes,  except  the  intestinal  discharges  became  gradually 
less  frequent  and  darker  color,  the  urinary  secretion  was  variable,  some- 
times quite  free  and  again  scanty,  with  a  large  excess  of  phosphatic  depos- 
its; the  temperature  also  varied  one  or  two  degrees  every  twenty-four 
hours,  but  at  no  time  rose  above  40°  C.  (104°  F.).  The  circulation  and 
respiration,  however,  became  gradually  more  impaired  by  the  steady  in- 
crease of  passive  infiltration  in  the  lungs,  more  feebleness  of  pulse,  and 
more  relaxation  and  sweating.  During  the  fourth  or  fifth  night  after  my 
first  visit,  the  symptoms  of  exhaustion  became  so  alarming  that  the  nurse 
gave,  on  his  own- responsibility,  an  extra  amount  of  brandy  over  that  I 
have  mentioned.  When  I  met  the  attending  physician  the  following 
morning,  we  learned  that  the  patient  had  passed  a  rather  restless  night, 
had  two  thin  intestinal  evacuations,  had  passed  very  little  urine  and 
none  had  accumulated  in  the  bladder,  but  had  spells  of  profuse  sweating, 
accompanied  by  symptoms  of  great   feebleness. 

The  whole  cutaneous  surface  was  still  wet  with  a  cool,  clammy  sweat; 
pulse  very  weak,  and  circulation  in  the  smaller  vessels  slow  and  imperfect, 
respiration  short,  with  very  little  expansion  of  the  right  side  of  the  chest; 
and  no  evidence  by  auscultation  that  the  air-ceils  of  the  lung  were  inflated 
during  inspiration;  diminished  resonance  over  the  whole  of  that  side  of 
the  chest,  and  the  posterior  part  of  the  left,  but  considerable  inflation, 
with  sharp  sub-mucous  rhonchi  in  all  the  anterior  and  lateral  part  of  the 
left  lung.  The  systolic  action  of  the  heart  was  short  and  weak.  The 
aspect  of  the  patient  was  such  as  to  render  it  probable  that  he  would  not 
live  another  day  unless  some  improvement  could  be  made  in  the  functions 
of  respiration  and  circulation.  Being  fully  satisfied  that  the  alchohol  in 
the  brandy  he  was  taking,  by  its  antesthetic  eifect  on  the  nervous  struc- 
tures, and  its  interference  w^ith  the  decarbonization  of  the  blood,  was  posi- 
tively adding  to  the  embarrassment  of  the  respiratory  and  circulatory  func- 
tions, I  advised  that  the  quantity  given  should  be  immediately  diminished 
one-third,  while  the  strychnia,  nitric  acid  and  emulsion  should  be  continued, 
and  an  effort  made  to  improve  the  circulation  and  check  the  sweats  by  the 
tinctures  of  digitalis  and  belladonna — two  parts  of  the  former  to  one  of  the 
latter — given  in  doses  of  one  cubic  centimetre  (15  minims)  every  three 
hours.  This  advice  was  strictly  followed,  and  instead  of  any  "  smH«/7,"  as 
so  many  anticipate  from  the  lessening  of  the  quantity  of  brandy,  the  next 


TREATMENT.  Ill 

morniniy  there  was  a  notable  improvement  in  both  the  respiration  and  cir- 
culation. The  patient  had  rested  more  quiet,  the  sweating  being  much 
diminished  and  the  urine  increased  in  quantity.  The  sul)-mucous  rhonchi 
were  some  legs  in  the  left  side  ot"  the  chest,  and  a  little  more  expansion  of 
the  right  l)y  inspiration. 

The  quantity  of  brandy  was  still  further  diminished  one-half,  and  in  two 
days  it  was  discontinued  altogether;  in  all  other  respects  the  treatment 
was  continued  the  same. 

The  respiration  and  circulation  continued  to  improve  slowly  for  two 
days,  and  subsequently  very  rapidly  with  coincident  improvement  in  all 
other  respects,  and  in  four  or  five  days  convalescence  was  fairly  estab- 
lished. I  have  thus  briefly  related  to  you  the  first  and  the  last  cases  of 
typhoid  fever  in  which  I  have  had  opportunity  for  carefully  noting  both 
the  effects  of  giving  a'coholic  remedies  regularly  and  efficiently,  and  the 
effects  of  their  entire  discontinuance  at  an  advanced  and  critical  stage  of 
the  disease.  During  the  quarter  of  a  century  or  more  that  has  intervened 
between  these  two  cases,  I  have  had  many  similar  opportunities  for  study- 
ing the  effects  of  these  remedies  at  the  bedside  of  fever  patients,  and 
almost  uniformly  with  similar  results.  The  only  exceptions  were  three 
cases  characterized  by  morbid  vigilance  or  sleeplessness,  mental  anxiety, 
rapid  pulse,  and  muscular  trembling. 

In  these,  pretty  full  doses  of  diluted  alcohol,  given  in  the  form  of  milk 
punch,  produced  sufficient  ana33thetic  effect  to  induce  sleep  and  quiet  the 
undue  nervou?  excitability,  after  which  it  was  gradually  withdrawn.  But 
the  use  of  almost  any  other  reliable  anns^thetic  would  have  produced  the 
same  results.  I  rep  jat,  therefore,  that  in  all  ordinary  cases  of  typhoid  or 
other  general  fevers,  the  continued  use  of  alcoholic  remedies,  either  fer- 
mented or  distilled,  from  day  to  day,  instead  of  strengthening  the  action 
of  the  heart  and  sustaining  the  functions  of  the  system,  positively  adds  to 
the  embarrassments  of  respiration  and  capillary  circulation  and  diminishes 
nerve  sensibility,  thereby  favoring  both  passive  congestions  in  the  lungs, 
spleen  and  kidneys,  and  fatty  degeneration  in  the  muscular  structure  of 
the  heart.  The  third  group  of  local  diseases  that  should  engage  your 
constant  attention  while  attending  cases  of  typhoid  fever,  are  found  in  the 
alimentary  canal  and  mesentery.  But  we  must  take  still  another  hour  to 
complete  the  consideration  of  this  important  subject. 


LECTURE   XIV. 

Typhoid  Fever  Concluded^Treatment,  Complications  and  Sequalffi, 

GENTLEMEN:  At  the  close  of  the  lecture  yesterday  I  was  about  to  di- 
rect your  attention  to  the  indications  f  t  treatment  specially  present- 
ed by  the  pathological  changes  in  the  alimentary  canal  which  accompany 
most  of  the  cases  of  typhoid  fever.  The  most  important  of  these  changes, 
as  I  have  already  described  to  you,  consist  in  asthenic  inflammation,  tume- 
faction, softening  and  ulceration  of  the  aggregated  and  solitary  glands  of 
the  lower  half  of  the  ilium,  the  enlargement  and  softening  of  the  mesenteric 


112  TYPHOID    FEVER. 

glands,  the  spleen,  and  in  a  lesser  degree  the  liver.  Of  these,  the  disease 
of  the  glands  in  the  mucous  raembi-ane  of  the  intestine  is  of  paramount 
importance  both  on  account  of  the  interference  with  the  nourishment  of 
the  patient  and  the  exhausting  diarrhoeal  discharges  that  generally  accom- 
pany it.  Yet  many  of  the  writers  and  teachers  of  the  present  day  appear 
to  inculcate  the  idea  that  these  extensive  morbid  changes  in  the  ilium  are 
only  the  efforts  of  nature  to  eliminate  the  supposed  fever  poison  through 
the  glands  of  Payer  and  Brunner,  and  consequently  the  resulting  diarrhoeal 
discharges  are  to  be  encouraged  rather  than  repressed,  especially  during 
the  first  week  of  the  patient's  confinement- 
There  is  no  more  evidence,  however,  that  the  inflammation  and  other 
destructive  changes  in  these  glands  have  anvthing  to  do  with  the  elimina- 
tion of  a  specific  fever  poison,  than  there  is  that  the  inflammation  of  the 
fauces  and  glands  of  the  neck  in  scarlatina  is  a  conservative  effort  of  na- 
ture to  eliminate  the  poison  of  that  disease,  or  that  the  contagium  of  measles 
escapes  from  the  irritated  mucous  membrane  of  the  nostrils  and  bronchial 
tubes. 

If  the  disease  of  the  glands  of  Payer  and  Brunner  served  the  purpose 
of  eliminating  from  the  blood  a  specific  fever  poison  that  had  induced  the 
general  fever,  then  the  earlier  they  become  involved  in  any  given  case 
and  the  more  free  the  diarrhoea  during  the  first  week,  the  shorter  and 
milder  should  be  the  subsequent  progress  of  the  disease.  But  neither  my 
own  clinical  experience  nor  the  recorded  observations  of  others  show  any 
such  result.  On  the  contrary,  it  may  be  stated,  as  a  general  rule,  that  the 
earlier  the  indications  of  intestinal  disease  appear  in  the  progress  of  the 
general  fever  and  the  more  copious  the  diarrhoea,  the  more  severe  and  pro- 
tracted will  be  the  course  of  the  general  disease.  The  proper  course  is  to 
regard  the  pathological  changes  in  the  ilium,  mesentery,  and  other  abdom- 
inal organs,  as  important  complications  of  the  general  fever,  capable  by 
their  extent  and  severity  of  adding  much  to  the  danger  of  fatal  results, 
and  consequently  to  be  watched  for  and  early  met  by  such  remedies  as  are 
capable  of  limiting  their  extent  and  mitigating  their  severity. 

In  selecting  remedies  to  counteract  these  intestinal  lesions,  you  must  re- 
member that  their  special  characteristics  are  strictly  asthenic.  We  have 
first  passive  congestion  from  impaired  tonicity  of  the  vessels,  accompanied 
by  aplastic  exudation  and  tumefaction;  next  softening  of  texture,  and  third 
ulceration,  disintegration  or  sloughing,  accompanied  throughout  by  morbid 
sensibility,  and  generally  by  increased  peristaltic  motion.  To  counteract 
these  pathological  conditions  you  must  bring  to  your  aid  such  remedies  as 
will  increase  the  natural  tonicity  or  contraction  of  the  vessels,  and  at  the  same 
time  lessen  both  the  morbid  sensitiveness  and  exaggerated  peristaltic  mo- 
tion. The  use  of  some  anodyne  conjointly  with,  at  first  (in  the  incipient 
stage)  small  doses  of  mercurials  or  iodine;  next  with  one  of  the  mineral 
acids,  nitrate  of  silver,  or  oil  of  turpentine,  and  throughout  the  midtlle  and 
later  stages,  the  last  mentioned  remedy  and  strychnia,  fulfills  the  rational 
indications  presented  better  than  by  any  other  means  with  which  I  am  ac- 
quainted. The  object  is  not  merely  to  lessen  the  amount  of  the  intestinal 
discharges,  but  to  limit  or  arrest  certain  dangerous  pathological  changes  in 
the  glandular  structures  both  within  and  without  the  intestines.  This  can- 
not be  done  by  a  simple  styptic  or  astringent  influence.  If  it  could,  any  of 
the  stronger  astringents,  as  tannin,  gallic  acid,  acetate  of  lead,  or  persulphate 
of  iron  would  answer  our  purpose.  These,  however,  tend  to  check  secre- 
tions generally  and  are  productive  of  more  harm  than  good,  except  when 
used  temporarily  for  the  arrest  of  actual  hemorrhage.  But  the  mineral  acids, 
nitrate  of  silver,  oil  of  turpentine,  and  strychnia,  improve  the  tonicity  of 


TREATMENT.  113 

the  smaller  vessels,  lessen  passive  congestion  and  exudation,  and  arrest  the 
tendencv  to  softening  and  disintegration,  by  increasing  the  general 
])rGperiy  of  the  tissues,  called  vital  affinity,  or  by  increasing  the  vaso-motor 
nervous  influence,  or  by  both.  Hence  they  improve  natural  secretory  ac- 
tion while  they  lessen  unnatural  discharges  from  passively  congested  tis- 
sues. The  distinction  I  here  make  is  one  of  much  practical  importance, 
and  yet  1  fear  it  has  been  often  overlooked. 

The  fifth  and  last  general  indication  or  object  that  I  have  named  to  you 
as  requiring  the  constant  attention  of  the  practitioner  while  managing  the 
treatment  of  typhoid  fever,  is,  to  sustain  the  patient  with  nourishment 
suitably  adjusted,  both  in  equality  and  quantity,  to  the  different  stages  of 
the  disease.  The  accomplishment  of  this  object  in  the  best  manner,  re- 
quires a  correct  knowledge  of  the  constituents  of  different  articles  of  food, 
tlie  facility  with  which  they  can  be  taken  up  from  the  surface  of  the  stom- 
ach, duodenum  and  first  half  of  the  small  intestines,  with  little  or  no  fecal 
residue  to  pass  over  the  more  irritable  and  diseased  surface  of  the  ilium, 
and  the  readiness  of  their  conversion  into  the  nutritive  constituents  of  the 
blood  capable  of  being  applied  to  the  repair  of  wasting  tissues.  The  fol- 
lowing brief  propositions  may  aid  you  in  the  study  of  this  subject.  First 
choose  such  articles  for  nourishment  as,  either  separately  or  conjoined, 
shall  contain  all  the  elementary  constituents  entering  into  the  composition 
of  the  blood  and  organized  structures  of  the  human  body.  Second,  the 
article  or  articles  selected  should  be  so  prepared,  that  when  taken  into  the 
stomach  they  are  capable  of  being  taken  up  and  assimilated  with  but  little 
influence  from  the  gastric  and  other  secretions  usually  rec[uired  for  the 
digestion  and  absorption  of  ordinary  food  in  health,  because  these  secretions 
are  generally  much  diminished,  especially  during  the  middle  and  later 
stages  of  the  disease. 

Third,  the  cj[uantity  given  at  any  one  time  should  be  so  limited  that  it 
will  be  all  absorbed  or  assimilated  before  any  part  of  it  has  time  to  un- 
dergo fermentation  or  putrefactive  changes  by  which  the  tympanites,  and 
the  irritation  of  the  glandular  patches  in  the  ilium,  might  be  increased; 
and  yet  the  aggregate  quantity  given  in  the  twenty-four  hours  must  be 
sufficient  to  afford  the  patient  a  fair  degree  of  support. 

The  practical  application  of  this  rule  requires,  on  the  part  of  the  attend- 
ing physician,  a  discriminating  judgment  founded  on  an  accurate  knowl- 
edge of  the  condition  of  the  digestive  organs  of  his  patient,  and  entire 
faithfulness  on  the  part  of  the  nurse. 

I  have  sometimes  thought  that  more  typhoid  fever  patiejits  had  been 
lost  from  errors  in  feeding  than  in  the  administration  of  medicines,  At 
one  time  they  are  starved  to  death  on  beef-tea  and  so-called  beef  juices 
and  essences,  which  contain  little  else  than  the  water,  soluble  salts,  and 
aroma  of  the  meat;  and  at  another  they  are  literally  stuffed  daily  with 
enough  beef-tea,  milk,  egg-nog,  and  brandy  or  whiskey  punch,  to  give  a 
healthy  day  laborer  a  fit  of  indigestion.  You  cannot  exercise  too  much 
care  in  avoiding  both  these  extremes.  As  a  general  rule,  well  prepared 
meat  broths  from  either  beef,  mutton  or  chicken,  suitably  seasoned  with 
salt,  constitute  the  best  nourishment  during  the  first  three  or  four  days 
after  the  patient  takes  to  his  bed,  and  the  quantity  allowed  to  be  taken  at 
one  time  may  be  safely  left  to  the  inclination  of  the  patient.  After  this, 
milk  should  be  alternated  with  the  beef-tea  or  used  altogether  as  a  substi- 
tute for  it;  and  so  soon  as  the  patient  begins  to  exhibit  that  mental  dull- 
ness which  makes  him  indifferent  or  averse  to  taking  food,  the  nourish- 
ment should  be  given  at  stated  intervals  aixd  in  prescribed  quantity  as 
regularly  as  the  administration  of  medicines.      In  the  middle   and   later 

8 


114  TYPHOID    FEVER. 

stages  of  the  disease,  when  the  bowels  are  more  or  less  tympanitic  and 
the  intestinal  discharges  thin  and  frequent,  the  milk  should  be  boiled 
and,  while  boiling,  a  little  wheat  flour  added  with  brisk  stirring  to  pre- 
vent its  forming  lumps,  and  give  it  the  form  of  a  thin,  homogenious  milk 
and  flour  gruel.  From  two  to  four  tablespoonfuls  of  this  may  be  given 
every  one  or  two  hours,  and  it  constitutes  the  best  nourishmont  for  such 
cases  that  I  have  been  able  to  devise.  It  contains  all  the  elements  necessa- 
ry to  supply  the  waste  of  the  blood  and  tissues  in  small  compass,  bland  and 
soothing  to  the  mucous  membrane,  and  easily  assimilated.  For  drinks,  noth- 
ing is  l;etter  than  milk-whey,  fresh  buttermilk,  and  cold  water,  given  in  small 
quantities  but  sufficiently  often  to  keep  the  mouth,  tongue  and  fauces  from 
becoming  too  dry.  When  there  is  much  muttering  delirium  with  subsultus, 
or  unusual  drowsiness,  tea  and  coffee,  as  pure  excitants  of  nerve-sensibil- 
ity, will  constitute  valuable  drinks. 

Some  of  you  may  be  surprised  that  I  have  not  included  in  the  list  of 
important  objects  to  be  accomplished  in  the  treatment  of  typhoid  fever, 
that  of  controlling  the  temperature  by  antipyretics.  The  omission  is  only 
apparent,  however.  The  increase  of  temperature  being  simply  a  symp- 
tom or  result  of  those  complex  molecular  and  functional  disturbances 
produced  by  the  action  of  the  predisposing  and  exciting  causes  on  the 
blood  and  general  properties  of  the  tissiies,  the  only  rational  and  curative 
mode  of  controlling  it,  is  by  removing  the  further  action  of  such  causes, 
and  restoring  the  disturbed  molecular  and  functional  actions  to  their  nor- 
mal condition,  as  I  explained  in  the  preceding  lecture,  while  speaking 
of  the  first,  second  and  third  objects  requiring  your  attention.  To  seize 
upon  one  leading  symptom  of  a  general  acute  disease  involving  many 
important  morbid  processes,  and  ixiake  its  control  the  principal  object  of 
treatment,  without  any  regard  to  the  morbid  processes  on  which  it  de- 
pends, is  both  unphilosophical  and  often  attended  by  bad  results.  You 
might  with  the  same  propriety  fix  your  attention  on  the  diarrhoea  that  so 
:genera]ly  attends  the  middle  and  advanced  stages  of  the  disease,  and 
endeavor  to  control  it  by  opia,tes,  astringents,  or  whatever  would  most 
speedily  suppress  it,  without  regard  to  the  special  character  of  the  mor- 
bid processes  in  the  intestines  by  which  it  was  produced,  as  to  take  your 
■clinical  thermometer  in  hand  and  undertake  to  arbitrarily  control  the  tem- 
perature of  your  patient  by  cold  baths,  quinine,  digitalis,  salicylic  acid, 
or  whatever  else  would  most  speedily  reduce  it  within  the  desired  limits, 
without  regard  to  the  effect  of  your  remedial  ag3nts,  or  antipyretics,  on 
the  blood,  the  nervous  centres,  or  any  of  the  other  important  processes 
involved.  Do  not  infer,  gentlemen,  that  I  am  undervaluing  either  the 
use  of  the  clinical  thermometer  or  of  the  various  remedies  called  anti- 
pyretics. The  introduction  of  the  former  into  use  at  the  bedside  has  added 
much  to  the  accuracy  of  our  knowledge  concerning  the  range  of  tem- 
perature in  acute  diseases,  and  the  connection  of  that  range  with  import- 
ant pathological  conditions,  and  the  new  modes  of  using  the  latter  have 
led  to  much  better  results  than  the  prevalent  method  of  stuffing  almost  all 
continued  fever  patients  with  wine,  egg-nog,  and  whiskey  or  brandy 
punch,  that  immediately  preceded  it.  This  latter  fact,  however,  does  not 
prove  that  these  better  results^  are  as  good  as  might  be  obtained  by  a  more 
discriminating  use  of  remedies.  I  would  warn  you  against  trusting  too 
exclusively  to  the  guidance  of  the  clinical  thermometer  on  the  one  hand, 
and  the  too  indiscriminate  application  of  powerful  remedial  agents  to  the 
control  of  a  single  symptom  on  the  other.  I  have  seen  several  fatal  cases 
of  typhoid  fever  in  which  the  daily  use  of  the  thermometer  by  the  attend- 
.ing  physician  failed  to  make  a  single  registration  above  40°  C.  (104°  F.). 


TREATMENT.  115 

One  of  these  died  from  perforation  of  the  intestine  at  tlie  end  of  the  fifth 
week  from  the  commencement  of  tlie  disease.* 

That  the  arbitrary  use  of  antipyretics  is  often  accompanied  by  dan- 
gerous results,  T  have  abundant  evidence  from  direct  clinical  observation. 
It  is  only  a  few  months  since  I  saw  a  case  of  uncomplicated  typhoid  fever, 
in  the  second  week  of  its  progress,  in  which  a  cold  pack  was  directly  fol- 
lowed by  a  protracted  chill  and  the  development  of  a  dangerous  degree 
of  pneumonia.  Within  the  last  three  or  four  years  I  have  been  called  to 
three  cases  under  the  care  of  three  different  practitioners,  in  which  0.6(3 
grams  (gr.  x.)  of  sulphate  of  quinine  had  been  given  every  hour  until 
2.0  grams  (gr.  .\xx.)  had  been  taken  to  reduce  the  temperature,  twice  in 
the  twenty-four  hours,  for  a  week  in  succession.  Two  of  the  patients 
were  adults,  the  other  a  child  of  about  twelve  years.  In  each  case,  at  the 
time  of  my  visit,  which  was  from  three  to  five  hours  after  the  last  dose  of 
the  quinine  had  been  given,  the  patients  were  found  in  a  dorsal  position, 
limbs  extended,  features  relaxed  and  pale,  profoundly  deaf,  the  respira- 
tion so  feeble  that  the  motion  of  the  chest  was  hardly  perceptible,  and 
the  circulation  alarmingly  feeble  ;  yet  in  neither  case  was  the  temperature 
below  38^3.  C.  (101"  F.). 

By  omitting  the  further  use  of  quinine  and  substituting  therefor  small 
doses  of  strychnia  and  nitric  acid,  with  such  other  remedies  as  the  condi- 
tion of  the  intestinal  discharges  and  urinary  secretion  indicated,  the  more 
dangerous  symptoms  disappeared  during  the  succeeding  twenty- four  hours, 
and  in  due  j^rocess  of  time  the  patients  recovered.  I  have  also  seen  a 
number  of  cases  in  which  the  most  alarming  symptoms  of  prostration  ac- 
companied the  use  of  salicylic  acid  in  the  second  week  of  the  progress  of 
the  general  fever. 

One  of  these  occurred  in  one  of  my  own  wards  of  the  Mercy  Hospital. 
A  laboring  man,  aged  about  30  years,  during  the  first  half  of  the  second 
week  of  his  confinement,  had  been  taking  0.66  grams  (gr.  x.)  of  salicylic 
acid  in  solution  with  bicarbonate  of  soda,  every  four  hours,  when  his 
pulse  went  rapidly  down  to  45  beats  per  minute,  with  all  the  accompany- 
ing symptoms  of  great  exhaustion.  The  remedies  were  changed,  and  the 
symptoms  of  extreme  depression  slowly  disappeared.  After  two  or  three 
days,  the  temperature  of  the  patient  being  too  high,  and  not  feeling 
certain  that  the  previous  bad  symptoms  had  been  caused  by  the  salicvlic 
acid  solution,  its  use  was  resumed,  and  in  about  forty-eight  hours  the 
same  symptoms  were  again  suddenly  developed.  Of  course,  the  further 
use  of  the  remedy  was  omitted;  the  disease  continued  through  a  pro- 
tracted and  severe  course,  but  finally  ended  in  convalescence.  If  by 
these  observations  I  can  induce  you  to  faithfudly  use  your  clinical  ther- 
mometers as  the  most  accurate  mode  of  determining  the  temperature  of 
your  patients,  that  you  may  carefully  compare  it  with  the  progress  of 
the  morbid  processes  on  which  it  depends;  and  to  so  study  the  modus 
operandi  of  the  several  antipyretics,  that  you  may  see  clearly  which  is 
best  adapted  for  the  removal  of  such  morbid  processes  and  conditions  as 
may  give  rise  to  an  increase  of  the  sensible  heat  or  high  temperature,  I 
shall  have  conferred  a  great  benefit,  both  upon  you  and  your  future 
patients. 

Having  thus  led  you  through  a  detailed,  and  perhaps  tedious,  analytical 
study  of  the  several  important  indications  to  be  fulfilled  or  objects  to  be 
accomplished,  in  the  treatment  of   typhoid  fever,  for  the  purpose  of   ena- 

*Dr.  Frantzel  has  recently  described  several  cases  of  typhoid  fever,  which  run  their  course  with 
low  temperature,  but  presented  serious  cerebral  symptoms,  general  collapse,  and  sometimes  gau 
grene  ot  the  lower  extremities.    See  Zelt.  fur  Kliu.  Med.,  Baud  ii..  S.  217. 


116  TYPHOID    FEVEE. 

bliag  you  to  comprehend  more  fully,  both  the  nature  and  extent  of  the 
morbid  processes  presented,  and  the  philosophy  of  their  management,  it 
only  remains  for  me  to  reverse  this  order,  and  by  a  synthetical  union  of 
indications  and  remedies,  briefly  conduct  you  through  the  actual  treatment 
of  some  fair  sample  cases,  as  though  we  were  at  the  bedside  of  the  pa- 
tients. When  called  to  a  fair  typical  case  of  typhoid  fever  during  the 
first  one  or  two  days  after  the  patient  has  taken  to  his  bed,  presenting  the 
svmptoms  I  have  already  described  to  you  as  belonging  to  that  stage,  I 
endeavor  to  secure  the  best  possible  hygienic  surroundings  for  the  pa- 
tient, by  fresh  air,  strict  cleanliness,  and  two  or  three  times  a  day  a  spong- 
ing of  the  cutaneous  surface  with  water  at  such  temperature  as  is  most 
agreeable  to  the  patient.  For  still  further  modifjdug  the  general  disturb- 
ances of  secretion  and  excretion  I  order  the  two  following  prescriptions: 

5.   Hydrargyri  Chloridi  Mitis,  0.40  grams     gr.     vi. 
Pulveris  Opii  Compositi,     2.00       "  "     xxx. 

Potassii  Nitratis,  2.00       "  "     xxx. 

Mix,  and  divide  into  six  powders,  one  to   be  given  every  four  hours. 
Jp   Liquoris  Ammonii  Acetatis,  60.  c.c.     |ii. 
Spiritus  Athens  Nitrosi,      60.  c.c.     ?ii. 
Mix,  and    give    4,  c.  centimeters,  or    one  tea-spoonful  every  four    hours 
between  the  powders. 

After  continuing  these  remedies  for  twenty-four  hours,  if  there  have 
been  no  evacuations  from  the  bowels,  I  order  an  enema  of  warm  water, 
holding  in  solution  a  little  common  salt,  or  sulphate  of  magnesia,  which 
will  usually  procure  one  or  more  free  evacuations.  If  it  is  not  convenient 
to  have  an  enema  administered,  a  mild  saline  laxative  may  be  given  by 
the  mouth.  The  further  use  of  the  powders  is  limited  to  one  every  even- 
ing for  two  or  three  nights,  after  which  they  are  entirely  omitted.  As 
soon  as  the  bowels  have  been  fairly  moved,  either  spontaneously  or  by  the 
use  of  the  mild  laxative  measures  just  mentioned,  I  direct  a  solution  of 
chlorate  of  potassium  with  hydrochloric  acid  in  gum  arable  water,  in  such 
proportion  that  15  cubic  centimeters  (3SS.),  or  one  table-spoonful,  will  con- 
tain from  0.33  to  0.50  grams,  (gr.  v.  to  gr.  viii.)  of  the  chlorate,  and  the 
same  number  of  minims  of  the  hydrochloric  acid,  and  have  this  amount 
given  every  four  hours,  alternating  with  the  liquor  ammoniee  acetatis,  and 
the  spirits  of  nitrous  aether.  These  remedies  and  such  frequent  sponging 
of  the  surface  with  water  as  the  heat  and  dryness  may  indicate,  I  continue 
so  long  as  the  abdominal  tympanitis  remains  only  moderate,  and  the  in- 
testinal discharges  do  not  exceed  one  or  two  in  the  twenty-four  hours. 
In  many  mild  cases  the  patients  pass  through  the  disease  to  an  early  con- 
valescence with  n)  other  medication.  But  the  more  severe  cases  seldom 
reach  the  end  of  the  first  week  after  taking  to  the  bed,  without  showing 
increased  fullness  of  the  abdomen,  more  dryness  of  the  tongue,  and  an 
increase  of  the  intestinal  discharges.  As  soon  as  these  symptoms  make 
their  appearance,  I  omit  the  further  use  of  the  prescription  containing  the 
liquor  ammonige  acetatis,  and  substitute  in  its  place  the  following  emulsion. 

J^   Olei  TerebinthinEe, 

Olfti  Gaultherige, 

Tincturse  Opii, 

Pulveris  Acaciee,  )  .,  ^k  t   ' 

e       X      -AH-        r  ai         20.  grams.         3vi. 
bacchari  Albi        )  ° 

Rub  together  thoroughly,  and  add 

Aquae  120.  c.  c.  |iv. 


12.  c.  c. 

3iii. 

2.  "  " 

3ss. 

15.  "  « 

3iv. 

15. 

c.c. 

3iv. 

15. 

grains. 

3iv. 

15. 

c.c. 

3iv. 

120. 

(( 

^iv. 

TEEATMEISIT.  117 

Mix  thorough]}'- and  give  4  cubic  centimeters  (3i),  or  an  ordinary  tea- 
spoonful  every  three,  four,  or  six  hours,  according  to  the  frequency  of  the 
discharges.  If  this  emulsion  is  faithfully  prepared  in  the  manner  I  have 
just  stated,  it  is  not  unpleasant  to  take  and  very  rarely  disagrees  with  the 
sromach  or  irritates  the  urinary  passages,  even  when  continued  for  ten 
days  or  two  weeks  without  interruption.  And  in  nine  cases  out  of  every 
ten,  if  its  use  is  commenced  as  early  as  I  have  indicated,  and  continued 
judiciously,  it  will  do  more  to  limit  the  extent  and  finally  arrest  the  pro- 
gress of  the  morbid  changes  taking  place  in  the  intestines  and  glands  of 
the  mesentery  than  any  other  remedies  that  I  have  used.  Yet,  I  occasion- 
ally meet  with  a  case  in  which  the  oil  of  turpentine  either  offends  the 
stomach  or  causes  painful  micturition  ;  and  if  either  of  these  effects  follow 
its  administration,  1  immediately  discontinue  it  and  give  instead  one  of  the 
following  formulae: 

J^        Argenti  Nitratis  0.66  grams  gr.    x. 

Extract!  Hvoscyami        2.00       "  "     xxx. 

Pulveris  Opii  2.00      "  "     xxx. 

Mix  intimately  and  divide  into  pills  xxx  ;  one  of  which  may  be  given 
just  as  often  as  you  would  otherwise  give  a  dose  of  the  emulsion. 

Or,    I^    Acidi  Sulphurici  Aroraatici 
Magnesia?  Sulphatis, 
Tincturae  Opii, 
AcpicG, 

Mix  and  give  four  cubic  centimeters  (11.  3)  or  one  teaspoonful  in  a  little 
additional  water,  every  three  or  four  hours,  instead  of  the  pills  or 
emulsion.  You  will  perceive  that  each  of  these  three  formula;  combine 
two  leading  properties:  one  capable  of  increasing  the  tone  of  the  congested 
vessels  in  the  diseased  glandular  structures  without  checking  any  of  the 
important  secretory  and  elitninative  processes;  the  other  capable  of  directly 
lessening  the  morbid  excitability  of  the  same  structures  and  thereby  lessen- 
ing the  morbid  intestinal  discharges.  Tlieir  administration  should  be  so 
graduated  in  size  of  dose  and  frequency  of  repetition  as  to  limit  the  intes- 
tinal evacuations  as  near  as  possible  to  one  or  two  in  the  twenty-four  hours 
until  they  become  consistent  and  natural.  If  it  should  happen  that  the 
evacuations  from  the  bowels  entirely  cease  for  twenty-four  or  thirty-six: 
hours  at  any  time  after  the  commencement  of  the  second  week,  do  not 
commit  so  great  a  blunder  as  to  administer  a  dose  of  physic  to  provoke 
them.  In  such  cases  nothing  more  is  necessary  than  to  suspend  the  use  of 
the  restraining  measures,  or  at  most  administer  a  warm  water  enema.  The 
giving  of  even  the  mildest  physic  in  the  advanced  stage  of  typhoid  fever 
is  always  attended  by  danger  to  the  patient.  It  is  only  a  few  weeks  since 
that  I  was  called  to  see  a  young  man  who  had  passed  nearly  through  a 
pretty  severe  course  of  the  fever,  and  defervescence  had  actually  com- 
menced, when,  on  account  of  the  failure  of  the  bowels  to  move  for  thirty-six 
hours,  a  moderate  dose  of  sulphate  of  magnesia  was  given,  which  not  only 
operated  promptly  and  freely,  but  was  followed  by  a  renewal  of  tympanites 
and  intestinal  discharges  so  frequent  and  persistent  that  fatal  exhaustion 
was  induced  in  a  few  days.  If  the  measures  I  have  now  indicated  fail  to 
exercise  sufficient  control  over  the  general  febrile  condition  and  at  any 
time  during  the  latter  part  of  the  first  or  in  the  second  week  the  tempera- 
ture rises  to  40^^  C.  (104.5"  F.)  accompanied  by  some  delirium,  restlessness, 
quick  pulse,  and  dryness  of  the  mucous  membrane  of  the  mouth  and  air 
passages,  1  wrap  the  patient  in  a  wet  sheet  and  keep  up  refrigeration  by 


118  TYPHOID    FEVEE. 

frequenth'  sprinkling'  the  sh^et  with  cold  water  until  the  temperature  falls 
to  30°  C.  (102.5°  F.).  This  process  may  be  resorted  to  once  or  twice  in 
the  twentv-four  hours  in  aid  of  the  ordinary  sponge  baths,  so  long  as  the 
temperature  continues  to  rise  for  anv  considerable  part  of  the  day  above 
40°  C.  (104.5°  F.). 

If  froua  the  inherent  gravity  of  the  disease  or  the  neglect  of  proper  meas- 
ures in  the  earlier  stages  of  its  progress,  the  patient  begins  to  exhibit  a 
low,  muttering  deliriuni,  or  a  dull,  drowsy  mental  condition,  with  more  or 
less  subsultus,  a  quick,  weak  pulse,  a  slowness  in  expelling  the  urine,  or 
an  imperfect  control  over  the  sphincters  of  the  rectum  and  bladder,  I 
promptly  direct  the  administration  of  strychnia  and  nitric  acid,  and  gen- 
erally in  accordance  with  the  following  formula  : 


^ 

Strychnise, 

0.066  grams. 

gr.  1. 

Acidi  Nitrici, 

4.         c.c. 

3i. 

Tincturge  Opii, 

15.         "  " 

3iv. 

Aquae, 

105.         "  " 

3iiiss, 

Mix  and  give  4  cubic  centimeters  (3i),  or  a  teaspoonful  in  sweetened 
water  every  three,  four  or  six  hours,  according  to  the  urgency  of  the 
symptoms.  At  the  same  time  the  administration  of  such  nourishment  as 
1  have  already  indicated  should  be  faithfully  attended  to.  The  region  of 
the  bladder  should  be  examined  at  every  visit,  and  if  it  fails  to  empty 
itself  completely  the  catheter  should  be  used  at  proper  intervals. 

If  the  abdomen  remains  very  tympanitic  and  the  intestinal  evacuations 
too  frequent,  a  dose  of  the  turpentine  and  laudanum  emulsion  may  be  given 
between  the  doses  of  the  strychnia  solution,  until  those  symptoms  are  suf- 
ficiently restrained. 

If,  finally,  signs  of  defervescence  begin  to  appear,  and  all  the  bad  symp- 
toms abate,  do  not  discontinue  your  remedies  suddenly,  but  simply 
lengthen  the  interval  between  the  doses  from  time  to  time  until  convales- 
cence is  fully  established  and  the  urinary  and  intestinal  discharges  have 
become  natural  in  quantity  and  quality.  The  foregoing  brief  outline  of 
treatment,  coupled  with  the  previous  full  discussion  of  the  indications  to 
be  fulfilled,  both  in  the  typical  and  untypical  cases,  is  sufficient  for  all 
ordinary  purposes.  But  there  are  some  important  symptoms  or  complica- 
tions that  occasionally  present  themselves  during  the  progress  of  typhoid 
fever,  the  management  of  which  needs  some  attention.  For  instance, 
there  are  cases  in  which  -diarrhoea  and  other  abdominal  symptoms  are 
prominent  from  the  commencement.  In  such  cases,  instead  of  giving  t'ne 
chlorate  of  potassium  and  hydrochloric  acid,  T  direct  at  once  the  turpentine 
and  laudanum  emulsion  or  some  one  of  the  formul;:e  for  allaying  the  intesti- 
nal irritation,  and  for  an  antiseptic  and  alterant  to  modify  the  general 
]")roperties  of  the  tissues,  iodine  may  be  given  in  solution  with  iodide  of 
potassium,  as  in  the  following  formula  : 


I^    lodinii 

0.5  grams. 

gr. 

viii. 

Potassii  lodidii 

2.0'     " 

u 

XXX. 

Aqute  Puraj 

30.0  c.c. 

u 

3i- 

Mix,  and  give  from  0.3  to  0.5  c.  c.  (minims  5  to  8)  every  six  hours,  in  a 
tablespoonful  of  sweetened  water.  In  all  grave  cases  of  the  general  fe- 
ver, the  action  of  the  kidneys  should  be  noted  carefully,  and  if  the  urine 
cither  becomes  very  scanty  or  albuminous,  or  both,  an  infusion  of  digi- 
talis leaves,  holding  in  solution  acetate  of  potassium,  administered  in  fair 
doses  ouce  in  four  hours,  will  be  found   one  of  the    best   remedies.     The 


HEMORKHAGE    AND    PERFORATION.  .  119 

giviiif^of  this  need  not  interfere  with  the  use  of  any  other  remedies  indi- 
cated in  th;;  case  at  the  same  time.  Sometimes,  iti  the  advanced  stages 
of  the  fever,  the  patient  becomes  subject  to  profuse  and  exhausting 
sweats,  coincident  with  scanty  urine  and  feeble  pulse.  To  check  this  I 
have  fiTund  a  combination  of  the  tincture  of  digitalis,  two  parts,  with  one 
part  of  the  tincture  of  belladonna,  given  in  doses  of  1.5  cubic  centi- 
metres (minims  xxv.)  every  two,  three  or  four  hours,  more  promptly  effi- 
cient than  anything  else  that  I  have  used.  I  hive  also  found  this  sam^ 
combination  useful  in  lessening  the  extreme  tympanitic  distension  of  the 
abdomen,  from  apparent  loss  of  action  in  the  muscular  coat  of  the  intes- 
tines, in  two  cases  recently  under  my  care  in  the  Mercy  Hospital.  You 
will  remember  that  when  speaking  of  the  svmptoms  of  typhoid  fever,  I 
stated  that  some  rare  cases  were  met  with,  in  which,  instead  of  dullness 
and  drowsiness,  we  had  morbid  vigilance  or  constant  wakefulness,  with 
nervous  agitatioo,  and  sometimes  delirium. 

To  allay  these  unpleasatit  symptoms  I  have  given  the  tincture  of  digi- 
talis and  chloroform,  each  0.5  to  1.0  c.  c.  (minims  viii.  to  xv.)  every  two 
or  three  hours,  with  the  effect  of  soon  inducins:  quiet  sleep  and  a  marked 
improA'ement  in  the  general  symptoms.  In  milder  cases  of  the  same 
kind,  pretty  full  doses  of  hyoscyaraus  and  camphor  have  been  sufficient  to 
procure  the  needed  rest,  especially  when  given  in  the  evening. 

Intestinal  Hemorrhage.  The  occurrence  of  true  intestinal  hemorrhage 
as  distinguished  from  the  simple  intermixture  of  a  small  quantity  of  blood 
with  the  fecal  evacuations,  is  not  of  frequent  occurrence,  though  occasion- 
ally met  with  at  any  part  of  the  progress  of  the  disease  after  the  middle  of 
the  second  week.  Its  occurrence  is  always  an  unfavorable  indication,  and 
generally  leads  to  a  speedy  and  fatal  collapse.  The  blood,  when  voided, 
IS  generally  very  dark  color,  partially  coagulated,  and  emitting  an  offensive 
odor.  For  arresting  the  hemorrhage,  oil  of  turpentine,  acetate  of  lead, 
gallic  acid,  ergotine,  and  nearly  all  the  more  important  vegetable  astring- 
ents, have  been  given  both  by  the  mouth  and  rectum,  and  sometimes  with 
success.  In  the  few  cases  that  have  come  under  my  own  observation, 
better  success  has  attended  the  administration  of  the  persulphate  of  iron 
in  doses  of  0.130  grams  (gr.  ii)  dissolved  in  water,  every  hour;  at  the 
same  time  continuing  the  ordinary  use  of  the  turpentine  and  laudanum 
emulsion. 

Perforation  of  the  Intestines.  The  extension  of  the  ulcerative  process 
in  some  one  of  the  aggregated  glands  of  the  lower  part  of  the  ilium,  so  far 
as  to  cause  perforation  of  all  the  coats  of  the  intestines,  and  the  production 
of  general  and  speedily  fatal  peritonitis,  is  liable  to  occur  at  anytime  during 
the  last  stage,  or  even  in  the  convalescence,  of  protracted  cases  of  typhoid 
fever.  This  accident  or  complication  is  certainly  not  of  frequent  occur- 
rence, as  I  have  met  with  but  two  instances  in  my  own  patients  during  the 
whole  period  of  my  practice.  The  first  of  these  occurred  in  1S51,  in  the 
person  of  a  young  man  who  was  studying  medicine.  He  had  passed 
through  a  regular  course  of  typhoid  fever,  and  convalesced  at  the  end  of 
the  third  week.  After  progressing  with  his  convalescence  nearly  a  week 
apparently  well,  and  being  up  a  part  of  each  day,  he  was  taken  suddenly 
with  very  sharp  pains  in  the  central  part  of  his  abdomen,  followed  by  a 
great  sense  of  prostration,  a  very  quick  and  weak  pulse,  rapid  increase  of  ten- 
derness and  distension  of  the  abdomen,  and  all  the  symptoms  of  general  peri- 
toniris,  under  which  he  died  in  less  than  forty-eight  hours.  The  other 
occurred  during  the  fourth  week  of  a  severe  case,  before  any  signs  of  con- 
valescence had  appeared.  The  treatment  of  such  cases  consists  mainly  in 
the  administration   of  opiates   sufficient   to  hold  the  intestines  quiet  and 


120  TYPHOID    FEVER. 

lessen  the  pain,  in  the  hope  that  adhesive  inflammation  may  be  se.t  up  in  the 
peritoneal  surface  around  the  perforation,  and  by  quickly  causin,g  the  parts 
in  contact  to  adhere  together,  prevent  the  contents  of  the  intestine  from 
becoming  diifused  in  the  peritoneal  cavity  generally,  atid  thereby  so  limit 
the  progress  of  the  inflammation  as  to  afl'ord  the  patient  a  chance  of  recovery. 
It  is  possible  that  some  cases  have  terminated  thus  fortunately'  By»t  as  a 
general  rule,  perforation  of  the  intestines  in  connection  with  tyg^oid  fgver, 
has  proved  speedily  fatal  in  despite  of  any  treatment  hitherto  Adopted. 

Sequelce.  The  three  most  important  pathological  conditions  liable  to 
result  from  a  severe  and  protracted  course  of  typhoid  fever,  are  chronic 
diarrhoea  from  imperfectly  repaired  ulcerations  in  the  ilium;  permanent 
impairment  of  the  capacity  of  the  lungs  for  air  through  failure  to  regain 
the  full  expansion  or  reopening  of  the  air-cells  in  those  parts  of  ^e  lungs 
which  had  suffered  either  from  protracted  hypostatic  infiltration, '«r  more 
likely  from  a  low  grade  of  pneumonic  exudation  during  .-the  progress  of 
the  fever;  and  a  condition  of  general  ■  debility  characterized  by  loss  of 
power  of  endurance  and  almost  constant  tendency  to  constipation  and 
moderate  inactivity  of  secretions  generally,  without  any  well  defined 
local  disease.  Such  patients  usually  say  they  feel  very  'vv^ll  as* long  as 
they  refrain  from  any  active  labor,  but  tire  out  as  soon  as  tfc^^y  commence 
work.  I  have  traced  many  such  cases  back  directly  to  attacks  of  typhoid 
fever  that  had  occurred  several  years  previously.  It  has  seemed  to  me 
that  in  these  cases  the  various  organized  tissues  had  never  regained  the^ 
full  activity  of  the  elementary  properties  that  govern  those  .-molecular 
changes  which  are  concerned  in  nutrition,  secretion  and  innervation. 
Consequently  all  these  processes  and  functions  are  conducted  (5n  a  lower 
grade  of  activity  than  natural.  Yet  most  of  this  class  of  patients  are  al- 
most constantly  dosed,  either  with  supposed  cholagogues,  to  act  on  the  liver 
and  remove  "biliousness,"  or  with  some  kind  of  alcoholic  "bitters"  to 
promote  strength  and  appetite,  or  both  alternately.  Under  such  treat- 
ment they  generally  get  gradually  worse  from  year  to  year.  There  are 
two  rational  indications  to  be  fulfilled  in  the  treatment  of  these  patients, 
namely,  to  increase  the  tone  and  sensibility  of  the  nervous  and  muscular 
structures,  and  to  promote  cell  growth  or  molecular  change.  To  fulfill 
the  first  I  give  a  pill  containing  strychnia  0.002  grams  (gr.  1-32),  sulphate 
of  iron  0.064  grams  (gr.  i)  before  each  meal-time;  and  for  the  second,  the 
syrup  of  the  lacto-phosphate  of  lime  4  cubic  centimetres  (fl.  3i.)  after  each 
meal.  If  the  bowels  are  decidedly  costive,  pulverized  aloes  0.016 
grams  (gr.  ^)  may  be  added  to  each  pill  during  the  first  week.  The 
continuance  of  these  remedies,  with  a  proper  supply  of  good  air,  very 
moderate  but  regular  out-door  exercise  daily,  and  a  fair  variety  of  plain 
food,  for  two  or  three  months,  has  seldom  failed  to  re-establish  a  fair  grade 
of  health  and  strength. 

The  second  class  of  patients  named  as  recovering  imperfectly  after  ty- 
phoid fever,  had  their  disability  founded  on  an  imperfect  restoration  of 
the  air-cells,  after  protracted  closure  from  infiltration  or  exudation  during 
the  middle  and  later  stages  of  the  general  fever.  The  exact  condition  of 
the  affected  portions  of  the  lungs  appears  to  consist  in  hj^pertrophy  of  the 
connective  tissue  with  obliteration  of  many  of  the  air-cells,  constituting  a 
condition  styled  by  the  writers  of  a  former  generation,  carnified. 

The  patients  suffer  chiefly  from  inability  to  take  active  exercise  without 
shortness  of  breath,  and  from  the  ordinary  consequences  of  habitually  im- 
perfect oxygenation  and  decarbonization  of  the  blood.  The  pathological 
change  of  structure  being  permanent,  the  treatment  must  be  altogether 
palliative;  and  consists  mainly  in  adjusting  the  daily  exercise  and  diet  of  the 


SEQUELS.  121 

patient  to  his  actual  capacity  for  enduring  the  one,  and  assimilating  the 
other.  If  tlie  defect  is  only  moderate  in  amount,  the  health  of  the  patient 
may  remain  in  statu  quo  for  many  years.  But  if  the  impairment  of  struc- 
ture is  extensive,  it  is  very  liable  to  cause  further  degenerative  changes, 
especially  of  a  fatty  or  caseous  character,  bringing  the  symptoms  and 
coTisequences  of  one  form  of  phthisis. 

Some  degree  of  chronic  diarrhoea,  as  a  sequel  of  the  general  fever,  is 
met  with  more  frequently  than  either  of  the  other  defects  of  which 
I  have  just  spoken.  You  must  remember  that  defervescence  often  takes 
place  while  there  is  still  considerable  looseness  of  the  bowels,  and  it  is 
not  very  uncommon  to  see  one  or  two  soft  or  semi-fluid  evacuations  for 
several  days  after  the  patient  appears  to  be  convalescent.  If  this  is  neg- 
lected and  a  liberal  diet  alloAved,  the  patients  will  gain  slowly  in  flesh  and 
strength,  and  in  a  few  weeks  get  about  their  ordinary  business,  though 
still  having  from  one  to  three  loose  stools  per  day,  and  not  feeling  as 
strong  as  they  think  they  ought  to.  After  two  or  three  months,  instead  of 
having  fully  recovered,  they  find  themselves  losing  both  in  flesh  and 
strength,  and  are  again  compelled  to  seek  medical  advice. 

It  is  now  found  that  they  are  having  a  regular  chronic  diarrhoea.  The 
stools  are  generally  thin,  greyish  or  reddish  brown  in  color,  and  occurring 
from  one  to  four  or  five  times  in  the  twenty-four  hours,  and  are  usually 
accompanied  by  little  or  no  pain.  In  some,  nearly  all  the  evacuations 
take  place  in  quick  succession  during  the  morning,  and  the  bowels  remain 
quiet  the  rest  of  the  day.  In  others,  an  evacuation  follows  almost  immedi- 
ately after  each  meal,  as  though  the  presence  of  food  in  the  stomach 
excited  an  undue  peristaltic  movement  throughout  the  whole  length  of  the 
alimentary  canal.  Occasionally  you  will  meet  with  a  case  that  presents 
regular  alternations  of  costiveness  and  diarrhoea  ;  the  bowels  remaining 
quiet  from  two  to  three  days,  with  an  increasing  sense  of  fullness  or  discom- 
fort, and  then  free  diarrhoeal  discharges  for  one  day,  or  until  the  contents 
of  the  bowels  have  been  fully  discharged.  During  the  war,  from  1861  to 
1864,  a  very  obstinate,  and  sometimes  fatal,  form  of  chronic  diarrhoea  was 
often  met  with  among  the  soldiers,  as  the  sequel  of  protracted  attacks  of 
typhoid  fever,  modified  by  the  co-existence  of  malarious  influences,  called 
by  many  "  typho-malarial  fever."  I  need  hardly  remind  you  that  the 
diarrhoea  found  following  an  attack  of  typhoid  fever  has  its  origin  in  the 
continuance  of  a  morbidly  sensitive  condition  of  the  recently  ulcerated 
glandular  structures  in  the  lower  part  of  the  ilium,  and  in  the  more  severe 
cases  the  continuance  of  the  ulcerated  patches  in  a  more  indolent  or 
chronic  form  ;  but  I  repeat  the  fact,  for  the  purpose  of  again  ui'ging  the 
importance  of  having  the  practitioner  give  close  attention  to  the  careful 
regulation  of  both  diet  and  medicines  through  the  period  of  convalescence, 
and  until  the  intestinal  discharges  have  become  reliably  natural,  both  in 
time  and  quality.  It  is  far  easier,  by  such  attention,  to  prevent  this 
troublesome  and  sometimes  dangerous  sequel,  than  to  cure  it  after  it  has 
become  established.  Yet,  the  great  majority  of  the  cases  I  have  met  with 
have  recovered  in  from  two  to  six  weeks  by  a  properly  regulated  diet  of 
milk  and  wheat-flour  gruel,  milk  and  light  bread  or  crackers,  and  meat 
broths  made  with  rice  added  to  the  meat,  aided  by  much  rest  in  the  recum- 
bent position,  and  a  dose  of  either  the  turpentine  and  laudanum  emulsion, 
or  of  the  nitrate  of  silver,  hyosciamus  and  opium  pills  each  morning,  noon, 
tea-time  and  at  bed-time.  The  number  of  doses  per  day  may  be  dimin- 
ished from  time  to  time,  as  the  discharges  become  less  frequent  and  more 
consistent.  In  such  cases  as  had  continued  until  the  blood  had  become 
much  impoverished  of  red  corpuscles   and  nutritive   elements,  giving  the 


122  TYPHUS    FEVER. 

j^atients  a  very  anferaic  appearance,  as  was  the  case  with  many  of  the 
eoldiers  returning  sick  from  the  military  camps,  I  obtained  very  good 
results  from  the  administration  of  a  powder  every  four  or  six  hours,  com- 
posed of  sub-nitrate  of  bismuth  0.5  grams  (gr.  viii.),  sub-carbonate  of  iron 
0.3  grams  (gr.  iii.),  and  sulphate  of  morphine  0.011  grams  (gr.  1-6).  In 
some  of  the  same  class  of  patients,  in  which  the  morphine  in  the  powders 
induced  secondary  nausea  and  depression,  I  substituted,  with  advantage, 
the  use  of  a  solution  of  bromine  with  bromide  of  potassium  and  distilled 
water,  as  in  the  following  formula  : 


J^     Brorainii  0.66  c.c. 

Potassii  Bromidi  4.  grams. 

Aquas  Distillatae,    120.  c.c. 


M      X. 

3i. 


Mix,  give  4  cubic  centimetres  (fl.  3i')  Of  one  teaspoonful  further  diluted, 
with  at  least  a  tablespoon ful  of  water  every  four  or  six  hours.  The  use  of 
this  remedy  was  first  suggested  to  me  as  valuable  in  chronic  diarrhoea  and 
dysentery  by  the  surgeon  in  charge  of  the  hospitals  in  connection  with  the 
military  camp  on  Rock  Island,  towards  the  close  of  the  war.  This,  gentle- 
men, completes  what  I  have  thought  important  to  say  to  you  concerning 
typhoid  fever,  which  is  the  most  important  because  the  most  universally 
prevalent  of  all  the  more  severe  acute  general  diseases. 


LECTURE    XV. 

Typhus  Fever— History,  Causes,  Symptoms,  Diagnosis,  Prognosis,  Special  Pathology,  Pathologi- 
cal Anatomy  and  Treatment. 

GENTLEMEN  : — Typhus  fever  has  been  recognized  and  described 
under  various  names,  from  the  earliest  periods  of  medical  history. 

The  word  typhus  means  dullness  or  stupor,  and  was  for  a  long  period 
applied  equally  to  the  typhoid  fever,  as  to  that  now  more  distinctively 
recognized  as  typhus.  It  was  not  until  the  early  part  of  the  present  cen- 
tury that  the  work  of  separating  the  two  diseases  was  fairly  begun  and 
prosecuted  with  great  care.  Prominent  among  those  who  have  contributed 
to  the  establishment  of  diagnostic  differences  between  them  are  Dr.  Enoch 
Hale,  of  Massachusetts,  in  1833  ;  Dr.  Gerhard,  of  Philadelphia,  in  1835  ; 
Dr.  A.  P.  Stewart,  in  1840  ;  M.  Louis,  of  Paris,  in  1841  ;  Dr.  E.  Bartlett, 
of  Massachusetts,  in  1842  ;  Dr.  Austin  Flint,  of  New  York,  in  1852  ;  and 
still  later.  Sir  William  Jenner,  of  London.  The  careful  and  extended  re- 
searches of  the  latter  have  been  considered  sufficient  to  demonstrate  the 
fact  that  the  typhoid  and  typhus  fevers  are  essentially  distinct  and  in- 
dependent types  of  continued  fever,  by  a  large  majority  of  the  profession. 
This  conviction,  however,  is  by  no  means  universal,  for  there  are  still  some 
who  regard  them  as  modifications  of  one  disease  caused  by  differences  in 
the  intensity  of  the  action  of  the  causes,  rather  than  by  essential  and 
specific  differences  in  their  nature. 

Assuming  that  typhus  is  a  distinct  form  of  general  fever,  we  find  the 
range  of  its  prevalence  much  more  limited  than  that  of  the  typhoid  type. 


HISTORY.  123 

AnJ  it  is  claimed  that  it  has  its  home  or  natural  habitation  in  Ireland, 
Poland,  and  the  Russian  provinces  bordering  on  the  Baltic,  as  distinctly 
as  yellow  fever  has  in  a  part  of  the  Atlantic  Coast  and  the  West  India 
Islands.  Certain  it  is,  that  no  other  part  of  the  civilized  world  has  been 
so  frequently  and  generally  scourged  by  the  epidemic  prevalence  of  typhus, 
as  Ireland.  "  According  to  Dr.  Hirsch  the  disease  was  generally  prevalent 
throughout  the  island  from  1797  to  1803,  in  1815,  from  1817  to'l819,  1821 
to  1822,  1825  to  1827,  in  1834,  1836,  1842,  and  from  1846  to  1818.  The 
same  author  states  that  during  the  years  1817,  1818,  1819,  not  less  than 
800,000  in  a  population  of  6,000,000  fell  sick,  and  45,000  died.  The  deaths 
were  not  all  from  typhus,  for  a  considerable  number  came  to  their  death 
directly  from  famine  and  dysentery. 

The  disease  not  only  finds  a  home  in  the  localities  just  named,  but  it 
appears  to  have  accompanied  the  Irish  emigrant  into  almost  every  other 
country  of  Europe  and  America. 

Dr.  Flint  tells  us  that  it  was  imported  from  Ireland,  and  began  to  pre- 
vail as  an  epidemic  in  New  York  in  1861,  and  from  that  time  to  1864, 
1428  cases  were  admitted  into  the  Bellevue  Hospital  alone.*  I  will  not 
occupy  your  time,  however,  by  any  detailed  history  of  the  appearance  and 
progress  of  this  variety  of  fever  in  different  countries,  or  even  in  our  own 
country.  It  is  sufficient  to  state  that  in  most  cases  where  emigrant  ships 
have  sailed,  either  from  Ireland,  or  some  parts  of  the  continent  of  Europe, 
with  such  numbers  of  emigrants  on  board  as  to  greatly  overcrowd  the 
ship,  typhus  fever  has  made  its  appearance  among  them  before  they 
reached  this  side  of  the  Atlantic,  and  often  caused  the  death  of  large 
numbers;  and  those  who  survived  introduced  the  disease  into  whatever 
port  or  town  they  were  permitted  to  enter. 

These  results  were  so  common  during  the  former  years  of  active  immi- 
gration into  our  own  country,  that  the  disease  came  to  be  familiarly  styled 
"ship  fever,"  or  "ship  typhus."  New  York,  Boston,  and  Philadelphia, 
were  the  chief  primary  receptacles  for  this  tide  of  humanity  and  the  dis- 
eases accompanying  it. 

But  as  large  numbers  who  were  not  actually  sick  on  their  arrival,  took 
passage  by  railroad  immediately  for  the  West,  or  some  town  in  the  inte- 
rior, some  of  them  would  commence  being  sick  on  the  route,  or  soon  after 
their  arrival.  In  this  way  the  disease  has  been  freshly  introduced  into  a 
great  many  localities  throughout  the  interior  of  the  country.  I  have  re- 
peatedly met  with  cases  in  this  city  among  those  who  had  just  arrived  by 
railroad  from  New  York,  having  passed  almost  directly  from  the  emigrant 
ship  to  the  cars.  Typhus  fever,  however,  has  been  observed  in  many 
places  in  our  country,  from  the  severe  epidemic  in  1807  in  New  England, 
to  the  present  time,  and  under  circumstances  when  it  could  not  be  traced 
to  any  foreign  source,  or  channel  of  communication  with  other  infected 
localities. 

Causes. — It  is  claimed  by  most  of  the  writers  and  investigators  of  the 
present  day,  that  typhus  fever  not  only  originates  solely  from  a  specific 
organic  poison,  but  that  the  poison  is  reproduced  in  the  bodies  of  the  sick, 
constitutins'  it  a  true  contaa-ion. 

All  agree  that  the  disease  is  found  chiefly  in  circumstances  character- 
ized by  the  presence  of  confined  and  foul  air,  caused  by  want  of  cleanli- 
ness and  ventilation,  overcrowding,  poverty  and  famine.  Crowded  ships, 
jails,  prisons,  poor  houses,  asylums,  manufacturing  establishments,  narrow 
and  crowded  streets  in  cities,  and  poorly  supplied  camps  of  armies,  are 

*  See  Practice  of  Medicine,  by  Austin  Flint,  M.  D.,  fifth  edition,  page  971.— 1831. 


124  TYPHUS    FEVER. 

the  places  in  which  typhus  has  been  found  to  chiefly  prevail  in  all  past 
periods  of  medical  history.  In  other  words,  it  is  the  same  kind  of  circum- 
stances, only  existing  in  a  more  concentrated  degree,  that  favors  the 
development  of  typhoid  fever,  as  I  have  already  pointed  out  to  you  in  the 
lectures  on  that  subject.  Most  of  the  advocates  of  a  specific  typhus  con- 
tagion claim  that  ali  the  bad  hygienic  conditions  to  which  I  have  alluded 
are  only  predisposing  or  favoring  circumstances,  and  in  no  case  capable 
of  originating  the  disease  until  the  specific  fever  germ  has  been  introduced 
from  without.  Yet  all  such  are  forced  to  admit  that  absolutely  nothing 
is  known  concerning  the  "  nature,  form,  and  condition  of  said  germ,"  * 
and  abundant  instances  have  been  observed  in  which  cases  of  the  disease 
have  occurred  under  circumstances  admitting  of  no  possible  connection 
that  could  be  traced,  with  any  outside  source  of  infection. 

Dr.  Austin  Flint  reported  four  cases  of  typhus  that  occurred  in  the  Erie 
county  almshouse  in  the  winter  of  1840-1,  that  strikingly  illustrate  this 
fact,"!"  and  many  others,  equally  well  observed  and  reliably  recorded, 
might  be  cited,  of  the  same  import.  Giving  due  credit  to  all  well  ascer- 
tained facts  concerning  the  origin  and  spread  of  typhus  fever,  without 
allowing  undue  weight  to  mere  theoretical  opinions,  I  have  been  led  to 
the  following  conclusions: 

First,  the  disease  is  capable  of  originating  from  the  use  of  an  atmos- 
phere strongly  impregnated  with  the  excretions  and  effluvia  from  the  hu- 
man body,  without  any  traceable  communication  with  other  sources  of 
infection,  as  in  the  many  instances  in  which  caies  have  occurred  in  alms- 
houses, jails,  ships,  and  other  over-crowded  places,  so  far  isolated  that  it 
was  hardly  possible  for  any  infection  or  specific  germs  to  have  been  in- 
troduced from  without  and  not  be  easily  discovered.  To  persist  in  assum- 
ing that  the  germs  must  have  been  introduced  from  some  foreign  source, 
merely  to  sustain  a  favorite  theory,  is  contrary  to  the  true  spirit  of  scien- 
tific inquiry,  and  is  much  less  rational  than  the  position  so  ably  main- 
tained by  the  late  Dr.  .Joseph  M.  Smith,  in  his  report  on  hygiene,  in  the 
third  volume  of  the  Transactions  of  the  American  Medical  Association, 
namely:  that  the  concentrated  organic  matter  in  the  air  of  such  places,  by 
further  decomposition,  developed  the  special  poison  that  caused  the  dis- 
ease. 

Second,  the  disease  when  once  developed,  is  capable  of  spreading  by 
contagion  or  direct  communication  from  one  individual  to  another  when- 
ever many  cases  are  crowded  together  \\\  the  same  hospital  ward,  or  the 
air  is  allowed  to  remain  unventilated  in  the  room  of  a  single  patient. 
But,  whenever  thorough  ventilation  and  cleanliness  are  maintained  in  the 
sick  room,  the  propagation  by  contagion  or  direct  communication  with  the 
sick  is  of  rare  occurrence. 

Third,  the  essential  cause  or  materies  morhi  that  produces  typhus, 
though  originating  under  circumstances  very  similar  to  those  giving  rise 
to  the  cause  of  typhoid  fever,  nevertheless  produces  its  effects  more  rap- 
idly, causing  a  more  profound  alteration  in  the  quality  of  the  blood  and 
excretions,  and  consequently  more  readily  contaminating  the  air  sur- 
rounding the  sick  with  infectious  effluvia,  capable  of  developing  the  same 
disease  in  those  who  may  inhale  it. 

Typhus  fever  is  generally  greatly  increased  in  its  prevalence  in  seasons 
of  famine,  and  by  all  such  circumstances  as  tend  to  keep  either  families 
or  larger  numbers  closely  indoors  with  inadequate  ventilation.  Conse- 
quently limited  outbursts  of  the  disease  have  occurred  more  frequently  in 

*  See  Practice  of  Medicine,  by  Roberts  Bartholow,  M.  D.,  etc,  etc.,  second  edition,  p.  705. 
t  See  Boston  Medi';al  and  Surgical  Journal  for  June,  1841. 


SYMPTOMS.  125 

the  winter  or  seasons  of  protracted  cold.  Otherwise  it  appears  to  be  but 
little  influenced  by  age,  sex,  or  seasons  of  the  year. 

^<lJm}Jtoms. — The  symptoms  that  accompany  typhus  from  its  initial  stage 
to  convalescence,  are  so  closely  analogous  to  those  of  typhoid  fever,  that  it 
is  onlv  necessary  to  call  your  attention  to  the  differences,  instead  of  the 
symptoms  in  detail.  The  initial  stage  of  typhus  is  shorter, •  usually  not 
more  than  from  two  to  five  days,  and  is  characterized  by  the  same  feelings 
of  dullness,  headache,  and  general  indisposition,  and  more  frequently  ends 
in  a  marked  chill,  as  the  patient  takes  to  his  bed.  During  the  first  three 
or  four  days  the  face  is  more  deeply  suffused  with  a  dingy  redness  ;  more 
congestion  of  the  surface  generally  ;  a  more  rapid  rise  of  temperature  ; 
greater  frequency  of  pulse  and  respiration  ;  and  more  tendency  to  early 
delirium,  than  in  the  typhoid  fever.  As  the  disease  progresses,  the  tongue 
becomes  more  thickly  coated,  and  changes  earlier  to  a  dark  brown  color, 
with  more  sordes  on  the  lips  and  teeth;  more  congestion  of  the  vessels 
of  the  conjunctiva;  a  continuance  of  more  frequency  and  feeble- 
ness of  pulse  ;  and  in  cases  marked  by  much  stupor  the  pupils  are  often 
much  contracted,  with  earlier  and  more  marked  subsultus.  The  symp- 
toms referable  to  the  respiratory  organs  do  not  difi"er  materially  from 
those  of  the  typhoid  disease  ;  while  those  indicating  disturbance  of  the 
alimentary  canal  are  much  less.  In  fact,  there  is  more  frequently  consti- 
pation during  the  first  week  in  typhus,  than  any  degree  of  diarrhoea,  and 
in  many  cases  the  bowels  are  disposed  to  remain  quiet  throughout  the 
whole  course  of  the  disease.  As  a  rule,  the  abdomen  is  much  less  tym- 
panitic and  more  doughy  or  inelastic  to  the  feel,  and  without  gurgling; 
and  both  the  eliptical  plates  in  the  ilium  and  the  glands  of  the  mesentary 
remain  but  little  altered.  Yet  in  quite  a  large  proportion  of  the  cases  of 
typhus,  the  second  week  is  accompanied  by  considerable  diarrhoea  and 
some  tympanites.  The  urine  undergoes  the  same  changes  as  in  typhoid 
fever,  being  on  the  average  more  scanty,  and  albumen  present  in  a  larger 
proportion  of  the  cases. 

As  a  general  rule,  the  skin  and  bronchial  membranes  are  dry,  but  in 
some  cases  periods  of  copious  sweating  occur  at  different  times  during 
their  progress.  Both  epistaxis  and  intestinal  hemorrhages  are  very  rare 
in  typhus.  The  average  range  of  temperature  differs  but  little  from  that 
of  typhoid  fever.  It  rises  more  rapidly  and  generally  reaches  its  climax 
about  the  fourth  or  fifth  day,  when  it  is  generally  from  40'^  to  41°  C.  (104° 
to  106°  F.),  according  to  the  severity  of  the  case.  From  that  time  to  the 
end  of  favorable  cases  the  morning  temperature  is  about  38°. 8  C.  (103°  F.), 
and  the  evening  39.5°  C.  (103.3°  F.)  In  the  cases  tending  towards  a  fatal 
result  the  average  temperature  is  usually  one  or  two  degrees  higher.  A 
rapid  decline  in  the  temperature  towards  the  end  of  the  second  week  gen- 
erally indicates  the  near  approach  of  convalescence.  The  average  fre- 
quency of  circulation  is  also  greater,  the  pulse  ranging  from  100  to  130 
per  minute,  and  the  respirations  are  more  frequent  than  in  the  typhoid 
disease.  The  average  duration  of  typhus  is  also  less,  being  about  two 
weeks,  while  the  extremes  vary  from  seven  days  to  twenty-eight  or 
thirty. 

The  defervescence  is  more  rapid  and  often  accompanied  by  critical  evac- 
uations from  the  skin,  kidneys  or  bowels. 

Perhaps  the  only  symptom  accompanying  typhus,  that  has  been  claimed 
to  be  different  in  kind  as  well  as  in  degree,  from  the  corresponding  symp- 
tom in  typhoid  fever,  is  the  eruption  or  maculte  on  the  skin.  Eruptions 
appear  on  the  skin  in  a  certain  proportion  of  both  forms  of  fever.  They 
appear  earlier  in  typhus,  usually  from  the  third  to  the  fifth  day,  are  more 


126  TYPHUS    FEVEE. 

copious  and  more  generally  diffused  both  on  the  trunk  and  extremities. 
They  are  smaller,  darker  colored,  less  elevated,  and  after  the  first  few  days 
the  color  does  not  disappear  on  pressure,  and  in  bad  cases,  towards  the 
close  of  the  disease  they  often  become  petechial. 

These  spots,  however,  are  often  absent  throughout  the  whole  course  of 
the  disease.  Dr.  Murchison  states  that  they  were  absent  in  11  per  cent, 
of  the  cases  admitted  to  the  London  fever  hospital.  In  65  cases  observed 
by  Dr.  Austin  Flint,  they  were  absent  in  12  per  cent.  Dr.  Lebert  makes 
them  absent  or  only  slight  in  20  per  cent,  of  his  cases.  My  own  observa- 
tions have  led  me  to  think  that  the  importance  of  the  eruptions  or  spots 
on  the  skin,  has  been  greatly  overrated  both  in  typhoid  and  typhus. 
They  are  not  only  absent  in  very  many  cases,  and  so  slight  as  to  require 
close  examination  to  find  them  in  many  more,  but  both  kinds  are  some- 
times present  and  freely  intermingled  on  the  skin  of  the  same  patient,  at 
the  same  time. 

Diagnosis. — You  cannot  fail  to  notice,  gentlemen,  that  in  what  I  have 
said  concerning  the  symptoms  of  typhus,  the  differences  from  those  of  the 
typhoid  disease,  are  all  expressed  in  terms  indicating  more  or  less;  that  is, 
differences  in  degree  and  not  in  kind.  And  you  will  find  the  same  charac- 
teristic in  all  your  works  on  practical  medicine.  There  is,  therefore,  no 
absolutely  reliable  diagnostic  symptom  by  which  all  cases  of  typhus  can 
be  readily  distinguished  from  typhoid  fever.  The  strongly  marked  typi- 
cal cases  of  both  varities  present  sufficient  points  of  difference  to  make 
them  easily  distinguishable.  But  practically  the  gap  between  these  is 
filled  by  cases  from  both  sides,  less  and  less  differing,  until  the  symptoms 
become  so  merged  and  intermingled  that  the  most  experienced  clinical 
observers  are  left  in  doubt  as  to  which  side  of  the  diagnostic  line  they 
should  be  placed.  Hence,  M.  Louis,  Jenner,  Flint  and  others  who  have 
analyzed  any  considerable  number  of  cases  for  the  purpose  of  proving  the 
non- identity  of  the  two  varieties  of  fever,  have  been  obliged  to  set  aside 
from  seven  to  ten  per  cent,  of  the  whole  number,  in  a  douhtful  list,  or 
defer  the  completion  of  their  diagnosis,  until  after  &  post  mortetn  examina- 
tion could  be  made. 

These  facts  certainly  show  a  very  close  relationship,  if  not  an  essential 
identity,  between  these  two  varieties  of  acute  general  disease. 

Prognosis. — From  the  statistics  of  mortality  gathered  by  Dr.  Murchison 
in  the  leading  hospitals  of  London,  Edinburg,  Glasgow,  Paris,  and  the 
provinces  of  France,  the  average  ratio  of  mortality  appears  to  be  18.78 
per  cent.,  or  1  in  5.27.  About  the  same  results  are  given  by  Lebert,  in 
his  article  on  Typhus  in  Ziemssen's  Cycloptedia  of  Practical  Medicine. 
You  will  notice  that  these  ratios  are  almost  identical  with  those  furnished 
from  the  same  sources  in  typhoid  fever.  There  are  great  differences  in 
the  ratio  of  mortality  in  epidemics  occurring  in  different  places,  and  in 
different  years  in  the  same  place.  In  some  instances  only  8  or  9  per  cent. 
have  died,  while  in  the  London  Fever  Hospital  in  1850,  according  to 
Murchison,  the  death  rate  rose  to  60  per  cent.  As  is  usual  in  all  epidemic 
diseases,  the  ratio  of  mortality  has  been  found  greater  at  the  beginning 
than  during  the  decline  of  an  epidemic.  It  is  slightly  higher  in  males 
than  in  females;  and  much  greater  in  adults  than  in  children.  There  are 
many  facts  on  record  indicating  that  the  mortality  from  typhus  is  greatly 
influenced  by  the  amount  of  fresh  air  supplied  to  the  patient.  A  f-ingle 
patient  occupying  a  large  and  well-ventilated  room,  or  an  open  tent,  not 
only  doubles  his  chances  of  recovery  compared  with  one  in  a  small,  im- 
perfectly ventilated  room  or  a  crowded  hospital  ward,  but  he  very  rarely 
communicates  the  disease  to  those  who  come  in  contact  with  him.     This 


SPECIAL    PATHOLOGY.  127 

Wiis  strikingly  illustrated  when,  in  18G4,  the  fever  cases,  mostly  typhus, 
were  tninslerred  from  the  Bellevue  Hospital  in  New  York,  to  tents  on 
Blackwell's  Island.  In  the  hospital  wards  the  ratio  of  deaths  had  been  a 
iittle  more  than  one  in  six,  but  when  over  500  had  been  treated  in  the 
tents,  it  was  found  that  the  ratio  was  only  a  fraction  more  than  one  in 
seventeen. 

Spicial  Pathology. — As  in  all  other  relations,  so  in  regard  to  the 
special  pathology,  there  is  a  close  analogy  between  the  typhus  and  typhoid 
forms  of  fever.  The  morbid  changes  in  the  blood,  the  general  properties 
of  the  tissues,  the  processes  of  nutrition  and  disintegration,  and  in  the 
functions  of  the  more  important  excretory  organs  are  in  the  same  direc- 
tion in  both.  It  has  seemed  to  me  that  the  essential  cause  or  causes  of 
typhus  acted  in  the  same  direction,  but  with  greater  intensity,  than  those 
of  the  typhoid  disease.  Consequently,  in  typhus  we  have  a  more  rapid 
development  of  the  disease,  a  more  profound  alteration  in  the  quality  of 
the  blood,  a  greater  depression  of  the  susceptibility  and  vital  affinity  of 
the  oi'ganized  structures,  causing  earlier  and  more  decided  disturbance  of 
nervous  functions,  capillary  circulation  and  secretion,  and  an  earlier  ter- 
mination either  in  death  or  recovery.  When  death  takes  place,  it  is  more 
generally  from  the  direct  and  extreme  impairment  of  the  quality  of  the 
blood,  and  of  the  properties  of  the  tissues,  rather  than  from  local  compli- 
cations; and  recoveries  are  more  frequently  marked  by  critical  evacuations. 

•Pathological  Anatomy. — The  post  mortem  appearances  presented  in 
cases  of  typhus  differ  from  those  found  after  death  from  typhoid  fever, 
chiefly  in  two  particulars.  First,  the  blood  in  typhus  is  more  decidedly 
dark  colored  and  uncoagulable,  and  all  its  constituents  more  impaired. 
This  was  fully  demonstrated  by  Dr.  Upham,  of  Boston,  in  a  paper  givino- 
in  detail  the  results  of  a  large  number  of  post  m.ortem  examinations  in 
the  emigrant  fever  hospital  on  Deer  Island,  near  Boston,  several  years 
since.  Second,  the  glandular  structures  in  the  mucous  membrane  of  the 
ilium  and  mesentery  are  much  less  changed  in  typhus  than  in  typhoid 
fever;  and  in  some  instances  they  have  undergone  no  appreciable  changes 
whatever.  In  many  cases,  however,  the  glands  of  Peyer  have  been  found 
congested  and  sufficiently  tumefied  to  render  their  outlines  distinct,  and 
in  a  few,  some  degree  of  ulceration  was  present.*  In  all  other  respects, 
the  description  I  gave  you  concerning  the  pathological  changes  in  typhoid 
fever,  will  apply  equally  well  to  those  found  after  death  from  typhus,  and 
consequently  I  need  not  repeat  it  at  this  time. 

Treatment. — The  indications  to  be  fulfilled  in  the  treatment  of  typhus, 
and  the  means  for  fulfilling  them,  are  the  same  as  in  the  typhoid  form  of 
fever.  And  as  these  were  very  fully  discussed  while  considering  the 
treatment  of  the  latter  disease,  it  would  be  a  needless  repetition  to  renew 
the  discussion  at  this  time.  As  the  fever  develops  more  rapidly  in  typhus, 
and  the  morbid  changes  in  the  blood  are  more  prominent,  so  the  three 
first  objects  to  be  accomplished  in  its  treatment,  as  mentioned  in  relation 
to  typhoid  fever,  should  receive  your  most  prompt  and  careful  attention. 
To  secure  for  each  patient  an  abundance  of  good  air,  cleanliness,  and  such 
sponging  of  the  surface  as  the  dryness  and  heat  may  indicate,  are  meas- 
ures of  primary  importance.  General  alteratives,  antiseptics,  and  mild, 
laxatives  are  more  needed,  and  may  be  given  with  more  freedom  during 
the  first  week  than  in  the  typhoid  form  of  disease.  On  the  other  hand, 
as  there  is  little  or  no  indication  of  intestinal  disease  in  the  majority  of 
cases  of  typhus,  you  will  have  less  opportunity  for  giving  the  turpentine 

*  See  Ziemssen's  Cyclopaedia  of  the  Practice  of  Medicine,  Vol,  I.,  p.  334. 


128  THE    PLAGUE. 

emulsion  and  other  remedies  recommended  for  relieving  the  intestinal 
complications.  But  in  all  such  cases  as  are  accompanied  by  too  much 
looseness  ot"  the  bowels  in  any  part  of  their  course,  these  same  remedies 
will  be  found  the  most  efficient  for  relieving  it.  In  all  other  respects,  the 
directions  I  have  given  you  in  relation  to  the  management  of  typhoid 
fever  are  equally  applicable  to  the  corresponding  stages  of  typhus. 

Propliylaxis. — To  prevent  the  propagation  or  spread  of  typhus,  the 
utmost  care  should  be  exercised  to  maintain  full  ventilation  and  scrupu- 
lous cleanliness;  to  avoid  all  over-crovs?ding  or  the  aggregation  of  many 
patients  in  close  proximity  to  each  other;  all  excretions  or  evacuations 
should  be  immediately  removed  from  the  room;  and  no  more  v^ell  persons 
admitted  to  the  presence  of  the  patients  than  is  necessary  for  giving  them 
proper  care  and  treatment. 

THE  PLAGUE. 

The  next  acute  general  disease,  to  which  I  will  call  your  attention,  is 
one  that  has  thus  far  never  been  recognized  as  having  an  existence  in  our 
country  or  on  this  continent. 

I  allude  to  the  Pest,  or  Plague,  which,  previous  to  the  middle  of  the 
seventeenth  century,  was  one  of  the  most  severe  and  fatal  scourges  of  the 
human  race.  The  words  Pest,  Pestilentia,  and  Plague,  were  originally 
used  to  designate  any  severe  epidemic  disease;  but  in  more  modern  times 
they  are  used  only  to  designate  a  severe  and  malignant  form  of  continued 
fever  which  has  generally  been  supposed  to  have  its  home  in  Egypt,  Syria, 
and  countries  bordering  on  the  eastern  shores  of  the  Mediterranean  Sea, 
and  the  rivers  that  empty  into  it.  There  are  evidences  of  its  having  pre- 
vailed in  those  countries  from  a  very  remote  period  of  antiquity.  From 
there  it  repeatedly  spread  over  Europe  and  Asia,  but  the  first  extensive 
prevalence  of  the  disease  throughout  Europe  of  which  we  have  a  reliable 
history,  occurred  about  the  middle  of  the  sixth  century,  and  is  known  as 
the  Plague  of  Justinian.  During  the  ten  subsequent  centuries  it  fre- 
quently j^revailed  in  an  epidemic  form  over  large  portions  of  Europe,  Asia, 
and  Africa,  and  in  some  places  destroyed  more  than  half  of  the  entire  pop- 
ulation during  a  single  epidemic.  Several  times  it  visited  both  London 
and  Paris.  After  the  middle  of  the  seventeenth  century  it  began  rapidly 
to  recede  from  western  Europe;  and  after  the  important  sanitary  improve- 
ments in  and  around  Cairo  and  other  parts  of  Egypt,  under  the  reign  of 
Mohamet  Ali,  its  prevalence  became  so  limited  that  it  hardly  attracted 
attention  in  any  part  of  the  world.  It  is  not  extinct,  however,  as  we  have 
accounts  of  its  prevalence  among  the  Arabs  in  North  Africa  in  1858  and 
1859;  in  Mesopotamia  in  1867;  in  Persian  Kurdistan  in  1871,  and  in  some 
of  the  provinces  overrun  by  the  armies  during  the  late  war  between  Rus- 
sia and  Turkey,  in  the  southeastern  part  of  Europe  and  the  border  of  Asia 
during  the  last  two  or  three  years. 

Causes. — Liebermeister  classes  the  Plague  among  the  contagious-mias- 
matic diseases;  and  if  we  give  full  credit  to  the  statements  of  those  who 
have  witnessed  its  prevalence  in  different  places  and  seasons,  it  would 
appear  to  be  capable  of  direct  communication  from  one  person  to  another 
by  contagion,  and  also  of  being  developed  and  propagated  in  the  midst  of 
impure  air,  uncleanness,  overcrowding  and  famine.  In  these  respects  it 
bears  a  close  analogy  to  typhus;  and,  like  the  latter,  is  very  rarely  con- 
tagious, except  when  many  patients  are  aggregated  together  in  dwellings 
or  hospital  wards,  or  where  both  ventilation  and  cleanliness  are  neglected 
in  the  room  of  a  single  patient. 


SYMPTOMS.  129 

That  bad  social  conditions  coupled  with  damp,  ill-ventilated,  and  over- 
crowded dwellings,  aided  by  a  soil  undrained,  and  permeated  by  foul 
water  are  capable  of  developing  specific  poisons  of  various  degrees  of  ac- 
tivity or  virulence,  which,  when  imbibed  by  human  beings  are  capable  of 
producing  typhus,  plague,  yellow  fever,  and  perhaps  other  pestilential 
diseases,  I  have  no  doubt.  That  such  specific  poisons  are  also  capable  of 
being  reproduced  in  the  emanations  from  the  bodies  of  those  sick  with 
the  diseases  named,  provided  they  remain  in  bad  sanitary  surroundings, 
and  under  such  circumstances  may  prove  highly  contagious,  appears  to 
be  proved  by  abundant  historical  facts.  But  facts  equally  abundant  fur- 
ther prove  that  no  amount  of  such  specific  poisons  can  be  propagated  or 
made  to  spread  disease  in  the  midst  of  pure  air  and  good  sanitary  regula- 
tions. The  plague  seldom  prevails  sporadically,  but  very  generally  as- 
sumes an  epidemic  form,  and  varies  much  in  its  severity  and  fatality  in 
different  epidemics.  Neither  age,  sex,  nor  season  of  the  year  exert  any 
notable  influence  over  the  development  and  progress  of  the  disease. 

S  1/7712^^0 fus. — Those  who  regard  the  disease  as  caused  exclusively  by  a 
specific  organic  poison  imbibed  from  without,  represent  the  period  of  in- 
cubation to  be  between  two  and  seven  days. 

The  commencement  of  active  symptoms  is  generally  marked  by  a  chill, 
or  at  least  rigors,  which  soon  give  place  to  fever  characterized  by  pains 
in  the  head,  back  and  limbs,  much  restlessness,  great  sense  of  weakness, 
dizziness,  sometimes  vomiting  and  purging,  with  inward  burning  and 
great  thirst.  The  skin  soon  becomes  hot  and  dry;  the  eyes  injected  ; 
tongue  covered  with  a  white  chalky-looking  coat ;  pulse  from  110  to  120 
per  minute,  and  breathing  correspondinglv  accelerated  ;  and  the  temper- 
ature often  from  3h.4°  to  40=  C.  (103°  to  104°  F.)  before  the  end  of  the 
first  twenty-four  hours.  During  the  second  and  third  days  the  symptoms 
present  all  the  characteristics  of  profound  typhus,  and  are  usually  followed 
on  the  third  and  fourth  days  by  the  appearance  of  inflammation  and  swell- 
ing of  the  lymphatic  glands  in  the  groins,  armpits,  or  neck.  These  swell- 
ings attain  a  size  varying  from  that  of  a  pea  to  that  of  a  hen's  egg  ;  and 
if  the  patient  does  not  die  before  the  end  of  the  first  week,  suppuration  in 
some  of  the  swellings  is  apt  to  occur.  Simultaneously  with  the  appear- 
ance of  the  glandular  swellings,  carbuncles  are  also  liable  to  appear  on 
the  back,  hips  and  extremities.  In  a  large  proportion  of  cases  the  pa- 
tients sink  early  into  a  constant  delirium,  stupor,  or  coma,  with  small, 
feeble,  irregular  pulse,  and  die  between  the  third  and  fifth  days.  If  they 
live  beyond  the  first  week,  the  fever  declines,  such  swellings  as  have  sup- 
purated discharge,  at  first  an  unhealthy  pus  with  considerable  destruction 
of  areolar  tissue  ;  and  if  carbuncles  have  formed,  their  sloughs  begin  to 
separate,  the  dryness  and  sordes  disappear  from  the  mouth  and  lips,  and 
the  patients  slowly  recover,  though  some  die  from  exhaustion  during  the 
suppurative  stage,  after  the  general  fever  has  disappeared.  In  some  cases 
occurring  during  the  height  of  a  severe  epidemic,  the  patient  has  exhibited 
sudden  and  extreme  paleness  of  features,  great  feebleness  of  cardiac  action, 
imperfect  respiration,  coldness  of  surface  and  extremities,  and  has  died  in 
a  few  hours  without  any  establishment  of  febrile  heat. 

Diagnosis. — The  plague  is  distinguished  from  typhus,  and  still  more 
from  the  typhoid  fever,  by  the  greater  abruptness  of  its  beginning,  the 
more  rapid  rise  of  temperature  and  greater  violence  of  all  the  symptoms 
during  the  first  two  days,  and  subsequently  by  the  appearance  of  pains 
and  swellings  in  some  part  of  the  lymphatic  system  of  glands,  to  which 
are  added  in  many  cases,  carbuncles  on  the  back  and  extremities.     The 

9 


130  THE    PLAGUE. 

whole  course  of  the  disease  is  more  violent,  and  shorter  in  duration,  than 
any  other  variety  of  continued  fever. 

Prognosis. — As  I  have  already  stated,  when  alluding  briefl}^  to  the  his- 
tory of  the  disease,  the  prognosis  is  extremely  unfavorable,  its  prevalence 
being  accompanied  by  a  larger  proportion  of  deaths  than  from  any  other 
Icnown  acute  general  disease. 

In  those  great  epidemics  of  the  disease  that  prevailed  over  nearly  all 
the  known  countries  of  Europe,  Asia  and  Africa,  in  the  middle  of  the 
sixth  century  called  the  "Plague  of  Justinian;''  in  the  middle  of  the  four- 
teenth called  the  ''Black  Death;*'  and  about  the  middle  of  the  seven- 
teenth centurj',  nearly  three-fourths  of  those  attacked,  died.  As  a  gen- 
eral rule,  if  the  patient  lives  beyond  the  seventh  day  from  the  commence- 
ment of  the  attack,  his  chances  of  recovery  are  much  improved.  Neither 
age  nor  sex  appears  to  exert  ai^y  marked  influence  over  the  ratio  of  mor- 
tality. 

special  Pathology. — KW  the  symptoms  accompanying  the  plague  in- 
dicate the  presence  of  some  morbid  material  or  special  poison  in  the 
blood,  vrhich  by  its  presence  impairs  both  the  quality  of  the  blood  and 
the  properties  of  the  organized  structures  of  the  body.  Sometimes  this 
impairment  is  so  profound  as  to  actually  suspend  molecular  changes  and 
cause  the  death  of  the  patient  within  the  first  forty-eight  hours.  If  this 
result  is  not  reached,  and  the  disease  is  prolonged,  there  is  developed  a 
special  inflammation  of  some  part  of  the  lymphatic  sj^stem  of  glands, 
most  frequently  in  the  groin  or  upper  part  of  the  thighs,  but  may  occur 
in  any  part  of  this  system  of  glands,  either  in  the  internal  or  external 
parts  of  the  body. 

Pathological  Anatomy. — In  many  cases  of  plague,  death  takes  place 
so  soon  after  the  commencement  of  the  disease,  that  the  evidences  of 
morbid  changes  of  structure  in  any  part  of  the  body  are  very  slight. 
The  blood  presents  the  same  dark  color  and  diminished  coagulability  as 
in  typhus.  When  death  has  resulted  at  any  time  after  the  third  day  in 
the  progress  of  the  disease,  in  addition  to  the  dark  and  uncoagulable  con- 
dition of  the  blood,  the  spleen  is  pretty  uniformly  enlarged,  softened  ami 
very  dark  color;  the  mesenteric  glands  a  little  enlarged,  and  presenting  ec- 
chymosed  spots.  The  latter  are  also  often  found  in  different  parts  of  the 
mucous  and  serous  membranes,  and  sometimes  in  the  parenchyma  of  the 
more  important  organs.  But  the  most  constant,  and  ajDparently  the  most 
characteristic,  anatomical  changes  are  found  in  some  part  of  the  lymphatic 
glands.  The  enlarged  and  morbid  condition  of  these  glands  is  found  in 
the  inguinal  regions,  axilla,  the  upper  part  of  the  thighs,  in  the  mediasti- 
num, along  the  larger  bronchial  tubes,  in  the  neck,  in  the  pelvis  and  in 
the  abdomen  just  below  the  diaphragm.  It  is  not  often  that  the  glands 
are  found  diseased  in  all  these  places  in  the  same  patient;  but  they  are 
pretty  uniformly  found  enlarged  and  increased  in  vascularity  in  one  or 
more  places,  When  laid  open,  the  diseased  glands  present  various  ap- 
pearances, some  being  uniformly  red,  others  white  and  granular,  but  all 
more  or  less  softened,  and  some  of  them  reduced  to  a  pulpy  or  jelly-like 
consistence.  I  think  the  pathological  condition  of  the  lymphatic  glands 
bears  the  same  relation  to  the  general  fever  in  the  plague,  that  the  disease 
of  the  glands  in  the  mucous  membrane  of  the  ilium  and  the  mesentery 
does  to  the  typhoid  variety  of  general  fever. 

Treatment. — Modern  writers  have  given  us  no  definite  instructions  in 
regard  to  the  treatment  of  this  form  of  fever.  From  the  virulence  of  the 
exciting  cause  or  causes,  and  the  rapid  impairment  of  the  qua,lity  of  the 
-blood  and  the  general  properties  of  the  tissues  which  result  from  their 


TREATMENT.  131 

action,  it  is  evident  that  a  large  proportion  of  the  cases  will  always  ter- 
minate fatally  before  any  treatment  can  develop  sufficient  influence  to 
arrest  the  progress  of  the  morbid  action.  And  yet,  both  the  symptoms 
during  life  and  the  changes  revealed  by  examinations  after  death  afford 
certain  rational  indications  for  our  guidaiice  in  the  selection  and  applica- 
tion of  remedial  agents.  These  are:  first,  to  suspend  as  far  as  possible,  the 
further  action  of  the  cavises,  either  by  removing  the  patient  beyond  their 
influence  or  by  neutralizing  their  effects;  second,  to  lessen  the  intensity 
of  the  febrile  movement,  and  promote  natural  secretory  action;  and  third, 
to  prevent  the  deterioration  of  the  blood  and  the  destructive  changes  so 
constantly  liable  to  occur  in  the  lymphatic  system  of  glands.  To  accom- 
plish the  first  you  must  secure  thorough  ventilation  and  cleanliness  of  the 
rooms  occupied  by  the  sick,  and  use  such  disinfectants  as  will  most  effect- 
ually destroy  the  noxious  quality  of  the  excretions  and  eliminations  from 
the  bodies  of  the  patients. 

To  lessen  the  rapid  rise  of  temperature  and  promote  more  healthy 
eliminations  from  the  skin  and  luno-s  during  the  first  two  or  three  days, 
frequent  sponging  of  the  whole  surface  with  cool  water,  aided,  if  neces- 
sary, by  the  wet  sheet  and  sprinkling  once  or  twice  in  the  day,  constitute 
the  safest  and  most  efficient  means  that  can  be  employed.  For  a  general 
alterant  to  sustain  the  molecular  changes  throughout  the  system,  and  to 
lessen  the  morbid  action  in  the  lymphatic  glandular  system,  I  should  have 
great  confidence  in  the  early  and  persistent  use  of  iodine  internally,  in  the 
form  of  aqueous  solution,  as  in  the  following  formula: 

^      lodinii,  0.5  grams,  gr.    viii 

Potassii  lodidi,         3.0  grams,  gr.    xlv 

Aquae  Distillatas,  45.0  c.  c.  |iss. 

Mix,  and  take  one  cubic  centimetre  or  fifteen  minims  every  three  or 
four  hours,  in  a  tablespoon ful  of  sweetened  water. 

In  all  other  respects  the  details  of  treatment  may  be  the  same  as  in  the 
more  severe  grades  of  typhus. 

Prophylaxis. — The  chief  prophylactic  measures  are,  thorough  ventila- 
tion, cleanliness,  and  a  proper  supply  of  good  food  and  wholesome  water, 
with  isolation  of  the  sick  as  far  as  practicable. 


LECTURE    XVI. 

Relapsing  Fever— Its  History,  Causes,  Symptoms,  Diagnosis,  Prognosis— Special  Pathology— Patho- 
logical Anatomy  and  Treatment. 

GENTLEMEN  : — The  acute  general  disease  now  familiarly  known  as 
Melcq^sing  Fever.,  has  undoubtedly  prevailed  at  different  times  and  in 
different  countries  from  an  early  period  of  medical  history,  but  until  after 
the  commencement  of  the  present  century  it  was  regarded  as  a  variety  of 
typhus,  and  alluded  to  under  various  names,  as  typhus  recurrens,  febris 
recurrens,  five-day  fever,  seven-day  fever,  bilious  typhus,  relapsing  fever, 


132  RELAPSING    FEVEE. 

and  mild  3'el!ow  fever.  The  first  description  of  it  as  a  distinct  form  of 
fever  which  attr:icted  attention,  was  that  given  by  Mr.  Rutty  in  his  His- 
tory of  the  diseases  of  Dublin,  founded  on  an  epidemic  that  prevailed  in 
that  city  in  1739  ;  and  another  epidemic  was  described  by  Dr.  Barker,  in 
ISOl.  The  disease  prevailed  in  Edinburg-h  in  1817-18,  and  was  accurately 
described  by  Dr.  Christison  and  Dr.  Welsh.  It  was  still  more  accurately 
described  by  Dr.  O'Brien  and  Dr.  Graves  in  1826.  From  1842  to  1848  it 
prevailed  still  more  extensively  in  Ireland,  Scotland  and  England,  and  it 
was  the  descriptions  given  of  the  epidemics  during  this  period  by  Drs. 
Mackenzie,  Corjmack  and  Craigie,  that  gave  still  more  prominence  to  the 
idea  of  it  as  a  distinct  form  of  fever.  An  epidemic  of  the  disease  appeared 
in  London  in  1847,  and  was  made  a  special  subject  of  study  by  Sir  Wil- 
liam Jenner  who,  in  1850,  so  clearly  presented  the  points  of  differential 
diagnosis  between  it  and  the  other  forms  of  continued  fever,  that  nearly 
all  subsequent  writers  have  assigned  it  an  independent  position  among 
the  idiojDathic  fevers.*  Diimmler  alludes  to  relapsing  fever  in  connection 
with  typhus  in  Upper  Silesia  in  1848  ;  Engel  had  also  made  similar  allu- 
sions in  connection  with  an  epidemic  of  typhus  in  Bukow'ina,  in  1846  ; 
Griesinger  still  more  particularly  described  it  as  prevailing  in  connection 
with  what  he  called  bilious  t3qDhoid  and  typhus  in  Cairo,  and  other  places 
in  Egypt,  in  1850  ;  and  it  prevailed  to  some  extent  in  the  armies  of 
France,  England  and  Russia,  during  the  war  between  those  nations  in  the 
Crimea.  In  1863  it  prevailed  severely  in  Odessa,  and  in  1865,  in  St. 
Petersburg.  In  1868  it  appeared  in  decided  epidemic  form  in  Berlin  and 
Breslau,  and  has  reappeared  from  time  to  time  in  those  cities,  and  other 
places  in  North  Germany,  until  the  present  date. 

The  first  cases  of  relapsing  fever  recognized  in  this  country  occurred  in 
a  company  of  Irish  immigrants  who  arrived  in  Philadelphia  in  June,  1844. 
Fifteen  of  their  number  were  admitted  into  the  Philadelphia  Hospital, 
and  the  disease  with  which  they  were  afflicted  was  recognized  and  de- 
scribed by  Dr.  Meredith  Clymer  as  genuine  relapsing  fever.  The  disease 
was  not  propagated  beyond  the  company  of  immigrants  mentioned,  and 
we  have  no  authentic  record  of  other  cases  until  1850-51,  when  fifteen 
cases  were  observed  and  recorded  in  the  Buffalo  City  Hospital,  by  Dr. 
Austin  Flint.  The  patients  were  all  Irish  immigrants,  six  of  whom  had 
arrived  within  the  space  of  five  weeks;  six  had  lived  in  this  country  be- 
tween six  and  sixteen  months;  one  four  and  one  five  years;  while  the  term 
of  residence  of  the  remaining  one  is  not  given.  It  does  not  appear  that 
they  came  from  any  one  locality  in  the  city,  or  that  they  had  any  particu- 
lar connection  with  each  other.  Two  were  admitted  to  the  hospital  in 
October,  four  in  November,  eight  in  December,  and  one  in  January ,| 
It  is  stated  b}'^  Dr,  Lebert  that  some  cases  of  relapsing  fever  were  intro- 
duced by  Irish  immigrants  into  New  York  city  in  1847. J  And  Dr.  Aus- 
tin Flint  alludes  probably  to  the  same  cases  when  he  says,  "a  few  (cases) 
reported  by  Dr.  A.   Dubois,  in  1848."  § 

Dr.  Dubois,  however,  simply  reported  some  cases  of  severe  "  inflainraa- 
tion  of  the  eye,  following  typhus  fever,  as  it  apiDeared  in  the  city  of  New 
York  in  1847-48,"  in  the  Annalist  for  June,  1848.  But  neither  in  this  paper 
nor  in  the  communication  on  the  same  subject,  furnished  to  the  Commit- 
tee on  Surgery  of  the  American  Medical  Association,  and  published  in 
the  first   volume  of  the  Transactions  of  that  body,  p.  373,  for  1847,  can  I 

*  See  Practice  of  Medicine,  by  George  B.  Wood,  M.  D.,  &c..  Vol.  1,  note.  p.  374,  fifth  edition.— 1858. 
f.See  Clinical  Reports  on  Continncd  Fever,  by  Austin  Flint.  M.  D.  p.  369,  1852. 


?  -^ee  A  Treatise  ou  the  Principles  and  Practice  of  Medicine,  Fifth  Ed.,  by  A.  Mint,  M.  D.,  &c., 
p.  982, 


CAUSES.  133 

find  any  adequate  proof  that  the  fever  which  preceded  the  cases  of  ophthal- 
mia rejjorted,  was  any  different  from  ordinary  typhus.  The  first  epidemic 
prevalance  of  .relapsing  fever,  of  which  we  have  any  account,  commenced 
in  the  city  of  New  York,  in  the  last  part  of  1869,  and  continued  through 
1870  and  the  first  part  of  1871.  The  epidemic  reached  the  climax  of  its 
prevalence  in  June  and  July,  1870;  after  which  it  rapidly  declined.  The 
whole  number  of  cases  reported  to  the  New  York  Board  of  Health  during 
the  year  1S70,  was  2,121,  of  which  1,594  occurred  during  the  first  half  of 
the  year.  During  the  same  year  the  fever  also  appeared  in  epidemic  form 
in  Philadelphia,  517  cases  having  been  admitted  into  the  Philadelphia 
Hospital  between  April  and  November  of  that  year.  At  the  same  time  a 
few  cases  of  the  disease  were  observed  in  many  of  the  towns  near  New 
York,  but  chiefly  in  the  persons  of  working  men  who  had  come  directly 
from  the  city.*  During  that  year  five  cases  came  under  my  observation 
in  this  city,  two  of  which  were  admitted  into  the  Mercy  Hospital.  Sev- 
eral cases  occvirred  in  the  practice  of  other  physicians,  but  not  sufficient 
to  attract  public  attention  or  indicate  the  existence  of  an  epidemic.  Since 
1871,  I  have  not  learned  of  the  prevalence  of  this  form  of  fever  in  any 
part  of  our  country. 

Causes. — From  the  foregoing  statements  in  regard  to  the  history  and 
geographical  distribution  of  relapsing  fever,  you  cannot  fail  to  notice  how 
closely  they  correspond  with  that  of  typhus.  It  has  not  only  prevailed  in 
the  same  localities  and  among  the  same  classes  of  people,  but  also  at  the 
same  times  and  seasons;  the  two  forms  of  fever  being  freely  intermingled 
in  the  same  epidemic.  So  far,  therefore,  as  relates  to  favoring  circum- 
stances or  predisposing  causes,  it  must  be  conceded  that  those  of  relaps- 
ing fever  are  the  same  as  we  have  already  discussed  in  relation  to  the 
typhoid,  typhus,  and  the  plague.  It  is  claimed  to  be  more  contagious 
than  typhus.  That  it  is  capable  of  being  communicated  from  the  sick  to 
the  well  under  certain  circumstances,  appears  fully  proved.  It  is  neces- 
sary that  the  contact  with  the  sick  should  be  close,  as  in  the  case  of 
nurses  and  attending  physicians,  or  that  the  atmosphere  surrounding  the 
sick  should  be  impure,  either  from  overcrowding  or  want  of  ventilation. 
Under  such  circumstances  many  of  those  coming  in  contact  with  the  sick, 
whether  physicians,  nurses,  or  visitors,  contract  the  disease.  But  when 
there  is  no  overcrowding  of  many  patients  together,  and  the  air  of  the 
sick  room  is  kept  fresh  and  good,  there  is  very  little  tendency  to  propa- 
gate the  disease  by  contagion.  Only  those  who  handle  the  patients  or 
their  clothing,  then,  contract  the  disease,  and  even  they  often  escape.  Its 
contagiousness  is,  therefore,  of  the  same  character  as  that  of  typhus.  In 
1873,  Obermeier  discovered  in  the  blood  of  relapsing  fever  patients,  dur- 
ing the  febrile  stages,  what  is  described  by  Lebert  as  "exceedingly  thin, 
thread-like,  spiral  fungi."  Dr.  Flint  calls  it  a  "  spiral-shaped  bacterium." 
It  has  been  named  by  common  consent  /SpwiUuvi  Oberrneieri.,  and  strongly 
resembles  the  spirochaete  plicatilis  seen  by  Cohn  in  mucus  from  the 
mouth.  Similar  spiral-shaped  bacteria  liave  been  discovered  by  Ehren- 
berg  in  water;  by  Billroth  in  the  fluid  from  noma;  and  by  Manassein  in 
the  contents  of  a  cyst.j- 

The  discovery  of  Obermeier  has  been  confirmed  by  Lebert  and  his  as- 
sistants, Weigert  and  Buchwald,  who  found  the  same  spirillum  in  the 
blood  of  all  the  relapsing  fever  patients  coming  under  their  care  in  the 
hospital  at  Breslau,  in  1873  and  1874. 

*  See  Report  on  Relapsing  Fever,  by  Stephen  Smith,  M.  D.,  in  the  Annual  Report  of  the  Board 
of  Health  of  New  York,  1870-71,  p.  456. 

tSee  Principles  and  Practice  of  Medicine,  by  Austin  Flint,  M.  D.,  etc.,  Fiftli  Edition,  p.  9&1. 


134  RELAPSING   FEVEE. 

No  one  of  the  observers,  however,  has  thus  far  discovered  any  of  these 
minute  paracites  in  the  organs  or  structures  of  the  body,  or  anywhere,  ex- 
cept in  the  blood  during  the  actual  presence  of  the  fever.  They  disap- 
pear quickly  after  the  commencement  of  the  intermission,  re-appear  in 
the  relapse,  and  again  quickly  disappear  with  the  final  defervescence. 
All  efforts  to  cultivate  or  propagate  them  have  failed,  yet  Lebert  confi- 
dently represents  them  as  the  essential  cause  of  the  fever.*  Such  a  con- 
clusion, however,  is  premature,  as  there  are  no  positive  facts  indicating 
whether  they  act  as  a  cause  or  are  merely  an  accompaniment  of  the  gen- 
eral fever.  On  the  contrary,  if  the  spirillum  discovered  by  Obermeier  is 
identical  with  the  spirochgete  of  Ehrenburg  and  Cohn,  it  is  by  no  means 
peculiar  to  the  b'ood  of  relapsing  fever  patients,  and  it  will  require  a 
much  more  extensive  and  varied  series  of  observations  than  have  yet  been 
made,  to  afford  a  sufficient  number  and  variety  of  facts  to  justify  the  an- 
nouncement of  positive  conclusions  concerning  the  protomycetic  origin  of 
this  variety  of  the  fever.  The  disease,  during  an  epidemic,  attacks  per- 
sons at  all  periods  of  life,  but  in  larger  proportion  children  under  fifteen 
years,  and  adults  between  twenty  and  thirty  years  of  age.  Neither  sex 
nor  season  of  the  year  appear  to  exert  any  influence  over  the  prevalence 
of  the  disease.  The  poor,  destitute  and  overcrowded  portions  of  the  pop- 
ulation furnish  most  of  the  victims  in  every  epidemic.  So  true  is  this, 
that  in  Ireland  it  is  frequently  called  famine  fever.  The  period  of  incu- 
bation is  supposed  to  vary  from  three  to  nine  days.  One  attack  does  not 
permanently  destroy  the  susceptibility  of  the  individual  to  one  or  more 
subsequent  attacks. 

Symptoms. — An  attack  of  relapsing  fever  commences  abruptly  with  a 
well  marked  chill  or  cold  stage,  which  is  generally  of  short  duration,  and 
is  followed  immediately  by  active  febrile  excitement.  The  skin  becomes 
hot,  the  face  flushed,  the  tongue  covered  with  a  thin,  white  fur,  the  pulse 
frequent  and  compressible,  usually  from  100  to  110  per  minute,  but  some- 
times reaching  130  before  the  end  of  the  first  twenty-four  hours  ;  respira- 
tions accelerated  in  frecjuency,  and  temperature  in  the  axilla  from  39°  C. 
(102  '.h°  F.)  to  40°  C.  (104.  2°  F.)  ;  very  severe  pains  in  the  head,  back  and 
limbs,  more  especially  in  the  muscles  and  joints  of  the  extremities  ;  there 
is  also  much  nausea  and  distress  in  the  epigastrium,  with  frequent  vomiting 
of  matter  tinged  with  the  coloring  matter  of  bile,  and  sometimes  diar- 
rhoea, but  more  frequently  moderate  constipation.  The  quantity  of  urine 
is  much  diminished,  redder  than  natural,  sometimes,  though  rarely  contains 
albumen,  and  still  more  rarely  blood-corpuscles  and  hyaline  casts.  The 
active  general  febrile  excitement  thus  established,  usually  continues  with 
but  little  change  in  the  assemblage  of  symptoms,  from  five  to  seven  days, 
when  it  declines  as  rapidly  as  it  was  developed.  During  the  whole  of 
this  period  the  patients  are  very  restless,  getting  but  short  intervals  of 
sleep,  suffering  severely  from  pains  in  the  parts  already  mentioned,  having 
occasionally  epistaxis,  and  temjDorary  sweating,  but  very  rarely  either  de- 
lirium or  stupor.  The  decline  of  the  fever  is  generally  marked  by  a  copi- 
ous perspiration,  during  which  the  temperature  returns  nearly  or  quite  to 
the  natural  standard,  and  the  patient  presents  all  the  ordinary  appear- 
ances of  real  convalescence.  This  state  of  apyrexia  or  intermission,  usu- 
ally continues  from  three  to  seven  days,  when  the  patient  is  again  attacked 
abruptly  by  a  chill  or  chilliness,  speedily  followed  by  fever  similar  in  all  re- 
spects to  the  first  attack,  except  in  being  a  little  less  severe.  It  alsocon- 
tmues  about  the  same  length  of  time,  namely,  from  five  to  seven  days,  and 
again  terminates  abruptly  in  a  copious  sweating. 

*  See  Cyclopaedia  of  the  Practice  of  Medicine  by  Ziemssen,  Vol.  I,  page  263. 


SYMPTOMS.  135 

Sometimes,  though  rarely,  the  crisis  is  marked  by  a  temporary  diar- 
rhoea, or  diuresis  instead  of  perspiration.  The  decline  of  the  second  feb- 
rile period  is  generally  followed  by  permanent  convalescence,  but  not  al- 
ways. In  a'  very  small  proportion  of  the  cases,  after  five  or  six  days  of 
intermission,  a  third  period  of  fever  supervenes,  presenting  the  same  char- 
acteristics as  the  second,  and  terminating  in  the  same  manner.  Even  a 
third  relapse  or  fourth  period  of  pyrexia  has  been  noticed  by  some  practi- 
tioners ;  and,  on  the  other  hand,  a  few  cases  have  been  observed  which 
presented  but  a  single  febrile  period  of  from  five  to  seven  days'  duration, 
followed  by  permanent  convalescence.  You  perceive  by  this  description 
that  the  ordinary  course  of  the  disease,  consisting  of  two  active  periods  of 
fever,  separated  by  a  few  days  of  intermission,  usually  occupies  from  two 
to  three  weeks,  while  the  extremes  may  vary  from  a  single  febrile  period 
of  three  or  four  days,  to  four  pyretic  periods,  which,  with  the  intervening 
intermissions,  may  extend  the  sickness  to  six  or  seven  weeks.  The  con- 
valescence in  all  cases  is  attended  by  considerable  muscular  weakness  and 
some  degree  of  impoverishment  of  the  blood,  but  it  is  seldom  followed  by 
any  important  sequels.  A  severe  form  of  ophthalmia  has  been  observed  as 
a  sequel  of  the  fever  in  a  limited  number  of  cases.*  In  some  of  the  more 
severe  epidemics,  many  of  the  patients  showed  a  moderate  yellowness  of 
the  skin,  which  gave  rise  to  the  name  of  "  mild  yellow  fever." 

In  the  few  instances  in  which  the  disease  has  terminated  fatally,  the  gas- 
tric symptoms  have  been  unusually  severe,  the  matter  vomited  presenting 
a  dark  cojlfee  ground  color,  the  secretion  of  urine  being  nearly  or  quite 
suppressed  ;  and  in  some  instances  petechial  spots  on  the  skin,  and  in 
others  the  nervous  disturbances  of  uremic  poisoning  have  preceded  the 
final  collapse.  In  some  cases  of  only  average  severity,  the  sudden  termi- 
nation of  the  febrile  period  in  the  intermission  or  the  convalescence  has 
caused  the  pulse  to  diminish  in  frequency,  in  four  or  five  hours,  from  130 
per  minute  to  54;  and  the  temperature  from  40.5°  C.  (105°  F.)  to  35°  C. 
(95°  F.). 

The  depression  below  the  natural  standard  of  pulse  and  temperature  in 
such  cases  proved  to  be  of  brief  duration,  and  was  attended  by  no  bad 
results. 

Diagnosis. — The  symptoms  more  specially  characteristic  of  this  vari- 
ety of  fever,  are  the  abruptness  of  its  beginning;  the  rapid  rise  of  temper- 
ature, the  severity  of  the  gastric  symptoms;  the  violence  of  the  pains  in 
the  muscles  and  joints;  the  sudden  decline  accompanied  by  copious 
sweating,  and  the  equally  sudden  relapse  after  several  days  of  complete 
intermission.  Negatively,  it  is  distinguished  from  the  epidemic  influenza, 
by  the  absence  of  catarrhal  symptoms;  from  the  dengue  by  the  absence  of 
the  scarlet  eruption  and  the  remission  of  fever  during  the  third  and  fourth 
days;  and  from  typhoid  and  typhus  by  the  absence  of  a  prodromic  or 
forming  stage,  and  the  dull  expression  of  countenance,  and  later,  the 
absence  of  either  rose  spots  or  maculte  on  the  skin,  and  ths  entire  absence 
of  gurgling,  abdominal  tympanites,  and  muttering  delirium. 

Prognosis. — Considering  the  severity  of  the  symptoms,  and  their  dura- 
tion, the  prognosis  is  unusually  favorable  in  this  disease.  ]n  the  majority 
of  seasons  when  it  has  prevailed,  the  ratio  of  mortality  has  not  exceeded 
two  per  cent,  of  the  number  attacked.  Of  one  hundred  and  three  cases 
admitted  into  the  Bellevue  Hospital  in  the  winter  of  1S69-T0,  only  two 
died.  One  of  these  died  suddenly  on  the  seventh  day,  supposed  to  be  from 
syncope.     The  other   died  from  uremic  convulsions   and   coma,  produced 

*  See  Transactions  of  American  Medical  Association,  Vol.  I,  p.  373.— 1S47. 


136  RELAPSING    FEVER. 

by  suppression  of  urine.*  In  some  unsually  severe  epidemics  the  ratio  of 
mortality  has  reached  ten  per  cent.  In  most  instances  the  fatal  termina- 
tion has  resulted  from  the  supervention  of  local  complications,  such  as 
pneumonia,  acute  nephritis,  meningitis,  etc.  Lebert  informs  us  that  in  an 
epidemic  at  Breslau,  pneumonia  was  the  principal  complication,  while 
during  a  severe  prevalence  of  the  disease  in  St.  Petersburg,  the  principal 
dangerous  complication  was  a  hEemorrhagic  pachymeningitis.  Fatty  de- 
generation of  the  heart  has  been  assigned  as  the  cause  of  death  in  some 
cases. 

During  the  prevalence  of  the  disease  in  Philadelphia  in  1870,  it  at- 
tacked a  considerable  number  of  the  colored  population,  and  proved  fatal 
in  a  much  larger  proportion  of  the  cases  than  among  the  whites.  When 
it  attacks  pregnant  women  it  very  generally  induces  an  abortion  or  pre- 
mature labor.     The  foetus  is  usually  born  dead,  but  the  mother  recovers. 

Special  Pathology. — It  is  evident  from  a  careful  study  of  the  symp- 
toms presented  by  this  disease,  and  the  results  as  found  on  2'iost  mortem 
examinations,  that  the  primary  change  in  the  properties  of  the  tissues  is 
neither  one  of  simple  exaltation  or  excitement,  as  in  the  febricute,  nor  of 
direct  depression,  as  in  the  typhoid  and  typhus  ;  but  rather  one  of  spe- 
cific character,  consisting  of  an  increase  of  the  susceptibility,  coupled  with 
a  moderate  impairment  of  the  vital  affinity.  The  action  of  the  special  cause 
or  causes  of  the  disease  in  the  directions  just  named,  produces  decided 
imiDairment  of  the  molecular  changes  constituting  nutrition,  disintegration 
and  secretion,  accompanied  by  active  disturbance  of  nervous  sensibility. 
The  latter  is  indicated  by  the  severe  pains  felt  by  the  patients  in  the 
head,  back,  and  extremities,  coupled  with  much  restlessness,  and  func- 
tional disturbance  of  the  stomach,  instead  of  the  dullness  and  indijferenee 
that  characterizes  the  typhoid  and  typhus.  The  comparatively  uniform 
and  limited  duration  of  the  febrile  symptoms,  ending  abruptly  in  critical 
evacuations,  show  the  nature  of  the  morbid  impressions  and  actions  to  be 
decidedly  that  of  irritation,  with  but  little  tendency  to  structural  changes 
in  any  of  the  tissues,  or  to  serious  impairment  of  the  constituents  of  the 
blood. 

Patholofjical  Anatomy. — There  are  no  pathological  changes  of  struc- 
ture specially  characteristic  of  relapsing  fever.  Careful,  microscopic  ex- 
aminations have  discovered  the  same  tendency  to  granular,  fatty  degener- 
ation in  nearly  all  the  important  organs  and  structures,  as  is  found  after 
death  from  typhoid  fever.  Slight  hseraorrhagic  exudations  or  infractions 
have  been  found  in  the  brain,  liver,  spleen,  and  kidneys.  The  spleen 
is  generally  much  enlarged,  dark  colored,  and  softened,  being  filled  up  with 
lymphoid  elements,  in  which  are  large  granular  cells  containing  fat,  and 
sometimes  red  blood  corpuscles.  More  rarely,  points  of  suppuration  have 
been  seen.  The  liver  and  kidneys  are  also  generally  enlarged  and  their 
texture  changed  in  the  same  direction  as  that  of  the  spleen,  but  less  in 
degree.  In  a  jnajority  of  cases  examined,  the  muscular  structure  of  the 
heart,  and  the  striated  muscular  structures  in  other  parts  of  the  body, 
were  found  in  various  stages  of  fatty  degeneration.  In  a  small  proportion 
of  the  cases  ecchym^oses  were  seen  in  the  mucous  membrane  of  the  stom- 
ach, the  pleura  and  pericardium,  and  petechial  spots  on  the  skin.  A  limi- 
ted amount  of  inflammation  has  generally  been  found  in  the  mucous  mem- 
brane of  the  ilium  and  colon,  with  enlargement  of  some  of  the  solitary 
glands.  The  only  differences  between  the  changes  I  have  now  described 
and  those  in  typhoid  fever,  consist  in  traces  of  more  active  inflammatory 

*  See  Principles  and  Practice  of  Medicine,  by  Austin  Flint,  M.  D.  etc.  Fifth  Edi.  p.  990. 


TREATMENT.  137 

action  in  the  kidneys  and  spleen,  and  a  greater  number  of  points  of  hsem- 
orrhagic  exudation  in  other  parts.  This  is  explained  in  part  by  the  fact 
that  in  relapsing  fever  the  susceptibility  of  the  tissues  is  less  impaired, 
and  in  part  by  the  further  fact  that  the  disease  seldom  terminates  fatally 
except  by  the  supervention  of  some  local  inflammatory  complication,  such 
as  nephritis,  pneumonia,  meningitis,  etc.  Dr.  Lebert  states  that  while  the 
disease  v\'as  prevailing  in  Breslau,  numerous  post  mortem  examinations 
were  made,  and  though  diligently  searched  for,  no  traces  of  the  Spirillum 
Obermeieri  were  found  in  any  of  the  structures  of  the  body.  The  blood 
was  uniformly  found  dark  in  color,  and  either  fluid  or  less  coagulable  than 
natural.  The  microscope  showed  an  increase  in  the  proportion  of  white 
corpuscles,  a  greater  number  of  minute  granular  bodies,  and  occasionally  a 
large  fatty  cell;  none  of  which,  however,  are  peculiar  to  the  blood  in  this 
disease. 

Treatment. — The  indications  for  treatment  are,  first,  to  suspend  as  far  as 
possible  the  further  influence  of  both  predisposing  and  exciting  causes; 
second,  to  relieve  the  suffering  of  the  patient  by  palliating  the  more  dis- 
tressing symptoms;  third,  to  prevent  the  development  of  important  local 
complications;  and  fourth,  to  sustain  the  strength  and  general  nutritive 
processes  until  convalescence  is  well  established.  The  predisposing  causes 
are  best  removed  by  securing  for  the  patient  fresh  air,  cleanliness,  rest,  and 
suitable  nourishment.  If  there  is  a  specific  exciting  cause  acting  through 
the  blood  upon  the  properties  and  functions  of  the  system,  whether  it 
consist  of  the  Spirilli  of  Obermeier,  the  Spirochjete  of  EhrenVjerg  and  Cohn, 
or  some  other  infectious  material,  it  would  afford  a  rational  indication  for 
the  early  and  persistent  use  of  some  antiseptic  or  parasiticide.  Keejiing  in 
mind  the  second  indication  I  have  mentioned,  namely,  to  lessen  the  se- 
verity of  the  patient's  suffering,  which  is  chiefly  from  the  intense  pains  in 
the  head,  back,  and  extremities,  with  epigastric  distress  and  vomiting,  we 
should  select  such  antiseptics  as  will  aid  most  in  alleviating  these  symp- 
toms at  the  same  time  that  they  tend  to  destroy  the  specific  infection  in 
the  blood.  For  accomplishing  both  these  purposes  there  are  probably  none 
more  efficient  than  the  carbolic  and  salicylic  acids. 

The  first  of  these  I  used  in  combination  with  gelsemium  and  camphor- 
ated tincture  of  opium,  in  the  treatment  of  the  few  cases  that  came  un- 
der ray  care  in  1870,  and  found  it  quite  efiicient  in  arresting  the  vomiting 
and  lessening  the  pains  and  restlessness.  From  the  known  efficacy  of 
salicylic  acid  in  relieving  the  intense  pains  of  acvite  rheumatic  fever  and 
its  efficiency  as  a  parasiticide,  I  should  expect  great  benefit  from  its 
prompt  use  in  the  early  stage  of  the  relapsing  fever,  if  the  stomach  would 
retain  it.  During  the  prevalence  of  the  disease  in  Berlin  in  1878—79, 
Dr.  Riess  reports  having  used  the  salicylate  of  sodium,  with  excellent  re- 
sults. In  the  early  stage  of  the  disease  the  salicylate  of  sodium  should 
be  given  in  0.66  gram  (gr.  x.)  doses  dissolved  in  water,  and  repeated 
every  two  or  three  hours  until  the  severe  pains  and  restlessness  abate, 
after  which  it  may  be  continued  at  longer  intervals  until  the  intermission 
supervenes,  unless  as  the  crisis  approaches  between  the  fifth  and  seventh 
days,  the  pulse  becomes  weak  and  slow,  the  face  pale,  with  a  sense  of 
weakness  or  weariness.  Should  these  symptoms  supervene,  the  salicy- 
late should  be  omitted,  and  in  its  place  0.13  grams  (gr.  ii.)  of  quinine 
may  be  given  every  four  hours,  and  alternating  with  it  a  powder  contain- 
ing 0.33  grams  (gr.  v.)  of  Dover's  powder  with  0.13  grams  (gr.  ii.)  of 
pulverized  gum  camphor.  If,  at  the  beginning,  the  nausea  and  vomiting 
is  sufficient  to   interfere  with    the   retention   of  the  salicylate   of    sodium, 


138  RELAPSING    FEVER. 

they  may  be  first  allayed  by  giving  during  the  first  twelve  to  twenty-four 
hours  the  carbolic  acid  combined  as  in  the  following  formula: 

^     Acidi  Carbolici,  0.5  grams  gr.    viii. 

Glycerinte,  15.0     c,  c.  3iv. 

Tincturse  Gelsemii,  15.0         "  3iv. 

Tincturse   Opii   Camphoratie,  60.0         "  §ii. 

Aquae,  60.0        "  |ii. 

Mix,  and  give  4  cubic  centimeters  (fl.  Z^-),  or  an  ordinary  teaspoonful 
every  two  or  three  hours,  until  the  vomiting  ceases.  This  may  be  aided 
by  the  application  of  cloths  wet  in  cold  water  to  the  head,  and  mustard 
finapisms  to  the  dorsal  part  of  the  spine  and  to  the  epigastrium.  When- 
ever the  skin  is  hot  and  dry,  frequent  sponging  of  the  surface  with  cool 
water,  will  be  both  grateful  to  the  patient  and  efficiently  antipyretic.  To 
prevent  local  complications,  daily  attention  should  be  given  to  the  quan- 
tity and  quality  of  the  urine,  and  if  it  becomes  very  scanty,  either  with  or 
without  the  presence  of  albumen,  digitalis  may  be  given  in  connection  with 
the  acetate  of  potassium.  If  diarrhoea  or  dysentery  supervene,  they 
should  be  checked  by  the  same  remedies  that  I  recommended  for  restrain- 
ing excessive  intestinal  evacuations  in  typhoid  fever.  As  soon  as  the  in- 
termission supervenes,  the  patient  should  have  as  much  nutritious  food  as 
will  be  readily  digested;  avoid  all  fatiguing  exercise  and  take  from 
0.66  to  1.00,  grams  (gr.  x.  to  xv.)  of  the  sulphite  or  hyposulphite  of  sodium 
dissolved  in  mint  water,  before  each  regular  meal-time,  and  at  bed-time,  and 
a  pill  containing  citrate  of  iron  and  quinine,  each  0.13  grams  (gr.  ii.),  af- 
ter each  meal-time.  By  the  action  of  the  salicylate  of  sodium  during  the 
febrile  stage,  and  the  sulphite  during  the  intermission,  I  should  expect  the 
relapse  to  be  entirely  prevented,  or  its  severity  greatly  lessened.  If,  at  the 
usual  time,  however,  the  febrile  stage  returns,  it  must  be  treated  on  the 
same  principles  and  by  the  same  means,  as  in  the  first  stage,  though  it  is  not 
generally  necessary  to  pursue  the  treatment  as  actively  as  at  first.  The 
same  vigilance  must  be  exercised  in  regard  to  the  checking  of  local  com- 
plications, and  more  care  must  be  taken  to  see  that  the  patient  is  supplied 
with  proper  nourishment.  When  convalescence  finally  comes,  the  patient 
should  continue  to  take  small  doses  of  quinine  and  iron,  plain  but  nutri- 
tious food,  and  be  very  cautious  about  taking  much  exercise  either  of 
body  or  mind,  until  the  strength  is  well  restored.  There  are  no  sequela? 
peculiar  to  relapsing  fever. 

Prophylaxis. — The  best  means  for  preventing  the  spread  of  the  dis- 
ease, are,  to  isolate  the  sick  as  far  as  practicable,  efficiently  enforce  whole- 
some sanitary  measures,  and  secure  for  the  masses  of  the  people  a  proper 
supply  of  good  food. 


YELLOW    FEVER.  139 


LECTUEE  XVII. 

Yellow  Fever— Its    Historj-,  Causes,  Symptoms,  Diagnosis,  Prognosis,  Pathological  Anatomy, 
Special  Pathology,  and  Treatment,  Prophylaxis. 

GENTLEMEN: — I  now  invite  your  attention  to  a  disease,  which,  from  its 
frequent  recurrence  in  epidemic  form,  the  high  ratio  of  mortality 
resulting  from  it,  and  its  serious  interference  with  important  commercial 
interests,  has  attracted  much  attention  in  this  country,  not  only  from  phy- 
sicians but  from  sanitarians  and  the  public  generally.  I  refer  to  Yellow 
Fever,  or  Typhus  Icterodes  of  the  ancients.  As  the  home  of  the  plague 
was  formerly  traced  to  Egypt  and  the  countries  bordering  on  the  eastern 
part  of  the  Mediterranean  Sea,  typhus  and  relapsing  fevei"  to  the  British 
Islands  and  the  countries  bordering  on  the  Baltic,  so  the  yellow  fever  is 
traced  still  more  definitely  to  a  home  or  permanent  habitat  in  the  Antilles 
or  West  Indian,  and  other  islands  in  the  tropical  part  of  the  Atlantic  Ocean 
and  Gulf  of  Mexico,  and  the  nortliwestern  part  of  the  coast  of  Africa. 
Within  the  limits  just  named  it  prevails  to  some  extent  every  year;  some- 
times very  mildly  and  in  other  seasons  with  great  severity.  At  irregular 
periods,  varying  from  three  to  ten  years,  it  breaks  over  these  apparently 
natural  boundaries,  and  appears  epidemically  in  the  principal  cities  and 
seaport  towns  bordering  on  the  Gulf  of  Mexico,  in  the  south  and  south- 
eistern  part  of  this  country,  in  the  northeastern  portion  of  South  America, 
as  far  south  as  Montevideo  and  Buenos  Ayres,  and  along  the  northwestern 
coast  of  Africa,  and  the  southwestern  coast  of  Europe,  to  the  borders  of 
Spain,  Portugal  and  France.  In  our  country,  it  has  at  times  extended 
inland,  chiefly  along  the  rivers  and  lines  of  commerce,  as  far  northward  as 
the  Ohio  River,  and  along  the  Atlantic  coast  northward  to  Norfolk  and 
Portsmouth  in  Virginia,  and  very  rarely  to  Philadelphia  and  New  York. 
Within  the  tropical  part  of  the  Atlantic  Ocean  it  often  makes  its  appear- 
ance on  shipboard  as  well  as  on  land.  It  has  not  been  known  to  prevail 
to  any  extent  on  any  of  the  islands  in,  or  coasts  bordering  on,  the  Pacific 
Ocean.  You  perceive  that  the  home  of  the  disease  is  in  warm  climates, 
but  why  it  should  habitually  prevail  on  the  islands,  ships  and  seaport  towns 
in  the  tropical  part  of  the  Atlantic,  and  not  in  correspoiiding  parts  of  the 
Pacific  Ocean,  is  not  easy  to  explain.  When  the  disease  extends  beyond 
its  ordinary  boundaries  in  an  epidemic  form,  it  is  always  during  the  warm 
season  of  the  year. 

Dr.  H.  Hartshorne  states  that  the  first  appearance  of  yellow  fever  in  any 
part  of  our  country,  of  which  we  have  any  record,  was  at  New  York  in 
1G68;  its  first  appearance  in  Philadelphia,  was  in  1695;  in  Mobile  in  1705; 
and  in  New  Orleans  in  1769.  Since  the  last  date  mentioned,  the  most  se- 
vere epidemics  have  been  in  1819,  '47,  '53,  '54,  '55,  '58,  '67,  and  '78.  From 
1695  to  1822,  the  disease  several  times  prevailed  severely  in  New  York 
and  Philadelphia,  but  since  the  latter  date  it  has  not  prevailed  sufficiently 
to  merit  the  name  of  an  epidemic  north  of  Portsmouth  and  Norfolk  on  the 
Atlantic  coast,  and  not  north  of  the  line  of  the  Ohio  river,  and  St.  Louis 
in  the  interior,  or  valley  of  the  Mississippi.  It  prevailed  to  a  very  limited 
extent  on  a  part  of  the  coast  of  Staten  Island,  at  the  entrance  of  New 
York  harbcr,  in  the  summer  of  1847.  Perhaps  the  most  extensive  epi- 
demic of  the  disease  that  has  ever  occurred  in  this  country,  was  that  of  1878. 


14:0  YELLOW    FEYER. 

Causes  of  ITellow  Fever. — The  circumstances  that  favor  the  prevalence 
of  yellow  fever  are  :  a  protracted  high  temperature,  giving  a  mean  above 
22°  C.  (72°  F.);  proximity  to  the  waters  of  the  Atlantic  ocean,  or  the 
orulfs,  rivers,  and  bays  communicating  with  it,  between  the  parallels  of 
latitu'Je  of  45^  north  and  35 '^  south;  and  low  altitudes,  or  such  as  approx- 
imate to  the  level  of  the  ocean.  In  regard  to  the  first  of  these  favoring 
circumstances,  or  predisposing  causes,  it  is  necessary  to  remind  you  that 
ii  is  not  the  mere  high  temperature  of  one  or  two  days,  but  of  several 
weeks,  that  appears  to  be  necessary  as  one  of  the  conditions  under  which 
the  disease  may  become  epidemic.  Hence  it  seldom  commences  to  attract 
public  attention  in  New  Orleans,  and  other  places  bordering  on  the  Grulf 
of  Mexico,  until  a  little  past  the  climax  of  summer  heat;  or,  in  other  words, 
not  until  the  last  half  of  Jul}^,  and  sometimes  not  until  in  August.  "When 
it  has  fairly  commenced,  it  generally  continues  until  so  far  in  Autumn 
that  the  atmospheric  temperature  falls  below  the  freezing  point,  after 
which  new  cases  become  infrequent,  and  the  disease  soon  disappears  from 
the  community.  Isolated  or  sporadic  cases  may  occur  earlier  in  the  season ; 
or  cases  may  be  introduced  from  on  board  ships  from  some  of  the  ^Yest 
India  Islands,  but  there  has  been  no  development  into  an  epidemic  preva- 
lence until  the  summer  temperature  has  been  well  advanced.  Previous 
to  the  epidemics  of  1867  and  1878,  '79,  the  disease  had  never  manifested 
much  tendency  to  extend  into  the  interior,  remote  from  the  sea  coast,  ex- 
cept along  rivers  and  water  courses  occupied  by  commerce,  and  opening 
into  the  sea  within  the  yellow  fever  zone.  But  in  these  two  later  epi- 
demics, it  extended  over  a  large  part  of  the  interior  of  the  states  border- 
ing on  the  Gulf,  and  northward  through  Tennessee  and  parts  of  Kentucky 
and  Missouri.  In  regard  to  the  influence  of  elevation,  I  think  the  hio-hest 
point  on  which  the  disease  has  jDrevailed  in  this  country,  was  at  Galli- 
opolis,  a  little  more  than  600  feet  above  the  ocean.  But  within  the  trop- 
ics the  disease  has  been  reported  at  New  Castle,  Jamaica,  at  an  elevation 
of  4,000  feet,  and  in  some  parts  of  Mexico  at  3,243.* 

During  the  last  few  years.  Dr.  W.  Huston  Ford,  of  St.  Louis,  has  pub- 
lished the  results  of  observations  concerning  the  relations  of  temperature 
to  the  prevalence  of  yellow  fever.  He  has  been  enabled  to  compare  the 
meteorological  and  mortuarj'^  records  of  Charleston,  South  Carolina, 
through  a  period  of  thirty-eight  years,  and  of  ten  other  southern  cities  for 
a  period  of  five  years.  Of  the  thirty-eight  years  included  in  the  records 
in  Charleston,  seventeen  were  characterized  by  more  or  less  prevalence  of 
yellow  fever.  In  six  of  these  seventeen  years  the  disease  assumed  a  se- 
vere epidemic  form  ;  in  six,  mildly  epidemic,  and  in  five,  only  a  few  spor- 
adic cases  occurred.  Only  twice  during  the  whole  period  did  the  disease 
prevail  in  decided  or  severe  epidemic  form  two  years  in  succession.  In 
nearly  all  instances  only  sporadic  or  scattering  cases  occurred  the  sum- 
mer succeeding  a  severe  epidemic.  The  commencement  of  the  disease 
was  generally  in  August,  and  its  j^revalence  was  limited  to  the  months  of 
August,  September  and  October.  On  comparing  the  meteorological  with 
the  mortuary  records  ibr  the  whole  period  of  thirty-eight  years.  Dr.  Ford 
found  that  the  years  in  which  the  yellow  fever  was  epidemic  were  the 
same  in  which  the  summer  heat  rose  to  the  highest  mean  for  the  three 
months  just  named  in  each  year.  The  six  years  of  severe  epidemic  prev- 
alence were  also  the  six  years  giving  the  maximum  mean  temperature  of 
the  summer  months.  The  six  years  of  slight  epidemics  ranked  next  in  the 
mean  temperature  of  the  same  months. 

•  See  A  System  of  Medicine,  by  J.  Eussell  E?ynolds,  M.  D.,  etc.    Vol.  1,  p.  2M,  Amr.  Edition,  1S79. 


CAUSES    OF    THE    DISEASE.  141 

The  five  years  of  sporadic  cases  gave  a  mean  temperature  for  summer 
and  autumn  less  than  those  in  which  the  disease  was  moderately  epidemic. 
In  the  remaining  twenty  years  in  which  there  was  no  prevalence  of  the 
yellow  fever,the  mean  temperature  of  the  summer  months  was  at  the 
minimum;  the  highest  of  any  of  these  years  being  lower  than  the  lowest 
of  those  in  which  the  disease  prevailed.  The  only  exception  to  this  rule 
was  in  1836,  when  ihe  mean  temperature  of  the  months  of  July,  August, 
September  and  October,  was  as  high  as  the  years  of  most  severe  epidemic 
prevalence  of  yellow  fever,  and  in  that  year  the  city  was  scourged  by  a 
severe  epidemic  of  cholera,  that  appeared  to  supercede  the  yellow  fever. 
Dr.  Ford  has  analysed  and  compared  these  statistics  of  Charleston  in  the 
most  varied  and  philosophical  manner,  but  always  arriving  at  the  same 
result,  namely,  that  the  seasons  of  yellow  fever  epidemics  are  identical 
with  those  of  highest  summer  temperature.  His  comparison  of  meteor- 
ological and  mortuary  statistics  in  the  other  ten  cities  situated  on  the  Gulf 
of  Mexico  and  along  the  Mississippi  River,  as  far  north  as  St.  Louis  and 
Louisville,  is  only  for  a  period  of  five  years,  including  1874-5-6-7-8. 
But  they  lead  to  precisely  the  same  conclusions. 

Thus  the  summers  of  1873-4,  were  a  little  above  the  average  mean  for 
a  series  of  ten  years,  and  there  were  moderate  epidemics  of  yellow  fever 
in  several  of  the  cities  on  the  lower  Mississippi  and  the  Gulf.  The  sum- 
mers of  1875-6-7,  were  decidedly  below  the  mean  temperature  for  a  series 
of  ten  consecutive  years,  and  there  were  no  epidemics  of  the  fever  in  any 
of  the  cities  under  consideration.  The  mean  temperature  for  July,  August, 
September  and  October,  was  the  lowest  in  1875,  from  which  an  annual  in- 
crease was  presented  in  1876  and  1877,  culminating  in  the  extraordinary 
summer  temperature  of  1878,  and  the  equally  extraordinary  epidemic  prev- 
alence of  the  disease.  The  mean  temperature  of  the  summer  of  1879,  falls 
below  that  of  1878,  yet  is  decidedly  above  the  average  for  a  series  of  years, 
especially  in  the  middle  and  lower  part  of  the  Mississippi  valley.  And 
true  to  the  law  already  deduced,  the  yellow  fever  re-appeared  fairly  epi- 
demic in  Memphis  and  its  vicinity,  and  sporadically  in  New  Orleans  and 
a  few  other  places.  These  eminently  philosophical  deductions  of  Dr.  Ford, 
are  corroborated  by  a  great  variety  of  other  facts;  and  are  sufficient  to 
show  a  necessary  connection  between  unusual  high  summer  temperature 
and  the  appearance  of  yellow  fever  epidemics.  If  the  investigations  re- 
lated only  to  the  years  1878  and  1879,  or  to  any  other  one  cr  two  years, 
the  co-existence  of  a  high,  mean  summer  temperature  and  an  epidemic 
prevalence  of  the  fever,  might  be  regarded  as  merely  accidental;  but  when 
the  statistics  cover  a  perio  1  of  thirty  or  forty  consecutive  years,  as  in  the 
case  of  Charleston,  and  the  same  co-existence  is  found  uniform  throughout, 
the  presumption  of  accidental  coincidence  ceases,  and  the  deduction  as- 
sumes the  importance  of  a  fixed  law.  The  same  series  of  investigations 
and  statistical  comparisons  also  establish  the  important  fact,  that  the  fever 
never  assumes  an  epidemic  character  until  the  high  summer  temperature 
has  progressed  two  months,  namely,  through  the  months  of  June  and  July; 
the  favorite  month  for  its  epidemic  ravages  to  commence  in  our  country, 
being  August.  And  in  the  few  instances  of  its  commencing  to  prevail 
epidemically  in  July,  it  is  found  that  the  high  summer  heat  had  com- 
menced in  May.  Such  was  the  case  in  Memphis,  in  the  summer  of  1879. 
In  the  temperate  zone  the  sun  reaches  a  position  relative  to  the  earth, 
which  gives  to  its  rays  most  directness  and  power  to  impart  the  greatest 
amount  of  heat  to  the  earth's  surface,  about  the  21st  of  June,  x^t  the 
same  time,  the  days  become  the  longest  compared  with  the  nights,  and 
conseci[uently,    more  heat  is    absorbed  each  day  by  the  earth  than  is  radi- 


142  YELLOW    FEVEE,. 

ated  into  the  air  during  the  night;  and  hence  there  is  a  steadily  increas- 
ing temperature  of  the  earth's  surface  through  June,  July  and  August, 
while  that  of  the  atmosyjhere  may  be  much  more  fluctuating.  Oftentimes, 
even  here  in  Chicago,  the  mercury  rises  higher  for  a  few  hours  in  the  mid- 
dle of  some  days  during  the  third  week  in  June,  than  in  any  other  days  of  the 
year,  but  the  nights  are  yet  cool,  and  no  visible  disturbances  of  health  re- 
sult from  such  temporary  high  temperature.  So  also  many  instances  have 
occurred  where  ships  having  yellow  fever  on  board,  have  arrived  in  New 
Orleans  and  other  Gulf  or  Atlantic  ports,  during  the  months  of  May  and 
June,  and  even  here  and  there  a  sporadic  case  has  occurred  in  those  cities, 
independent  of  any  known  importation,  during  those  months;  yet  no  gen- 
eral or  epidemic  development  has  appeared,  until  the  latter  part  of  July 
or  in  August,  and  in  many  instances,  not  until  early  in  September,  These 
facts  show  that  it  is  not  merely  high  temperature,  but  such  temperature 
continued  until  the  surface  of  the  earth  reaches  a  degree  of  heat  and  mois- 
ture most  favorable  for  rapid  decomposition  of  organic  matter,  and  the  sus- 
pension of  the  products  of  such  decomposition,  with  aqueous  vapor  in  the 
atmosphere,  that  we  get  the  exact  meteorological  condition  necessary  for 
originating  or  sustaining  an  epidemic  of  yellow  fever.  But  even  when 
the  temperature  is  sufficiently  high  and  long  continued,  with  a  moisture 
most  favorable  for  fermentation  or  decomposition  of  organic  matter,  yet 
no  epidemic  yellow  fever  will  be  developed,  unless  the  particular  kind  of 
organic  matter  required  be  present  to  undergo  such  change,  in  sufficient 
quantity  to  impregnate  the  atmosphere  to  a  considerable  extent.  Just 
what  the  deleterious  material  is  that  is  engendered  and  diffused  in  the  at- 
mosphere as  the  pabulum  for  supporting  yellow  fever,  is  not  yet  known. 
Neither  is  it  lully  known  what  kind  of  fermentative  or  decomposible 
organic  matter  is  necessary  to  furnish  the  pabulum  on  which  the  heat  and 
moisture  are  to  act.  Yet  all  the  facts  connected  with  the  origin  and  prog- 
ress of  the  j^ellow  fever  during  the  years  1878-9  point  unmistakably 
to  local  atmospheric  and  topographical  conditions  as  exerting  a  controll- 
ing influence  over  the  spread  or  continuance  of  the  disease,  whether  its 
supposed  essential  cause  was  imported  or  not.  For  instance,  in  the  sum- 
mer of  1878,  the  disease  assumed  an  epidemic  form  in  New  Orleans  dur- 
ing the  month  of  July,  and  prevailed  nearly  a  month  before  any  cases 
were  recognized  in  Memphis,  although  there  was  constant  communication 
between  the  two  cities,  both  by  river  and  railroad.  And  at  a  still  later 
period  the  disease  made  its  appearance  in  many  smaller  places,  more  or 
less  distant  from  each  other,  so  nearly  simultaneous  as  to  preclude  the 
possibility  that  it  had  been  communicated  from  one  to  another. 

Again,  in  the  year  1879,  as  is  well  knoAvn,  the  disease  commenced  in 
Memphis,  and  prevailed  severely  before  it  had  appeared  in  New  Orleans, 
or  any  other  place  bordering  on  the  Gulf,  More  than  half  the  population 
speedily  abandoned  the  city,  scattering  themselves  widely  over  the  more 
northern  parts  of  the  country;  many  hundred  more  went  into  camps  on 
well  chosen  ground  only  twenty  or  thirty  miles  distant  from  the  city;  while 
the  local  board  of  health,  aided  by  the  State  and  national  health  organiza- 
tions, not  only  established  and  enforced  the  most  rigid  quarantine,  but 
waged  an  unceasing  warfare  upon  the  disease  in  the  city  by  isolation  and 
disinfection,  using  almost  unlimited  quantities  of  the  best  antiseptic  and 
disinfecting  remedies  known;  and  yet  the  epidemic  continued  the  even 
tenor  of  its  way  in  the  city,  and  after  five  weeks  made  its  appearance  in  a 
score  or  more  of  smaller  places  in  different  directions  from  Memphis, 
But  the  moment  a  severe  frost  made  its  appearance,  reducing  the  temper- 
ature of  the  atmosphere  a  little  below  0^  C,  or  32°  F.,  the  disease,  which 


CAUSES  OF  YELLOW  FEVER.  143 

for  nearly  throe  months  had  bid  defiance  to  hundreds  of  tons  of  disinfect- 
ants and  any  number  of  quarantines,  even  when  aided  by  shot-f^uns,  dis- 
appeared as  if  by  magic.  If  we  put  the  facts  recently  developed  in  re- 
gard to  the  necessary  influence  of  continuous  high  temperature  in  origi- 
nating an  epidemic  of  yellow  fever,  with  the  long  known  fact  that  a  loio 
temperature  invariably  extinguishes  it,  we  have  proof  amounting  to  dem- 
onstration that  the  propositions  already  stated  in  relation  to  the  several 
conditions  that  7mist  co-exist  in  any  given  locality  to  allow  the  develop- 
ment of  an  epidemic  of  this  disease,  are  correct. 

Without  entering  further  into  details  in  reference  to  the  etiology 
of  yellow  fever,  I  will  simply  state  that  the  contagium  vivum  theory, 
which  assumes  the  essential  cause  of  the  disease  to  be  an  organic  germ, 
capable  of  self  propagation,  and  without  the  introduction  of  which  from 
some  prior  case,  no  combination  of  circumstances  can  produce  the  dis- 
ease, is  purely  hypothetical  and  unsupported  by  any  basis  of  ascertained 
facts.  No  organic  germs  peculiar  to  this  disease  have  been  found  either 
in  the  blood,  secretions,  or  tissues  of  yellow  fever  patients,  though  dili- 
gently sought  for  by  many  of  the  most  competent  microscopic  investiga- 
tors, both  in  this  country  and  Europe.* 

The  well  known  fact  that  sporadic  cases  of  yellow  fever  03cur  in  thr; 
West  Indies  and  in  New  Orleans  almost  every  summer,  and  that  cases  are 
brought  on  ships  to  more  northern  parts  often,  without  causing  any  spread 
of  the  disease,  show  that  if  there  is  a  fever  germ^  it  certainly  requires 
some  peculiar  local  condition  of  the  atmosphere  for  its  prop3gation.  An- 
other fact  still  more  difficult  to  explain  on  the  germ  theory,  is,  that  the 
disease  very  rarely  prevails,  as  an  epidemic,  more  than  one  or  two  years  in 
succession  in  the  same  place.  The  same  general  series  of  facts  bear  still 
stronger  against  the  doctrine  of  personal  contagion.  For  a  full  and  in- 
teresting discussion  of  the  whole  subject  of  the  etiology  of  yellow  fever, 
however,  I  must  refer  you  to  the  very  complete  work  of  Dr.  R.  LaRoche, 
of  Philadelphia,  in  two  full  sized  octavo  volumes,  published  in  1S55.  They 
constitute  the  most  complete  treatise  on  this  disease  in  our  language.  Ba- 
fore  leaving  this  part  of  our  subject,  it  is  proper  to  remind  you  that  many 
of  those  v/ho  have  had  ample  opportunities  for  the  personal  study  of  yel- 
low fever,  and  who  have  been  eminently  qualified  to  judge  correctly,  hive 
regarded  it  as  simply  a  modified  form  of  tlie  ordinary  endemic  malarious 
fever  of  the  southern  States.  Thus  Dr.  Benj.  Rush  regarded  the  disease 
as  it  prevailed  in  Philadelphia  during  his  day,  as '•  nothing  but  a.  high 
grade  of  bilious  fever;"  and  Dr.  E.  D.  Fenner,  of  New  Orleans,  who  in- 
vestigated with  great  care  the  origin  and  progress  of  no  less  than  twelve 
epidemics  in  that  city,  says  :  "  Our  position  is,  that  yellow  fever  is  only 
one  of  the  forms  of  endemic  fever  (malarious,  if  you  will),  which  derives 
its  characteristic  features  from  the  localivy  and  attendant  circumstances 
where  it  prevails."  f 

Persons  who  have  suffered  from  one  attack  of  the  fever,  rarely  become 
susceptible  to  subsequent  attacks,  although  there  are  many  exceptions  to 
this  rule.  It  attacks  persons  at  all  periods  of  life,  yet  the  highest  ratio 
both  in  numbers  attacked  and  in  fatality,  is  during  the  period  of  vigor- 
ous adult  life,  between  20  and  40  years  of  age.     Sex  appears  to  exert  but 

*  See  Pathology  and  Treatment  of  yellow  fever,  with  some  remarks  on  the  nature  of  its  cause  and 
its  prevention,  by  H.  D.  Schmidt,  M.  D.,  of  New  Orleans,  La.,  in  the  Chicago  Medical  Journal  and 
Examiner  for  October,  1881,  p.  364. 

The  Microphytes  which  have  been  found  in  the  b'ood  and  their  relations  to  disease,  bv  Timothy 
Richard  Lewis,  M.  D.,  etc.,  in  the  Quarterly  Journal  of  Microscopical  Science,  for  July,  1879. 

The  Microscopic  Germ-Theory  of  Disease,  bv  H.  Charlton  Bastian,  M.  D.,  in  Monthly  Microscopi- 
cal Journal,  August.  1875. 

tSee  Transactions  of  the  American  Medical  Associa  ion,  Vol.  VII,  p.  536,  1854.  Report  on  Epi- 
demics of  Louisiana. 


14  i  YELLOW    FEVER. 

little  influence.  The  colored  population  have  generally  suffered  much 
less  during  yellow  fever  epidemics  than  the  white.  Long  residence  or 
full  acclimation  has  a  very  marked  effect  in  diminishing  the  susceptibility 
to  the  disease,  while  but  few  of  those  who  have  recently  come  within  the 
yellow  fever  zone,  escape  an  attack  during  the  prevalence  of  an  epidemic. 

/SytJiptoms. — The  symptoms  of  yellow  fever  vary  very  much  in  their 
severity,  in  different  cases  and  in  different  epidemics.  There  is  generally  a 
forming  or  prodromic  stage  of  from  one  to  three  days  duration,  character- 
ized by  a  sense  of  weakness  or  indisposition  to  mental  or  physical  activ- 
ity; some  aching  in  the  head,  back,  and  limbs;  with  alternate  feelings  of 
heat  and  cold.  These  are  followed  by  a  more  distinct  chill,  though  of 
short  duration,  and  active  febrile  reaction,  giving  to  the  face  a  deep  suf- 
fused redness;  a  red  and  watery  appearance  of  the  eves;  a  hot  and  dry 
skin,  the  temperature  rising  rapidly  to  39°  or  40°  C.  (i02.5°  or  104.3°  F.) 
and  sometimes  to  43°  C.  (110°  F.);  pulse  from  90  to  100  per  minute,  and 
moderately  full;  tongue  covered  with  a  white  or  yellowish  white  fur,  and 
moist;  severe  pains  in  the  frontal  region  of  the  head  and  lumbar  part  of 
the  spine,  with  general  restlessness;  much  distress  and  tenderness  in  the 
epigastrium;  considerable  thii'st,  and  in  many  cases  frequent  and  severe 
vomiting,  with  more  or  less  constipation  of  the  bowels.  The  urine  is 
scanty  and  high  colored;  and  though  the  mind  is  generally  clear,  in  many 
of  the  more  severe  cases,  delirivim  is  an  early  and  prominent  symptom. 
The  group  of  active  pyretic  symptoms  I  have  now  enumerated,  are  all 
well  developed  if  not  at  their  climax  before  the  end  of  the  first  twenty- 
four  hours  after  the  initial  chill,  and  they  continue  with  but  little  change 
in  their  character  from  two  to  five  days,  when  they  begin  rajDidly  to  de- 
cline, and  in  a  few  hours  the  patient  is  in  a  state  of  apyrexia,  and  so  quiet 
and  comfortable  as  to  present  almost  all  the  features  of  an  actual  conva- 
lesence.  And  in  the  mildest  class  of  cases  there  is  no  renewal  of  un- 
pleasant symptoms,  and  the  convalesence  is  complete.  In  far  the  greater 
number  of  cases  however,  this  intermission  or  "  period  of  calm  "  is  only 
transient,  lasting  from  six  to  twenty-four  hours,  when  febrile  symptoms 
return,  in  some  cases  in  a  much  less  active  form  than  during  the  first  par- 
oxysm, and  after  a  mild  course  of  from  one  to  two  weeks,  ending  in  recov- 
ery; and  in  many  others  in  a  form  so  severe  as  to  prove  speedily  fatal. 

It  is  generally  during  the  intermission,  and  the  subsequent  renewal  of 
febrile  symptoms,  that  the  skin  begins  to  present  the  peculiar  yellow  hue 
which  has  given  the  name  to  the  disease.  In  all  the  more  severe  cases 
the  intermission  is  speedily  followed  by  a  soft,  compressible,  or  gaseous 
pulse,  either  very  frequent  or  preternaturally  slow,  sometimes  falling  to 
40  per  minute,  or  even  slower;  the  skin  cool;  the  mind  dull,  wandering 
and  incoherent;  the  urine  very  scanty  and  albuminous,  or  suppressed; 
and  frequent  vomiting,  sometimes  of  a  thin,  white,  and  sour  fluid,  but 
much  more  frequently  the  matter  vomited  is  thin,  copious,  and  dark- 
brown,  from  the  presence  of  flakes  of  a  black  coffee-ground  appearance, 
consisting  of  altered  blood  corpuscles,  and  sometimes  it  is  real,  unaltered 
blood.  In  bad  cases  the  skin  becomes  hourly  more  yellow;  tlae  eyes  re- 
taining their  redness,  gives  a  peculiarity  of  expression  highly  character- 
istic of  this  disease;  the  pulse  becomes  weaker  and  more  irregular;  the 
vomiting  more  copious,  being  more  like  regurgitation  than  ordinary  vom- 
iting; the  discharges  from  the  bowels  dark-brown,  sometimes  thick  and 
black,  like  tar,  and  at  other  times  much  like  the  dark  coffee-ground  mate- 
rial ejected  by  vomiting;  blood  not  unfrequently  oozes  from  the  nose, 
gums,  ears,  fingers,  kindeys,  uterus,  and  into  the  skin,  causing  petgechial 
spots  or  vibices,  especially  over  the  posterior  part  of  the  trunk  of  the  body 


SYMPTOMS    AND    DIAGNOSIS.  145 

and  extramitics;  complete  collapse  and  death  soon  follows.  Sometimes 
the  death  is  preceded  by  entire  suppression  of  urine,  convulsions  and 
coma,  and  in  other  cases  the  mind  remains  clear  or  free  from  derange- 
ment until  the  end.  The  entire  group  of  symptoms  I  have  thus  stated  as 
followino-  the  brief  23ei'iod  of  calm  on  the  subsidence  of  the  first  run  of 
active  fever,  may  develop  so  rapidly  as  to  cause  death  in  the  first  twenty- 
ibur  hours,  or  this  result  may  not  be  reached  until  the  end  of  the  fourth 
or  fifth  day.  And  in  a  few  instances,  even  after  well-marked  black  vom- 
it, recoveries  have  taken  place.  In  cases  of  less  severity  than  those 
I  have  just  described,  the  calm  or  remission  is  followed  by  the  re-estab- 
lishment of  fever,  more  resembling  the  typhoid  in  its  grade  and  general 
features,  which  may  continue  from  one  to  two  weeks,  and  generally  ends 
in  convalescence.  During  the  more  severe  epidemics,  a  few  cases  are 
usually  met  with  in  which  the  attack  is  sudden,  and  the  morbid  actions 
established  in  the  blood  and  tissues  so  intense,  that  life  is  destroyed  in 
from  twenty-four  to  forty-eight  hours.  On  the  other  hand,  in  the  absence 
of  special  epidemic  influence,  the  disease  as  it  prevails  endemically  in  the 
West  Indies  and  sporadically  in  New  Orleans,  often  runs  a  very  mild 
"course  of  from  five  to  seven  days,  and  ends  in  permanent  convalescence. 
During  seasons  of  epidemic  prevalence,  however,  nearly  all  the  cases  pie- 
sent  a  well-marked  active  febrile  paroxysm,  continuing  from  three  to  seven 
days,  a  brief  period  of  calm  or  intermission,  and  a  renewal  of  febrile 
symptoms  of  greater  or  less  severity,  which  may  continue  from  a  single 
day  to  two  weeks.  Most  w^riters  describe  this  order  of  phenomena  as 
three  stages  of  the  disease;  the  first,  a  protracted  paroxysm  of  active 
fever;  the  second,  a  brief  stage  of  apyrexia  or  intermission;  and  the  third, 
a  period  of  secondary  fever.  Dr.  Austin  Flint  and  some  others,  prefer  to 
regard  the  disease  as  consisting  in  a  single  protracted  paroxysm  of  fever, 
and  the  periods  of  intermission  and  secondary  fever  as  sequelae. 

Diagnosis. — The  chief  diagnostic  symptoms  in  the  early  stage,  are  sud- 
denness of  access,  unusual  redness  of  the  eyes,  severity  of  pains  in  the 
head,  back  and  limbs,  epigastric  tenderness,  and  in  many  cases,  active 
vomiting.  The  continuance  of  these  symptoms  from  three  to  five  days, 
ending  rather  suddenly  in  an  intermission,  accompanied  by  the  develop- 
ment of  yellowness  of  the  skin,  and  such  intermission  followed  in  a  few 
hours,  by  a  renewal  of  fever  with  increased  yellowness,  with  or  without 
the  vomiting  of  dark  coffee-ground  material,  renders  the  diagnosis  reason- 
ably certain.  If  to  these  symptoms  are  added,  hemorrhages  from  the 
bowels,  nose,  mouth,  and  petechiee,  or  hemorrhagic  spots  on  the  surface,  with 
scanty  and  albuminous  urine,  the  diagnosis  is  complete.  You  will  see  by 
these  statements,  that  when  a  well-marked  case  of  yellow  fever  is  attended 
through  its  successive  stages  to  the  end,  there  is  no  difficulty  in  distin- 
guishmg  it  from  all  other  febrile  affections. 

But  in  the  very  mild  cases  that  terminate  in  convalescence,  at  the  end. 
of  the  first  febrile  stage,  there  are  no  symptoms  so  distinctive  or  specially 
characteristic,  as  to  enable  the  practitioner  to  differentiate  them  with  cer- 
tainty, from  cases  of  febricula  on  the  one  hand,  or  of  mild  remittents  on 
the  other.  And  in  the  early  stage  of  cases  of  ordinary  severity,  there  are 
no  symptons  except  such  as  may  be  occasionally  seen  in  the  early  exacer- 
bations of  intermittent  and  remittent  fevers.  So  true  is  this,  that  the  most 
intelligent  and  experienced  physicians  in  those  southern  cities  most  subject 
to  the  prevalence  of  yellow  fever,  differ  in  opinion  about  the  diagnosis  of 
the  first  few  cases  that  occur  at  the  commencement  of  every  epidemic* 

*The  late  Dr.  E.  D.  Fenner,  of  New  Orleans,  writes  in  regard  to  this  subject,  as  follows :    "  The 
general  impression  derived  frcm  reading  descriptions  of  yellow  fever  is,  that.it  is  a  violent  fever 

10 


146  YELLOW    FEVEE. 

Dr,  Aitken  and  some  other  eminent  English  writers,  endeavor  to  make 
a  distinction  between  the  '•'•true  yellow  fever,"  which  they  claim  to  be 
specific  and  propagated  by  personal  contagion,  and  "a  malarious  form  of 
yellow  fever,"  which  is  allied  to  the  ordinary  periodical  fevers.  They  ac- 
knowledge that  yellowness  of  the  skin,  black  vomit  and  other  hemorrhages 
occur  in  both,  and  that  the  only  reliable  distinction  is  the  coramunicabil- 
ity  of  the  true  or  specific  disease,  from  person  to  person,  and  its  occur- 
rence in  the  same  individual  but  once.* 

Judged  by  these  tests,  most  of  the  important  epidemics  that  have  ap- 
peared in  this  country,  would  have  to  be  classed  as  false  or  malarious  yel- 
low fever.  I  think  the  distinction  is  not  sustained  by  a  sufficient  number 
of  accurately  observed  facts,  and  cannot  be  maintained  at  the  bedside  of 
the  sick. 

Prognosis. — The  yellow  fever  as  it  occurs  endemically  within  the  prop- 
er yellow  fever  zone,  is  often  a  mild,  febrile  disease  and  attended  by  a  very 
small  ratio  of  mortality.  In  its  epidemic  form,  however,  it  is  always  at- 
tended by  a  high  ratio  of  deaths;  and  yet  the  fatality  accompanying  one 
epidemic  has  difi'ered  much  from  that  of  others;  and  the  same  epidemic 
has  proved  much  more  severe  in  some  localities  than  in  others,  and  gen- 
erally more  fatal  at  the  beginning  and  during  increase,  than  during  its 
decline.  Dr.  LaRoche  estimates  the  average  mortality  of  the  disease  in 
its  epidemic  form  to  be  1  in  3.33.  The  highest  ratio  that  I  have  seen 
reported  was  75  per  centum.  You  must  remember,  however,  that  the  fa- 
tality as  stated  by  T3r.  LaRoche  and  most  other  writers,  is  based  mostly 
upon  official  reports  from  hospitals,  boards  of  health,  etc.,  and  do  not  cor- 
rectly indicate  the  ratio  of  mortality  in  the  private  practice  of  intelligent 
and  efficient  physicians.  For  instance,  in  the  severe  epidemic  Avhich  pre- 
vailed in  New  Orleans  in  the  summer  of  1853,  there  were  reported  from 
official  sources  15,363  cases,  of  which  5,054  proved  fatal,  being  33.11  per 
centum;  while  Ur.  Fenner  tells  us  that  of  137  cases  occurring  in  his  pri- 
vate practice  during  the  same  ej)idemic,  only  7.87  per  centum  died,  or  a 
little  more  than  1  in  13. 

A  part  of  this  difference  is  attributable  to  the  fact,  that  the  cases  treated 
in  their  own  homes  by  their  regular  family  physician,  are  generally  seen 
earlier  and  the  whole  treatment  conducted  under  more  favorable  circum- 
stances, than  those  taken  to  hospitals  or  placed  in  charge  of  official  organ- 
izations. 

The  symptoms  that  are  regarded  as  pointing  more  directly  towards  a 
fatal  result  arc,  the  black  vomit  and  other  severe  hemorrhages,  suppressed 
or  scanty  and  highly  albuminous  urine,  convulsions,  and  coma.  The  two 
last  indicate  the  presence  of  uremic  poisoning.  Most  writers  represent  the 
black  vomit  alone  as  a  certain  forerunner  of  death.  But  such  is  not 
always  the  case,  although  it  is  an  exceedingly  unfavorable  symptom.  In 
the  epidemic  of  1853  in  New  Orleans,  according  to  Dr.  Fenner's  report, 

of  a  single  paroxysm,  lasting  about  seventy  two  hours,  and  presenting  strongly  marked  characteris- 
tic sj-mptoms,  bywhich  it  may  readiiy  be  distinguished  from  all  other  types  of  fever.  I  have  nut 
found  it  so;  nor  have  I  yet  found  the  man  who  could  ahvay=:  say  correctly  whether  a  case,  ex- 
amined per  se.  was  yellow  fever  or  not.  I  have  already  shown  what  diflFerences  of  opinion  were  ex- 
pressed about  the  first  cases  that  appeared  this  year  (1853),  and  have  only  to  add  that  the  same  thing 
occurs  here  every  year.  The  truth  is,  yellow  fever  is  so  closely  allied  to  remittent  and  intermittent 
fever  ,  that  no  uniform  and  reliable  distinction  can  be  drawn  between  them  in  the  early  stages, 
and  the  only  way  we  get  at  the  fact  that  yellow  fever  is  prevailing,  is  by  observing  the  #rtaZ  resitfts, 
whether  in  denth  or  convalescence ;  and  the  former  is  by  far  the  most  conclusive  of  the  two.  Even 
in  such  an  epid;mic  as  this,  thousands  of  cases  occurred  which  no  one  would  have  thought  of  call- 
ing yellow  fever,  if  it  had  not  been  generally  known  that  many  of  the  same  character  and  appear- 
ance had  terminated  in  fatal  black  vomit." — See  report  on  the  Epidemics  of  Louisiana,  etc.,  for 
1853,  by  E.  D.  Fenner,  M.  D.,  in  the  trausaction.s  of  the  American  Medical  Association,  Vol.  7, 1854, 
p.  466. 

*See  the  Science  and  Practice  of  Medicine,  by  Wm.  Aitken,  M.  D.,  etc.,  Third  Amer.  Edition,  pp. 
5G5-6. 


PATHOLOGICAL    ANATOMY.  147 

to  wliicli  I  have  already  several  times  alluded,  about  seven  per  centum  of 
the  well  marked  cases  of  black  vomit  recovered.  And  he  enumerates  no 
less  than  thirty-eight  similar  cases  of  recovery  in  the  private  practice  of 
six  or  seven  well  known  practitioners  in  that  city.  The  prognosis  in  all 
cases  of  yellow  fever  must  be  given  with  caution,  as  there  is  no  other 
general  acute  disease  so  deceptive,  or  subject  to  such  sudden  and  unex- 
pected changes  of  an  unfavorable  character. 

The  intemperate,  or  those  who  use  freely  alcoholic  liquors,  give  a  very 
high  ratio  of  mortality  when  attacked  with  this  disease.* 

Pathological  Anatomy. — The  peculiar  yellow  color  presented  by  the 
skin  in  most  fatal  cases,  is  also  seen  on  making  post  mortem  examinations, 
staining  all  the  membranous  structures  in  some  degree.  Slight  serous 
eflusions  have  been  found  in  some  cases  in  the  membranes  of  the  brain, 
the  pericardium  and  pleura,  and  more  or  less  hypostatic  congestion  of  por- 
tions of  the  lungs.  But  no  pathological  or  structural  changes,  peculiar  to 
yellow  fever,  have  been  found  in  the  contents  of  the  cranium  or  chest.  In 
the  abdomen  the  chief  morbid  changes  are  found  in  the  liver,  stomach, 
duodenum,  and  kidneys.  The  liver  is  not  much  enlarged,  but  is  altered 
in  color  and  texture.  It  presents  a  light  yellow  or  fawn  color,  in  some  cases 
throughout  the  whole  organ,  and  in  others  it  is  limited  to  particular  parts. 

This  change  of  color  which  differs  much  in  degree  in  different  cases, 
appears  to  depend  on  an  infiltration  of  fatty  matter  and  oil  globules,  with 
some  degree  of  true  fatty  degeneration  of  the  hepatic  cells.  This  was  first 
demonstrated  by  Dr.  Alonzo  Clark,  of  New  York,  in  1853,  and  has  been 
confirmed  by  many  other  observers  since.  Dr.  Schmidt,  of  New  Orleans, 
from  his  numerous  examinations  during  the  epidemics  of  1867  and  1878, 
not  only  recognized  the  marked  accumulation  of  the  fatty  matter,  but  also 
pointed  out  the  staining  of  the  hepatic  cells  with  hfemoglobin  from  im- 
paired blood  corpuscles. 

The  spleen  presents  no  marked  alterations  from  the  natural  condition. 

The  mucous  membrane  of  the  stomach  is  intensely  congested,  giving 
it  a  tumefied  and  reddened  appearance,  and  in  some  places  quite  dark  color. 

The  accumulation  of  blood  is  chiefly  in  the  small  veins  and  capillaries. 
In  some  cases  spots  of  blood  extravasation  or  ecchymoses  exist,  and  the 
stomach  generally  contains  more  or  less  of  a  dark  brown  or  black  liquid, 
which  is  identical  with  the  black  matter  vomited  before  death.  This  dark 
liquid  is  made  up  of  serum,  altered  blood  corpuscles,  epithelium,  and  the 
debris  of  ingesta.  The  duodenum  and  upper  part  of  the  small  intestine 
present  more  or  less  of  the  same  changes  in  the  mucous  membrane  and  its 
contents,  as  in  the  stomach.  The  glands  of  the  ilium  and  mesentery 
show  no  marked  morbid  changes. 

The  kidneys  are  found  more  or  less  congested  in  nearly  all  the  cases  ex- 
amined. The  epithelium  of  the  tubules  has  undergone  some  granular  de- 
generation; the  cortex  is  often  swollen,  yellowish-white,  with  congested 
and  hemorrhagic  spots;  and  small  points  of  suppuration  are  sometimes, 
though  rarely  seen.  The  urine  contains  but  little  urea  and  uric  acid,  their 
places  being  supplied  by  leucin  and  tyrosin,  and  very  generally  a  consid- 
erable amount  of  albumen. 

It  also  contains  both  blood  and  bile  pigments,  giving  it  a  deep  reddish 
yellow  color.  Dr.  Schmidt  has  also  called  attention  to  some  changes  in 
the  supra-renal  capsules,  and  in  the  semilunar  and  other  ganglia  of  the 
sympathetic  nerves,  none  of  which,  however,  appear  to  be  peculiar  to  yel- 
low fever  patients. 

*See  Practice  of  Medicine  by  Roberts  Bartholow,  M.  D.,  page  722. 


148  YELLOW    FEVER. 

The  blood  in  yellow  fever  undergoes  no  characteristic  changes,  unless, 
it  be  a  rapid  crenation  of  the  red  corpuscles,  with  diffusion  of  the  hae- 
moglobin in  the  serum  and  other  parts  of  the  body  *  Dr.  J.  G.  Richajd- 
son,  of  Philadelphia,  claimed  to  have  discovered  a  peculiar  £>«ci!ermm  in  the 
biood;  but  his  observations  have  not  been  confirmed  by  other  competent 
observers. 

Special  Pathology. — Both  the  symptoms  during  life  and  the  post  mor- 
tem appearances,  indicate  that  in  yellow  fever  the  general  properties  of 
the  tissues,  and  consequently,  the  molecular  changes  concerned  in  nutri- 
tion, disintegration  and  secretion,  are  profoundly  altered,  in  such  direc- 
tions as  to  increase  the  susceptibility  and  diminish  the  vital  affinity,  in 
consequence  of  which  the  molecular  changes  are  universally  retarded  or 
perverted  from  their  natural  direction. 

The  direct  action  of  the  cause  or  causes  in  increasing  the  susceptibility 
is  shown  in  the  intensity  of  the  febrile  excitement,  while  the  impairment 
of  the  vital  affinity  is  shown  by  the  impairment  of  the  red  blood  corpus- 
cles, the  molecular  degenerations,  the  arrest  of  secretions,  and  especially 
by  the  general  tendency  to  hemorrhages  of  a  passive  character.  Besides 
these  general  morbid  conditions,  there  is  something  in  the  nature  of  the 
efficient  cause,  that  gives  it  a  special  tendency  to  establish  a  grade  of  in- 
flammatory, or  at  least,  irritative  action  in  the  liver,  kidneys  and  mucous 
membrane  of  the  stomach  and  duodenum.  This  is  shown  as  clearly  by  the 
almost  uniform  presence  of  epigastric  tenderness,  scanty  and  albuminous 
urine,  and  morbid  bile  during  life,  as  by  the  changes  seen  in  these  organs 
after  death.  Yet  the  morbid  actions  set  up  in  these  several  important  or- 
gans, are  not  the  cause  of  the  general  fever,  but  only  an  accompaniment, 
developing  during  its  progress  and  often  adding  much  to  its  fatality. 

I  regard  them  as  bearing  the  same  relation  to  yellow  fever  as  the  mor- 
bid condition  of  the  glands  in  the  ilium  and  mesentery  does  to  typhoid  fever. 

Treatment. — The  rational  indications  for  treatment  in  this  fever  are: 
first,  to  suspend  the  further  action  of  the  exciting  cause  ;  second,  to  lessen 
the  intensity  of  the  general  excitability,  ^nd  maintain  the  natural  secretory 
actions;  third,  to  counteract  the  development  of  local  complications  in  the 
stomach,  liver  and  kidneys;  and  fourth,  to  sustain  the  patient  with  proper 
nourishment,  adjusted  to  the  different  stages  of  the  disease.  In  fulfilling 
the  first  of  these  indications,  the  same  attention  to  the  supply  of  pure  air, 
the  rigid  enforcement  of  cleanliness,  and  the  prompt  removal  of  all  evacua- 
tions, is  necessary,  as  I  explained  fully  when  speaking  to  you  of  the  first 
indication  in  the  treatment  of  typhoid  fever.  As  high  atmospheric  tem- 
perature is,  at  least,  one  of  the  important  elements  in  the  causation  of  the 
disease,  keeping  the  temperature  of  the  sick-room  reduced  as  near  the 
standard  of  healthy  comfort  as  possible,  is  very  desirable,  and  the  benefi- 
cial effects  of  this,  may  be  increased  by  frequent  sponge-baths,  and  cold 
applications  to  the  head,  and  as  complete  rest  as  possible  both  for  body 
and  mind.  If,  in  addition  to  high  temperature,  we  have,  as  a  specific 
cause,  some  modification  of  malarious  infection  pervading  the  atmosphere, 
whether  it  be  in  the  form  of  germs  or  not,  the  proper  use  of  disinfectants 
may  be  of  some  value.  On  the  proper  fulfillment  of  the  several  indications 
I  have  named,  will  depend,  in  a  great  degree,  the  success  of  the  treatment. 

In  proportion  as  the  intensity  of  the  morbid  excitement  can  be 
moderated,  and  the  natural  molecular  and  secretory  actions  maintained 
during  the  first  three  days,  in  the  same  degree  will  the  subsequent  pro- 
gress of  the  disease,  be  rendered  safe. 

*See  paper  in  the  New  York  Medical  Journal  for  February,  1S79,  by  H.  D.  Schmidt,  M.  D.,  of 
New  Orleans. 


TREATMENT.  149 

Concerning  the  best  means  for  accompHshing-  this  purpose,  there  is  now 
and  ever  has  been,  great  diversity  of  opinion  among  those  who  have  had 
the  best  opportunities  for  practical  observation  and  experience.  During 
the  earlier  epidemics  in  the  days  of  Drs.  Rush,  Physic,  Hosack  and  Bard, 
covering  the  half  century  preceding  18:i5,  the  purely  antiphlogistic  meth- 
ods of  treating  disease,  were  dominant,  and  the  object  now  under  consid- 
eration was  sought  to  be  accomplished  by  free  venesection  and  evacuants. 
A  laro-e  ])roportion  of  the  more  severe  cases  were  bled  freely,  when  seen 
during  the  first  twenty-four  hours  from  the  commencement  of  the  attack, 
and,  as  was  claimed  by  Dr,  Rush  and  many  others,  with  decided  benefit. 
It  was  applicable,  however,  to  the  first  and  second  days  only;  if  practised 
later,  it  only  served  to  hasten  the  stage  of  dangerous  prostration.  It 
was  claimed  by  the  advocates  of  venesection,  that  free  bleeding  at  the 
commencement  of  an  attack,  lessened  the  danger  of  copious  hemorrhages 
from  the  stomach  and  other  parts  later  in  the  progress  of  the  case;  and 
this  was  doubtless  to  some  extent  true.  Yet  Dr.  Fenner  tells  us  that  he 
saw  a  man  die  with  copious  black- vomit  after  having  lost  near  4  litres  or 
100  ounces  of  blood  by  venesection,  and  cups  during  the  first  stage.  As 
the  strictly  antiphlogistic  methods  of  treatment  lost  their  popularity,  the 
abstraction  of  blood  in  the  treatment  of  yellow  fever  came  to  be  limited 
to  leeching  and  cupping,  and  the  more  active  evacuants  gave  place  to 
arterial  sedatives,  alteratives  and  Peruvian  bark  or  quinine.  So  early  as 
the  year  1800,  two  eminent  Spanish  physicians  gave  large  doses  of  Peru- 
vian bark,  amounting  in  all  to  between  180  and  1^50  grams  (3vi  and  3viii) 
during  the  first  forty-eight  hours  after  the  initial  chill,  by  which  they 
claimed  extraordinary  success  in  arresting  the  progress,  and  curing  severe 
casis  of  this  fever.  They  gave  from  8  to  12  grams  (3ii  to  3iii)  of  the 
bark  every  two  hours,  commencing  immediately  after  the  initial  chill.* 

During  the  prevalence  of  the  fever  in  New  Orleans  in  18-17,  and  from 
that  time  to  1853,  Dr.  E.  D.  Fenner  and  others  gave  from  0.66  to  2.00 
grams  (gr.  x.  to  gr.  xxx.)  of  quinine  at  once,  and  repeated  the  dose  from 
one  to  three  times  in  the  twenty-four  hours,  during  the  first  two  or  three 
days  of  the  fever,  with  the  effect  of  rapidly  reducing  the  temperature  and 
general  excitement,  causing  free  perspiration,  and  arresting  the  further 
progress  of  the  disease.  The  epidemic  of  1847,  however,  was  mild  in  its 
character,  and  so  were  all  the  seasons  of  the  recurrence  of  the  fever  from 
that  date  until  the  very  severe  prevalence  of  the  disease  in  1853.  Durino- 
the  epidemic  of  the  last  named  year.  Dr.  Fenner  himself  tells  us  that  he 
could  not  obtain  the  same  beneficial  effects  from  the  large  doses  of  qui- 
nine, and  was  obliged  to  substitute  other  and  milder  means  in  the  man- 
agement of  the  disease. f  I  should  remark  that  Dr.  Fenner  and  others,  in 
giving  the  full  doses  of  quinine,  generally  gave  some  calomel  with  them. 
Since  the  promulgation  of  the  more  recent  doctrines  concerning  the  treat- 
ment of  fevers,  mainly  by  antipyretics,  we  have  had  the  severe  epidemics 
of  yellow  fever  of  1867  and  1878-79.  In  the  latter,  more  especially  in 
New  Orleans,  the  antipyretic  treatment  by  cold  baths,  packs,  the  wet  sheet, 
and  cold  water  spray,  was  tried  in  all  forms  and  with  all  degrees  of  per- 
sistence, but  with  no  specific  results  other  than  the  temporary  reduction  of 
the  temperature.  And  one  physician  who  had  invented  a  most  ingenious 
bed  and  apparatus  for  carrying  out  antipyretic  treatment,  heroically  died 
from  the  disease  while  endeavoring  to  demonstrate  the  value  of  his  appa- 
ratus, and  the   particular  treatment  for   which    it  was  designed.     As  the 

*See  Philadelphia  Medical  and  Physical  Journal  for  1808.  Also  Transactions  of  the  Amer.  Med. 
Association.  Vol.  vii,  p.  54f). 

fi^ee  Report  on  the  epidemics  of  Louisiana,  etc.,  by  E.  D.  Fenner,  M.  D.,  in  Trans.  Amer.  Med. 
Association,  Vol.  vii.  p.  421. 


0.5  grams 

gv. 

15.0  c.  c. 

3iv 

15.0    "    " 

3iv 

6.0    "    " 

3iss 

60.0   "    " 

?ii 

150  YELLOW   FEVER. 

the  tendency  to  develop  local  hyperasmia  and  irritation  in  the  stomach, 
liver  and  kidneys,  causes  in  many  cases  a  persistent  tendency  to  reject  all 
remedies  and  nourishment  by  vomitincr,  we  must  practically  unite  the  meas- 
ures calculated  to  repress  or  lessen  these  important  local  complications, 
which  I  have  designated  as  the  third  object  to  be  accomplished,  with  those 
for  fulfilling  the  second.  In  doing  this,  if  called  to  a  patient  with  severe 
yellow  fever  soon  after  the  initial  chill,  we  find  the  epigastric  distress, 
tenderness,  and  tendency  to  vomit,  prominent  symptoms;  from  six  to 
twelve  leeches  may  be  applied  to  the  epigastrium,  or  in  their  absence, 
free  cupping  over  the  dorsal  and  lumbar  portions  of  the  spine,  with  mus- 
tard sinapisms  to  the  epigastric  region;  hot  mustard  bath  for  the  feet, 
with  cold  cloths  to  the  head;  and  if  the  skin  be  very  hot  and  dry,  cold 
sponging  over  the  face,  neck,  and  trunk  of  the  body,  while  internally  may 
be  administered,  for  the  triple  purpose  of  helping  to  allay  gastric  irrita- 
tion, lessening  general  febrile  excitement,  and  proinoting  the  more  im- 
portant secretory  actions,  the  two  following  formulae: 

]^   Acidi  Carbolici  0.5  grams  gr.     viii 

Glycerin  36 
TincturEe  Gelsemii 
Tincturge  Veratri  Viridis 
Tincturge  Opii  Camphoratge  60.0 
AquEe  60.0    "    "  |ii 

Mix,  and  give  four  cubic  centimetres  (fl  3i):  or  a  teaspoonful  every  two, 
three   or  four  hours,  according  to  the   urgency  of  the   symptoms.     Also, 

Ip   Hydrargyri  Chloridi  Mitis         0.8  grams  gr.    xii 

Sodii  Bicarbonatis  2.0       "  "     xxx 

Mix,  divide  into  six  powders;  one  of  which  may  be  given,  mixed  with 
a  very  little  moistened  sugar,  half  way  between  the  doses  of  the  liqu  d 
formula  just  given.  If  the  case  is  located  in  an  actively  malarious  dis- 
trict, as  shown  by  the  coincident  prevalence  of  cases  of  ordinary  inter- 
mittent and  remittent  fevers,  I  would  give  as  early  as  possible  in  addi- 
tion to  the  fo-egoing,  one  or  two  full  sedative  or  antipyretic  doses  of  qui- 
nine, administering  it  either  hypodermically,  or  by  rectal  enema. 

If  the  bowels  do  not  move  until  two  hours  after  the  last  of  the  six  pow- 
ders are  taken,  a  laxative  should  be  given  sufficient  to  procure  one  or  two 
free  evacuations.  As  soon  as  this  has  been  accomplished,  the  action  of 
the  skin  and  kidneys  may  be  further  promoted  by  giving  an  equal  mixture 
of  liquor  ammonii  acetatis  and  nitrous  ether,  in  doses  of  four  cubic  centi- 
metres, or  one  teaspoonful,  between  the  doses  of  the  carbolic  acid  formula. 
The  efficient  carrying  out  of  the  measures  I  have  detailed,  will  necessarily 
occupy  the  first  two  days,  at  the  end  of  which  time,  if  any  beneficial  re- 
sults are  being  produced,  all  the  more  important  symptoms  will  have  been 
mitigated.  The  temperature  will  have  been  lowered,  the  restlessness  and 
pains  abated,  the  urine  more  free  with  little  or  no  albumen,  the  skin 
moist,  and  the  patient  more  restful. 

If  such  has  been  the  result,  the  veratrum  viride  should  be  excluded 
from  the  carbolic  acid  formula,  lest  its  further  use  should  increase  the 
sedative  action  so  far  as  to  renew  the  gastric  irritability  and  vomiting. 
In  other  respects  the  treatment  may  be  continued  until  either  conva- 
lescence is  established,  or  the  yellow  color  and  other  symptoms  of  the 
stage  of  apyrexia  begin  to  appear.  If  this  period  of  calm  and  rapid  sub- 
sidence of  the  febrile  symptoms  commences,  the  leading  object  is  to  pre- 


TREATMENT.  151 

vent  the  congested  gastric  veins  as  well  as  the  smaller  blood-vessels 
generally,  from  yielding  so  far  as  to  allow  the  escape  of  blood  in  the  form 
of  black  vomit  or  other  hemorrhagic  appearances.  The  patient  must  be 
kept  entirely  at  rest,  and  only  the  most  bland  and  unirritating  materials 
allowed  to  enter  the  stomach  for  nourishment.  The  medicines  adminis- 
tered should  be  such  as  are  calculated  to  sustain  the  tone  and  integrity 
of  the  vascular  system,  and  lessen  the  tendency  to  further  deteriora- 
tion of  the  blood  itself.  Moderate  but  frequently  repeated  doses  of 
the  tincture  of  chloride  of  iron  given  well  diluted;  the  oil  of  turpentine 
emulsion  carefully  prepared  as  1  directed  when  speaking  of  the  treatment 
of  typhoid  fever;  and  small  doses  of  quinine  or  strychnine  with  a  mineral 
acid,  would  appear  to  constitute  the  best  means  for  accomplishing  the 
object  just  stated.  But  whichever  of  these  or  other  remedies  are  chosen, 
the  mode  of  administration  must  be  such  as  is  least  likely  to  provoke 
vomiting,  or  any  degree  of  irritation  in  the  stomach.  The  required 
amount  of  either  quinine  or  strychnine  could  be  readily  given  by  hypo- 
dermic injection,  and  much  of  the  nourishment  needed  might  be  given  in 
the  form  of  enemas. 

If  this  critical  period  is  passed  without  being  followed  by  copious  hem- 
orrhages, as  indicated  by  vomiting  of  dark  "coffee  ground"  material  and 
rapid  prostration,  the  subsequent  management  may  be  similar  to  that  of 
a  moderate  grade  of  typhoid  fever,  only  being  more  careful  to  insist  on  the 
most  bland  and  simple  nourishment,  with  as  perfect  rest  of  body  and 
mind  as  possible,  until  convalescence  is  fully  established.  Throughout 
all  the  active  stage  of  the  disease,  the  patient's  thirst  should  be  alleviated 
chiefly  by  frequent  bits  of  ice,  with  here  and  there  a  spoonful  of  cold  water, 
or  of  orange-leaf  tea  ;  and  the  nourishment  should  be  chiefly  milk  and  lime- 
water,  given  in  doses  of  only  one  or  two  tablespoonfuls,  but  frequently  re- 
peated. If  any  meat  broths  are  allowed,  they  should  be  properly  seasoned 
with  salt,  and  given  in  the  same  limited  doses  as  the  milk  and  lime-water. 

In  the  more  advanced  stages,  if  a  gentle  stimulant  is  required,  small 
doses  of  well  prepared  tea  or  coffee  will  supply  the  want  better  than  any 
other  articles.  Solid  food  of  any  kind  appears  to  be  unsafe,  until  after  full 
convalescence,  and  even  then  must  be  given  with  caution.  During  the 
active  stage  of  some  cases,  excited  delirium  and  persistent  wakefulness 
exist,  and  may  be  relieved  by  using  judiciously  morphine,  combined  with 
atropia  hypodermically.  But  morphine  and  other  preparations  of  opium 
must  be  used  with  great  caution,  lest  they  help  to  check  the  action  of  the 
kidneys.  The  recovery  after  full  convalescence  is  generally  rapid,  and 
not  attended  by  any  troublesome  sequelfe. 

Prophylaxis. — In  relation  to  the  best  means  for  preventing  the  develop- 
ment and  spread  of  yellow  fever,  I  would  state  that  the  most  important  of 
all  the  measures  devised  for  these  purposes,  are  such  as  have  for  their  object, 
the  removal  of  one  or  more  of  the  conditions  known  to  be  necessary  for 
the  production  and  spread  of  the  disease. 

Of  these  conditions,  the  one  most  readily  under  human  control  is  the 
contamination  of  the  atmosphere  from  local  sources  of  vegetable  and  ani- 
mal decomposition.  It  is  well  known  that  the  chief  sources  of  such  de- 
composition are  imperfect  and  uncleanly  sewers  or  cess-pools,  foul  and 
stagnant  water,  and  low,  moist  ground,  rich  in  vegetable  matter. 

To  remove  these  sources  of  atmospheric  impurity  early  in  each  year,  and 
keep  them  thoroughly  removed  until  the  close  of  the  warm  season,  and 
thereby  prevent  the  supply  of  local  material  on  which  the  essential  cause 
of  yellow  fever  depends  for  its  propagation,  is  the  only  reliable  safeguard 
against  the  development  of  this  disease  in  any  place  within  the  geograph- 


152  YELLOW    FEVEE. 

ical  range  of  its  prevalence.  If  this  is  neglected  until  the  atmosphere  of 
aey  locality  becomes  filled  with  miasms  as  a  pabulum  for  the  fever  poi- 
son, and  the  summer  temperature  prove  continuously  high,  the  disease 
will  prevail  and  spread  in  defiance  of  all  the  inland  quarantines  that  can 
be  devised.  But  if  a  sufficient  degree  of  cleanliness  ia  regard  to  streets, 
alleys,  gutters,  sewers  and  stagnant  waters,  to  prevent  the  atmosphere 
from  becoming  tilled  with  the  products  of  decomposition  and  impurities, 
is  secured  earlv  in  the  season,  and  faithfully  maintained  until  the 
frosts  of  autumn,  there  will  be  no  danger  of  the  prevalence  of  yellow 
fever,  either  by  importation  or  otherwise.  The  point  of  vital  importance 
is  ^o  prevent  the  development  of  the  noxious  material  that  constitutes  the 
pabulum  on  which  the  essential  cause  of  the  disease  feeds  or  out  of 
which  it  originates. 

In  addition  to  this,  the  municipal  and  health  authorities  of  every  impor- 
tant city  or  town  on  the  coast  of  the  Gulf  from  the  Mexican  boundary  to 
Charleston  on  the  Atlantic;  on  the  Mississippi  from  Xew  Orleans  to  St. 
Louis;  on  the  Red  River  below  Shreveport;  on  the  Ohio  below  Pittsburgh, 
and  on  the  principal  lines  of  railroad  in  immediate  connection  with  such 
cities  and  towns,  should  deliberately  select  the  nearest  unoccupied,  dry, 
elevated  place;  cofitaining  pure  air  and  good  water,  and  as  readily  accessi- 
ble as  possible,  to  which  all  families  willing  to  go  could  be  speedily  re- 
moved from  an  infected  street  or  section  of  a  town  or  city,  and  accomo- 
dated in  tents  or  other  temporary  structures  until  they  could  safely  return 
to  their  homes. 

^Tierever  this  principle  of  speedy  removal  was  acted  upon  by  our 
army,  it  proved  entirely  successful  in  stopping  the  spread  of  the  disease 
among  the  soldiers,  and  its  imperfect  and  limited  adoption  at  Memphis  in 
1879,  was  of  great  value. 

If  the  proper  places  were  carefully  selected  beforehand,  and  a  supply 
of  tents  or  other  material  kept  under  the  control  of  the  proper  authori- 
ties, so  that  on  a  first  appearance  of  the  disease  in  a  neighborhood  those 
exposed  could  be  removed  without  delay,  and  ordinar}'  supplies  of  pro- 
visions for  the  poor  dealt  out  only  at  the  camp  or  camps,  there  would  be 
but  little  difficuly  in  limiting  the  local  spread  and  fatalitj'-  of  any  epidemic. 
While  such  camps  would  chiefly  operate  for  the  benefit  of  the  poorer 
classes  (and  wherever  it  should  be  possible  to  find  the  proper  grounds  on 
railroad  lines  within  a  radius  of  from  ten  to  twenty  miles  of  the  city,  many 
of  the  workingmen  could  go  in  every  morning  and  continue  many  kinds 
of  work),  all  who  were  able  to  provide  for  themselves  and  their  families 
away  from  home  and  were  not  thoroughly  acclimated,  should  be  encour- 
aged to  go  early  and  freely,  the  only  condition  imposed  being  that  they 
should  not  stop  until  they  had  passed  entirely  north  of  the  climatic  zone 
of  the  vellow  fever.  The  only  internal  or  inland  quarantine  regulations 
required  are  the  selection  of  suitable  and  well  prepared  healthy  stations 
a  few  miles  from  each  of  the  more  important  cities  on  the  great  lines  of 
travel,  whether  by  river  or  railroad,  where  boats  and  trains  shall  halt  long 
enough  for  inspection,  and  if  any  are  found  sick  of  the  fever  they  shall  be 
transferred  directly  to  the  station  and  cared  for,  the  boat  or  car  being 
thoroughly  ventilated,  and  allowed  to  proceed  with  all  the  well  persons,  to 
anv  proper  northern  destination.  The  groat  northwestern  region  boimded 
on  the  east  by  Waukesha,  Mackinac  and  Marquette,  extending  indefinitely 
westward  over  the  northern  peninsula  of  Michigan,  northern  Wisconsin 
and  Minnesota;  and  the  whole  Alleghany  range  in  the  northeast,  from 
Virginia  to  the  Adirondacks,  are  sufficient  to  accommodate  every  unac- 
climated  person  in   the  lower  Mississipi  Valley  and   in  our  southern  sea- 


PKOPHYLAXIS.  153 

port  cities;    and   they  could   no  more    spread  the  yellow  fever  in  those  re- 
gions than  interuiittent  fever  could  be  spread  on  Mount  Washington. 

The  same  principles  apply  to  commerce  and  business.  There  is  no  pos- 
itive evidence  whatever,  that  the  disease  is  ever  transmitted  by  simple 
contact  with  the  sick,  nor  by  either  articles  of  clothing  or  merchandise 
that  have  been  freely  exposed  to  the  air  outside  of  an  infected  locality. 
It  is  only  when  the  infected  air  of  the  locality  where  the  disease  is  pre- 
vailing, is  shut  up  in  the  hold  or  apartments  of  a  ship,  boat  or  car,  or 
boxed  up  with  goods  in  boxes  or  trunks,  that  it  can  be  carried  to  distant 
places  and  retain  its  active  properties.  And  even  when  so  carried,  it 
must  be  let  out  in  an  atmosphere  in  the  new  locality  at  the  proper  high 
temperature  and  containing  the  necessary  local  miasms  or  impurities,  or  it 
becomes  utterly  harndess.  All  that  is  necessary,  therefore,  is  to  have  all 
ships,  boats,  and  cars,  carrying  freight,  stopped  at  suitable  places  outside 
of  populous  towns,  inspected,  all  parts  thoroughly  ventilated  and  cleansed; 
and  where  goods  had  been  packed  in  bales,  boxes,  or  trunks,  the  same 
opened  and  aired  before  they  are  received  by  the  parties  to  whom  they 
are  consigned. 

The  proposition  that,  on  the  appearance  of  an  epidemic  in  any  given 
place,  all  persons  not  being  fully  acclimated  or  protected  by  previous  at- 
tacks of  the  disease,  should  be  encouraged  to  immediately  remove  to 
healthy  districts;  such  as  were  pecuniarily  able,  to  go  beyond  the  yellow- 
fever  zone;  and  those  who  were  not  able,  to  go  into  well-selected  camps  in 
the  vicinity,  was  subjected  to  a  pretty  fair  test  in  Memphis,  in  the  summer 
of  1879. 

On  the  outbreak  of  the  epidemic  the  utmost  facilities  were  afforded  for 
all  who  Avished  to  go  to  the  North,  and  three  camps  were  established  in 
judiciously  selected  localities,  within  twenty  or  thirty  miles  of  the  city, 
in  which  many  hundreds  of  the  poorer  classes  took  refuge.  The  result 
was  most  gratifying.  Those  in  the  camps  remained  perfectly  free  from 
the  disease;  only  a  very  few  of  those  who  fled  to  the  North  were  taken 
sick  after  their  departure,  and  yet  the  population  left  in  the  city  was  re- 
duced to  ten  or  twelve  thousand,  and  the  aggregate  number  of  deaths 
from  the  fever  during  the  whole  season  was  only  about  550,  instead  of 
2,500,  as  during  the  epidemic  of  1878. 

The  suggestion  to  carefully  select  stations  in  proper  places  along  the 
lines  of  travel  and  commerce,  both  by  rivers  and  railroads,  at  which  boats 
or  cars  from  infected  places,  should  be  stopped  for  inspection,  and,  when 
necessary,  thoroughly  ventilated  and  cleansed,  with  the  removal  of  any 
found  sick  to  a  hospital  for  proper  care,  while  the  well  were  allowed  to 
proceed  on  their  way,  thereby  substituting  systematic  inspection,  with  en- 
forcement of  ventilation,  cleanliness,  and  care  of  the  sick,  in  the  place  of 
quarantines,  has  been  tested  only  to  a  limited  extent.  A  stntion  of  this 
kind  was  established  during  the  summer  of  1879,  at  Island  No.  1, 
below  Cairo,  and  in  a  less  perfect  manner  on  the  Ohio,  below  Louisville 
and  Cincinnati.  The  quarantine  station,  fourteen  miles  below  St.  Louis, 
was  also  managed  p:irtly  on  the  same  plan.  The  results  at  each  of  these 
places  were  most  beneficial,  and  fully  demonstrated  that  if  the  plan  of  es- 
tablishing «?s;:)ec^/on  s^<r/;!io;«s,  with  temporary  hospital  accommodations  at- 
tached, should  be  carried  out  in  the  systematic  manner  I  have  suggested, 
it  would  afford  a  far  better  protection  against  the  spread  of  the  disease,  from 
one  place  to  another,  than  the  ordinary  methods  of  quarantine. 


154  EKYSIPELAS. 


LECTURE    XVIII. 

Erysipelas— Its  History,  Causes.  Symptoms,  Diagnosis,  Prognosis,  Pathological  Anatomy,  Special 
Pathology,  Treatment  and  Prophylaxis. 

GENTLEMEN  : — Erysipelas  presents  itself  to  us  in  two  aspects.  In 
one,  it  has  the  characteristics  of  a  general  acute  disease,  accompanied 
during'  its  progress  by  a  peculiar  local  inflammation.  In  the  other,  it  is 
chiefly  characterized  by  the  local  inflammation  occurring  in  connection 
with  wounds,  injuries,  etc.,  not  necessarily  preceded  or  accompanied  by 
geiieral  fever.  The  first  is  called  idiopathic  erysijyelas,  and  the  second, 
traumatic.  The  E"'rench  designate  the  one  as  medical  and  the  other  as 
surgical  erysipelas.  It  is  the  first  only  that  will  occupy  our  attention  at 
this  time,  as  the  second  is  always  fully  considered  in  the  department  of 
surgery.  Sporadic  cases  of  idiopathic  erj'sipelas  are  met  with  in  general 
practice  every  year,  and  at  times  it  assumes  an  epidemic  form  and  extends 
its  prevalence  over  laige  districts  of  country.  One  of  the  most  noted  of 
these  epidemics  prevailed  in  our  country  from  1841  to  1846.  During  those 
years  it  extended  over  large  portions  of  Vermont,  Massachusetts,  New 
York,  some  parts  of  Pennsylvania,  Ohio,  Michigan,  Illinois,  and  Indiana. 
It  commenced  in  the  Eas  ern  states  in  1841,  extended  westward  through 
New  York  with  great  severity  during  1843,  '44,  and  invaded  many  places 
in  the  states  intervening  between  New  York  and  the  Mississippi,  between 
1844-46. 

Hirsch  alludes  to  this  epidemic  as  extending  over  a  great  part  of  North 
America,  and  both  he  and  Zuelzer,  in  his  chapter  on  erysipelas  in  Ziemssen's 
Cyclopaedia,  intimate  that  it  was  not  true  erysipelas,  but  "an  acute  infect- 
ious disease  closely  related  to  diphtheria."* 

As  it  was  my  fortune  to  see  some  part  of  that  epidemic,  in  the  years 
1843-44,  as  it  prevailed  in  Binghamton,  New  York,  where  I  was  then 
practicing,  I  must  differ  from  this  opinion  of  these  learned  writers.  The 
cases  that  came  under  my  observation  presented  all  the  symptoms  charac- 
teristic of  erysipelas  in  a  strongly  marked  degree,  while  nothing  peculiar 
to  diphtheria  was  observed  at  any  stage  of  their  progress,  neither  did  I  see 
a  single  sequel  usually  seen  after  diphtheritic  attacks. 

The  disease  as  it  prevailed  in  Vermont,  New  Hampshire,  and  other  parts 
of  the  New  England  States,  was  fully  and  accurately  described  by  Drs.  J. 
A.  Allen,  Charles  Hall,  and  George  J.  Dexter  ;  in  the  Western  part  of 
New  York  by  Dr.  Sanford  B.  Hunt  ;  in  Indiana  by  Dr.  George  Sutton, 
and  in  Illinois  by  Dr.  D.  Meeker,  and  I  have  failed  to  find  a  single  allusion 
by  any  of  these  writers  to  a  diphtheritic  exudation,  either  upon  the  fauces 
or  elsewhere,  or  to  any  symptoms  specially  analagous  to  those  of  diphtheria. f 

Epidemics  of  erysipelas  have  prevailed  and  been  accurately  described 
under  various  names  ever  since  the  days  of  Hippocrates. 

Epidemics  of  the  disease  occupying  limited  districts  have  occurred  in 
almost  all  parts  of  this  country,  at  different  periods  from  the  first  settle- 
ments to  the  present  time. 

An  epidemic  of  considerable  severity  prevailed  in  this  city  in  the  sum- 

*  See  Ziemssen's  Cyclopsedia,  Vol.  II.  p.  424. 

tFor  a  more  full  acoouiit  of  this  epIiLmic,  see  Copeland's  Dictionary  of  Medicine,  edited  by 
Charles  A.  Lee,  M.  D.,  Vol.  I,  pp.  954-5-6-7. 


CAUSES.  155 

mer  and  autumn  of  1SG3,  and  also  in  many  other  places  in  this  and  the 
adjoining  States   durincr  the   years  18f>3-G4.* 

Durinof  the  time  the  disease  was  prevailing  in  this  city,  in  the  latter  part 
of  the  summer  and  autumn  of  1803,  the  water  in  the  Chicago  River  had 
become  so  impregnated  with  the  Llood  and  otfal  from  slaughtering-houses 
on  its  banks,  that  the  fish  all  died,  and  the  stench  from  it  rendered  the  air 
offensive  to  the  nostrils  over  large  portions  of  the  city.  Many  of  the  phy- 
sicians attributed  the  erysipelas,  as  well  as  a  coincident  unusual  prevalence 
of  typhoid  fever,  to  this  impregnation  of  the  a:r  with  putrid  animal  matter. f 
As  it  was  prevailing  at  the  same  time,  however,  in  remote  interior  districts, 
it  is  probable  that  other  causes  at  least  contributed  to  its  production  here. 
A  fact  of  great  practical  impoi'tance  is,  that  in  nearly  all  the  epidemics  of 
ervsipelns,  women  undergoing  confinement  in  child-bed  are  extremely 
liable  to  be  attacked  with  puerperal  fever  or,  in  other  words,  erysipelatous 
inflammation  of  the  peritongeum.  This  was  notably  true  in  the  great 
epidemic  from  1842-46.  According  to  Drs.  Hall  and  Dexter,  in  the 
county  of  Caledonia,  Vermont,  thirty  cases  of  puerperal  peritonitis  occurred 
within  a  few  weeks,  of  whom  only  one  recovered.  In  the  town  of  Bath, 
N.  H.,  Avith  not  more  than  fifteen  hundred  inhabitants,  twenty  mothers 
died  with  the  puerperal  disease. |  The  same  connection  between  the 
prevalence  of  erysipelas  and  puerperal  fever  was  n  ticed  in  all  parts  of  the 
country;  and  in  all  places  the  puerperal  disease  was  exceedingly  fatal.  It 
is  well  for  each  of  you  to  remember  this  connection  between  erysipelas 
and  puerperal  fever,  and  be  exceedingly  careful  about  attending  cases  of 
obstetrics  while  at  the  same  time  attending  cases  of  erysipelas,  as  there  is 
much  evidence  going  to  show  that  a  physician,  under  such  circumstances, 
may  convey  the  specific  infection  to  the  lying-in  woman. 

Causes. — In  a  general  sense,  I  may  say  that  all  the  circumstances 
which  have  been  mentioned  as  favoring  the  development  and  spread  of 
typhoid  and  typhus  fevers,  also  act  as  predisposing  influences  in  favoring 
the  occurrence  of  erysipelas;  yet  it  is  highly  probable  that  the  immediate 
or  specific  cause  of  the  latter  is  a  subtle  organic  poison  or  idio-miasm, 
derived  from  the  retrograde  metamorphoses  of  animal  matter,  which  may 
take  place  either  within  or  without  the  living  body.  In  many  of  the 
sporadic  cases  the  specific  cause  is  evolved  in  the  system  by  derangement 
of  the  processes  of  disintegration  and  elimination.  Whatever  interferes 
with  the  natural  tissue  changes,  by  preventing  the  proper  oxidation  of  the 
tissue  materials  and  their  conversion  into  the  forms  capable  of  ready  excre- 
tion or  elimination,  will  favor  this  result.  Consequently,  you  will  find 
those  who  habitually  use  alcoholic  drinks;  those  living  in  small,  damp,  and 
poorly- ventilated  apartments;  and  those  confined  to  over-crowded  rooms, 
with  inadequate  supply  of  air,  to  be  more  liable  to  erysipelatous  attacks. 
Cases  arising  from  the  absorption  of  poison  generated  on  the  surface  of  ill- 
conditioned  wounds,  ulcers,  etc.,  are  numerous  among  the  traumatic  forms 
of  the  disease.  Very  strong  proof  has  been  given  that  sewer-gas  is  capa- 
ble of  sometimes  causing  attacks  of  the  disease.  For  instance,  beds 
standing  over  or  alongside  of  sewer-pipes  from  which  gases  escaped,  have 
been  found  to  impart  erysipelas  to  their  occupants,  but  which  was  imme- 
diately changed  by  simply  repairing  the  pipes. || 

Dr.  Orth   claims  to   have  induced   erysipelas  in  rabbits  by  inoculating 

*  See  Report  on  Practical  Medicine  and  Epidemic  Diseases,  by  N.  S.  Davis,  M.  D.,  Vol.  Trans.  111. 
State  Medical  Soci  ty,  l.'^^j!.  p.  14. 

t  See  a  short  but  interesting  article  on  this  subject,  by  Dr.  E.  Andrews,  in  the  Chicago  Medical  Ex- 
aminer, Vol.  V,  p.  17.  1S64. 

tSee  Account  of  the  Erysipelatous  Fever,  an  it  appeared  in  the  northern  part  of  Vermont  and 
New  Harapsliire  in  1842— l>i.  in  Amer.  Jour.  Med.  Sciences,  Jan.,  1814. 

jl  See  Ziemsseii's  Cycioptedia  of  Practical  Medicine,  Vol.  II,  p.  440.  ' 


156  ERYSIPELAS. 

them  with  the  serum  from  the  vesicles  on  an  erysipelatous  surface,  and 
also  by  using  the  blood  of  patients  affected  with  the  disease.  While  it  is 
not  d.fficult  to  account  for  cases  of  sporadic  and  traumatic  erysipelas,  by 
supposing  the  ex  stence  of  a  local  animal  poison,  it  is  not  so  easy  to  see 
how  such  a  poison  could  be  generated  and  diffused  so  widely  as  to  cause 
the  prevalence  of  epidemics  over  extensive  districts  of  country.  It  is  a 
well-known  fact,  however,  that  a  variable  quantity  of  organic  albuminoid 
matter  generally  exists  in  the  atmosphere;  and  I  see  no  reason  why,  under 
some  combination  of  atmospheric  conditions,  this  luight  not  be  so  changed 
as  to  constitute  the  special  infection  for  producing  an  epidemic  of 
erysipelas. 

Neither  age,  sex,  nor  season  of  the  year  appear  to  exert  much  influence 
over  the  susceptibility  to  this  disease.  The  greater  number  of  cases  have 
occurred  during  the  active  period  of  adult  life — that  is,  between  ^0  and 
45  years  of  age.  But  cases  are  liable  to  occur  at  any  period  of  life, 
between  the  first  few  days  after  birth  and  old  age. 

Some  have  claimed  that  a  larger  number  of  females  suffer  from  attacks 
of  the  disease  than  of  males.  There  is,  however,  no  uniformity  in  this 
respect;  for  close  examinations  of  the  results  of  several  epidemics  show 
that  in  some  seasons  the  majority  of  those  attacked  were  males,  and  in 
others  females.  "While  the  prevalence  of  the  disease  is  not  limited  to  any 
particular  part  of  the  year,  it  has  occurred  most  frequently  in  the  spring 
and  autumn.  One  attack  of  erj^sipelas  does  not  in  any  degree  lessen  the 
susceptibility  of  the  individual  to  subsequent  attacks.  There  is  no  proof 
that  the  disease  is  communicable  from  one  individual  to  another  by  per- 
sonal contagion  through  the  atmosphere;  but  it  is  readily  communicated 
b}'  actual  contact  or  inoculation. 

Symptoms. — Idiopathic  erysipelas,  whether  occurring  sporadically  or  in 
the  midst  of  an  epidemic,  usualh^  begins  with  a  feeling  of  indisposition 
similar  to  that  which  precedes  the  active  stage  of  most  febrile  affections. 
This  is  seldom  noticeable  more  than  from  one  to  three  days,  when  a  cold 
stage,  varying  from  slight  chilliness  to  a  decided  chili  of  Irom  fifteen  to 
forty-five  minutes'  duration,  marks  the  commencement  of  the  active  phe- 
nomena of  the  disease.  The  brief,  and  generally  slight  chill,  is  immediately 
followed  by  more  or  less  pains  in  the  head,  back,  and  limbs;  some  flushing  of 
the  face;  dryness  and  heat  of  the  skin;  increased  frequency  and  fullness  of 
the  pulse;  some  thirst;  a  white  fur  on  the  tongue;  scantiness  of  urine;  and 
quiet  or  inactive  state  of  the  bowels,  with  loss  of  appetite  and  some  thirst. 

In  the  more  severe  cases  the  headache  is  severe  and  not  unfrequently 
accompanied  by  vomiting  of  matters  mixed  with  bile.  In  cases  of  average 
severity  the  febrile  symptoms  develop  with  such  rapidity  th.at  at  the  end 
of  the  first  twenty-four  hours  the  temperature  ranges  between  39°  and  40° 
C.  (102°  and  104°  F.),  and  the  pulse  from  90  to  110  per  minute.  A  mod- 
erate increase  usually  continues  until  the  end  of  the  third  day,  when  the 
general  febrile  symptoms  reach  the  climax  of  their  intensity,  the  temper- 
ature being  in  many  cases  40.5°  or  41°C.  (105°  or  106°  F.),  the  pulse  120, 
and  the  urine  containing  more  or  less  albumen.  During  the  fourth,  fifth, 
and  sixth  days  the  aggregate  of  general  symptoms  remains  nearly  the 
same,  although  the  temperature  may  fluctuate  to  the  extent  of  two  or  three 
degrees  every  day,  the  maximum  being  in  the  morning  quite  as  often  as 
in  the  evening.  Decided  defervescence  usually  commences  between  the 
fifth  and  seventh  days,  and  progresses  to  the  full  establishment  of  conva- 
lescence, between  the  ninth  and  eleventh  days. 

In  some  instances,  coincident  with  the  initial  chill,  or  immediately  after 
it — but  more  generally  in  the  latter  part  of  the   first  day  of  fever — the 


SYMPTOMS.  157 

patient  complains  of  some  soreness  in  the  fauces,  which  on  inspection  pre- 
sent a  deep  red  appearance,  with  slii^ht  tumefaction  of  the  mucous  mem- 
brane. Sometimes  a  sense  of  soreness,  stiffness,  or  tension  is  felt  in  sonte 
part  of  the  cutaneous  surface,  but  at  first  no  redness.  In  most  cases,  on 
the  morning  of  the  second  or  third  day,  a  deep  red  spot  has  made  its 
appearance  on  the  face  near  the  wing  of  the  nose,  or  at  the  lobe  of  tJie  ear, 
the  nates,  the  vulva,  or  some  part  of  the  extremities,  usually  at  the  place 
that  had  been  previously  feeling  tense  and  sore.  The  red  spot  is  at  first 
small,  but  ace  >mpanied  ijy  tumefaction,  heat,  and  soreness,  and  is  bounded 
by  an  abrupt,  well-defined  margin.  It  commences  far  more  frequently  on 
the  face  than  on  any  part  of  the  body  or  extremities.  With  the  appear- 
ance of  the  inflammation  on  the  surface  the  soreness  and  redness  of  the 
fauces  disappear;  but  the  general  febrile  symptoms  continue  unabated,  or 
increase  in  intensity.  The  local  inflammation  extends  rapidly  in  all  direc- 
tions, and  usually  covers  the  whole  face,  ears,  and  mastoid  spaces  in  from 
two  to  three  days;  and  in  severe  cases  it  continues  its  spread  over  the 
whole  head  and  neck,  to  the  shoulders  and  back.  In  extending  over  the 
face,  the  tumefaction  from  infiltration  into  the  subcutaneous  areolar  tissue 
is  sufficient  to  close  the  eyelids  and  make  the  whole  surface  appear 
intensely  red  and  much  swollen,  while  vesications  or  blisters,  varying  in 
size  from  the  circumference  of  a  pea  to  that  of  a  hickory  nut,  make  their 
appearance,  mostly  upon  the  cheeks,  forehead,  and  ears.  If  the  inflamma- 
tion extends  over  the  broader  surfaces  on  the  trunk  of  the  body,  or  on  the 
lower  extremities,  the  blisters  are  sometimes  much  larger;  and  though 
generally  filled  with  a  transparent  serous  fluid,  yet  in  unusually  severe  cases 
the  fluid  is  more  turbid  and  dark  purple,  from  intermixture  of  blood.  The 
external  erysipelatous  inflammation  generally  ceases  its  further  extension 
in  from  five  to  seven  days,  and  from  that  time  declines,  pari  passu^  with 
the  decline  of  the  general  fever.  As  soon  as  the  inflammation  begins  to 
abate,  the  redness  changes  to  a  darker  hue,  the  swelling  diminishes,  the 
vesicles  shrivel  and  soon  become  dry  and  covered  with  a  thin  scab  or  crust, 
composed  of  the  dried  serum  and  shriveled  cuticle,  and  of  a  dark  brown 
color.  The  tumefaction  also  diminishes  rapidly,  allowing  the  eyelids  again 
to  open;  and  by  the  time  defervescence  is  complete,  the  whole  recently 
red,  burning,  and  swollen  surface  presents  a  shrunken,  dingy,  or  brownish 
aspect,  rough  from  exfoliating  cuticle,  but  free  from  heat  and  pain. 

While  the  description  I  have  now  given  you  applies  with  sufficient  accu- 
racy to  the  great  majority  of  cases  of  erysipelas,  as  they  are  met  with  by 
the  general  practitioner,  there  are  many  and  important  deviations  from  it 
in  individual  cases.  One  of  these  deviations  consists  in  the  presentation 
of  a  milder  grade  of  general  fever,  a  slower  spread  of  the  local  inflamma- 
tion, less  tumefaction,  little  or  no  vesication,  but  persistent  in  duration 
until  large  surfaces  had  been  occupied  or  passed  over,  the  redness  and  heat 
disappearing  from  the  parts  first  attacked,  while  it  is  still  extending  to  new 
parts  on  its  margins.  I  recollect  one  nursing  infant  on  whom  the  inflam- 
mation spread  thus  superficially,  but  persistently,  until  it  had  extended 
over  every  square  inch  of  its  cutaneous  surface,  and  occupied  nearly  two 
weeks  of  time;  ending  finally  in  diarrhoea  and  fatal  exhaustion.  In  a  very 
few  instances  of  this  superficial  variety  I  have  seen  the  inflammation,  after 
having  passed  successively  over  the  face  and  scalp,  return  to  the  part  first 
attacked  and  go  over  the  same  surfaces  a  second  time;  but  all  of  this 
variety  of  cases  coming  under  my  care  have  recovered,  except  the  infant  I 
have  just  mentioned.  During  the  prevalence  of  erysipelas  in  this  city  in 
1(SG3,  a  case  occurred  in  the  practice  of  Dr.  W.  H.  Byford,  in  which  an 
adult  male,  aged  45  years,  had   a  regular  attack  of  fever,  followed  by 


158  ERYSIPELAS. 

erysipelatous  inflammation,  commencing  on  the  nose  and  spreading  rapidly 
until  it  had  occupied  the  Avhole  face  and  scalp,  and  seven  days  of  time. 
Defervescence  then  commenced,  and  by  the  thirteenth  day  convalescence 
appeared  to  be  fully  established.  In  less  than  forty-eight  hours  he  vpas 
again  attacked  by  a  chill,  followed  by  fever  and  a  reappearance  of  the 
erysipelatous  inflammation  on  the  nose,  just  as  at  first.  The  febrile  symp- 
toms continued,  and  the  external  inflammation  spread  over  precisely  the 
same  surface  as  in  the  first  attack,  and  completing  its  course  in  five  days, 
declined  so  rapidly  that  on  the  seventh  day  he  was  again  fully  conva- 
lescent. But  on  the  very  next  day  he  was  again  attacked  in  the  same 
mariner,  by  a  chill  followed  by  fever,  and  a  fresh  eruption  of  the  erysip- 
elatous inflammation  on  the  nose,  which  again,  for  the  third  time,  regularly 
extended  over  the  whole  face  and  head,  presenting  every  characteristic  of 
the  disease,  and  again  completing  its  course  in  seven  days.  The  first 
attack  commenced  on  the  5th  of  .Tune,  and  the  third  ended  on  the  3d  of 
Julv,  soon  after  which  the  patient  was  sent  out  of  the  city  for  a  change  of 
air,  and  he  remained  free  from  the  disease.  He  was  treated  from  the 
beginning  to  the  end  with  efficient  doses  of  the  tincture  of  chloride  of  iron. 
Dr.  Byford,  in  recording  the  case,  remarked  that  in  a  practice  of  twenty- 
five  years  he  had  seen  no  parallel  case  of  relapsing  erysipelas.* 

Another  deviation  from  the  ordinary  typical  course  of  the  disease  con- 
sists in  a  greater  amount  of  subcutaneous  infiltration  and  consequent 
swelling,  making  the  skin  very  tense,  dark  purplish  color,  the  vesicles  filled 
with  dark  bloody  serum,  and  the  accompanying  fever  more  of  a  typhoid 
character,  with  more  or  less  delirium,  subsultus,  and  cold  extremities.  In 
these  cases  there  is  apt  to  be  suppuration  in  those  parts  of  the  areolar 
tissue  most  tensely  engorged,  such  as  the  loose  tissue  under  the  eyelids, 
behind  the  angle  of  the  jaw,  and  in  the  scalp. 

Three  such  cases  came  under  my  care  in  the  Mercy  Hospital  during  the 
epidemic  of  1863.  In  two  of  them  the  destruction  of  the  tissue  under  the 
eyelids  by  suppuration  was  so  extensive  that  when  recovery  had  taken 
place,  the  contraction  of  the  cicatrices  caused  a  moderate  eversion  of  the 
tarsus  of  the  lids,  with  inability  to  completely  close  them. 

A  still  more  imoortant  deviation  from  the  ordinary  course  of  the  disease 
is  presented  by  those  cases  in  which  the  erysipelatous  inflammation,  instead 
of  appearing  on  any  part  of  the  cutaneous  surface,  attacks  the  fauces, 
tongue,  pharynx,  and  sometimes  the  bronchial  tubes  and  membranes  of  the 
brain.  During  the  severe  epidemic  of  184:3-44  there  were  many  cases  in 
which  the  whole  force  of  the  inflammation  fell  upon  the  fauces,  tongue, 
and  pharynx,  causing  those  parts  to  become  dark  red,  and  so  much  swollen 
as  to  render  breathing  and  deglutition  extremely  difficult.  The  lips  and 
swollen  tongue  became  early  covered  with  a  thick,  dry,  and  black  coating, 
so  prominent  that  in  many  places  the  disease  was  popularly  styled  "  the 
black  tongue."  When  the  inflammation  attacked  the  bronchial  tubes  there 
was  severe  burning  pain  in  the  chest,  very  distressing  cough,  with  great 
difficulty  of  breathing,  and  rapid  exhaustion.  If  the  membranes  of  the 
brain  became  involved,  it  gave  rise  to  severe  pain  in  the  head,  early  and 
excited  delirium,  very  frequent  pulse,  followed  in  two  or  three  days  by 
coma,  dilated  pupils,  and  death.  A  very  large  proportion  of  all  those  in 
which  the  local  inflammation  failed  to  develop  on  some  part  of  the  cutane- 
ous surface,  but  attacked  more  internal  structures,  terminated  speedily  in 
death.  A  much  smaller  proportion  of  this  class  of  cases  was  noticed  during 
the  epidemic  of  1863-64  than  in  that  of  1843-44,     Most  writers  state  that 

•  See  Chicago  Medical  Examiner,  Vol.  IV,  pp.  495-6-7,  1863. 


DIAGNOSIS.  159 

the  erysipelatous  inflammition,  after  havinir  been  established  in  some  part 
of  the  cutaneous  surface,  is  liable  to  suddenly  recede  and  attack  the 
stomach,  meninges  of  the  brain,  or  other  internal  structures;  and  it  is 
probalile  that'  such  cases  have  been  occasionally  observed,  though  none 
have  ever  come  under  my  own  observation. 

Diarpiosis. — In  most  cases  erysipelas  is  easily  distinguished  from  all 
other  acute  febrile  affections.  The  appearance  of  an  inflammation  on 
some  portion  of  the  surface  soon  after  the  development  of  general  fever, 
presenting  a  deep  red  color  and  abrupt  margins,  with  burning  pain,  and  a 
disposition  to  spread  by  continuity,  is  so  characteristic  or  unique,  that  the 
most  inexperienced  observer  can  hardly  err  in  his  diagnosis.  And  yet  I 
have  met  with  several  cases  of  acute  eczema  rabrum,  especially  on  the 
face,  that  had  been  mistaken  for  erysipelas  and  treated  accordingly.  But 
if  you  remember  that  acute  eczema  simply  presents  a  red  surface  closely 
studded  with  minute  pointed  vesicles,  accompanied  by  fiery  heat  and  itch- 
ing, the  red  surface  having  no  abrupt  margin  in  any  part  of  its  circum- 
ference, and  the  minute  vesicles  weeping  a  serous  fluid  whenever  they  are 
broken  by  friction  or  scratching,  and  accompanied  by  very  little,  if  any, 
general  febrile  symptoms,  you  will  exhibit  extraordinary  skill  in  blunder- 
ing if  you  confound  it  with  erysipelatous  inflammation. 

Erythema  is  distinguished  from  erysipelas  by  its  presenting  a  simple 
red  surface,  with  little  or  no  tumefaction,  accompanied  by  no  general  fever, 
and  without  an  abrupt  margin.  When  the  inflammation  accompanying 
erysipelatous  fever  is  restricted  to  the  fauces,  tongue,  and  pharynx,  there 
maybe  some  danger  of  confounding  it  with  either  catarrhal  or  diphtheritic 
inflammation  of  those  parts.  From  the  first,  however,  it  is  distinguished 
by  the  deeper,  darker  redness  of  the  inflamed  surface;  its  more  rapid 
spread  and  the  greater  temperature  of  the  parts,  and  the  far  more  violent 
and  dangerous  general  febrile  symptoms  accompanying  it.  From  the  sec- 
ond it  is  distinguished  by  the  absence  of  any  diphtheritic  membranous 
exudation;  by  the  greater  dryness  and  heat  of  the  surfaces  involved;  and 
the  more  speedy  formation  of  a  dark  brown  or  black  coating  over  the 
swollen  tongue  and  fauces. 

Prognosis. — Idiopathic  erysipelas,  as  it  occurs  sporadically  or  in  mild 
epidemic  form,  is  a  self-limited  general  feVjrile  affection,  almost  alwavs 
tending  to  recovery,  and  consequently  productive  of  a  very  low  ratio  of 
mortality.  But  in  its  more  severe  epidemic  forms  the  mortality  occasioned 
by  it  has  been  very  great.  Striking  examples  of  the  latter  were  presented 
in  many  of  the  places  visited  by  the  disease  during  the  wide  spread  epi- 
demic that  prevailed  from  1841  to  1846.  The  epidemic  of  1863-t)4  was  of 
milder  character.  During  the  six  months  ending  March  1st,  1864,  there 
came  under  my  care  in  the  wards  of  the  Mercy  Hospital  in  this  city, 
twenty-one  cases,  and  forty-five  more  in  private  practice.  Of  these  sixty- 
six  cases  only  one  died.  The  one  fatal  case  was  a  female  child  only  four 
weeks  old,  the  symptoms  accompanying  which  I  have  already  alluded  to.* 
It  may  be  stated  as  a  general  rule  that  erysipelatous  fever,  accompanied 
by  inflammation  on  any  part  of  the  cutaneous  surface,  tends  strongly  to 
recovery,  the  convalescence  being  established  between  the  seventh  and 
foiirteenth  days.  But  when  this  variety  of  fever  is  attended  by  the  de- 
velopment of  inflammation  in  any  of  the  internal  membranes,  whether 
mucous  or  serous,  its  progress  involves  great  danger  to  the  life  of  the 
patient. 

Pathological   Anatomy. — Fatal  cases  of  erysipelas  leave   no  internal 

*  See  report  on  Practical  Medicine  and  Epidemcs,  in  the  Transactions  of  the  Illinois  State  Med- 
ical Society  for  1S64  p.  16. 


IGO  ERYSIPELAS. 

changes  of  structure  which  are  in  any  degree  characteristic  of  this  variety 
of  fever.  In  diftV-rent  cases  have  been  found  all  the  usual  appearances  of 
inflammation  of  the  meninges  of  the  brain,  pleura,  peritoneum  and  other 
serous  membranes  ;  also  of  the  mucous  membranes  in  the  throat,  nasal 
passages,  stomach  and  upper  part  of  the  intestines,  as  well  as  in  the  bron- 
chial membranes  and  parenchyma  of  the  lungs.  But  all  these  appearances 
resulted  from  internal  complicating  inflammations,  and  not  from  changes 
necessarily  belonging  to  the  erysipelatous  afi"ection.  The  blood  has  been 
described  as  thinner  and  darker  color  than  natural,  and  sometimes  con- 
taining a  few  motionless  bacteria.  The  latter  are  found  much  more  abun- 
dantly in  the  serum  of  the  vesicles  and  that  infiltrating  the  sub-cutaneous 
arealor  tissue  of  those  parts  of  the  surface  involved  in  the  erysipelatous 
inflammation.  They  appear  to  be  indentical,  however,  witli  the  bacteria 
found  in  serous  and  other  organic  liquids  undergoing  deteriorative  changes, 
having  no  connection  with  erysipelas  or  any  other  kindred  disease.  In  a 
large  proportion  of  the  fatal  cases,  the  spleen  has  been  found  engorged 
with  dai'k  blood  and  enlarged,  and  the  cortical  substance  of  the  kidneys 
in  a  state  of  active  hyperasmia. 

Special  Pathology. — The  general  character  of  the  erysipelatous  fever, 
together  with  the  peculiar  mode  of  development,  spread,  and  disappear- 
ance of  the  accompanying  cutaneous  inflammation,  furnish  strong  evidence 
that  the  disease  arises  from  the  presence,  in  the  blood  of  a  specific 
materies  inorbi,  which  so  acts  upon  the  properties  of  the  living  tissues  as 
to  increase  their  elementary  susceptibility  and  pervert  in  a  peculiar  man- 
ner the  vital  affinity,  inducing  thereby  those  singular  molecular  changes 
which  so  clearly  distinguish  the  erysipelatous  from  all  other  grades  of  in- 
flammation. The  very  general  tendency  of  the  disease  to  disappear 
spontaneously  after  from  one  to  two  weeks'  duration,  shows  that  the 
specific  causative  material  is  either  incapable  of  continued  propagation, 
or  is  rapidly  destroyed  and  eliminated  from  the  living  system  during  the 
progress  of  the  morbid  processes  which  its  presence  has  induced.  But  of 
the  identity  and  nature  of  the  specific  poison,  and  of  the  exact  mode  of 
its  elimination,  no  satisfactory  knowledge  has  yet  been  obtained. 

Treatment. — If  the  opinion  I  have  just  expressed  concerning  the  de- 
pendence of  idiopathic  erysipelas  upon  a  specific  poison  which  has  in  some 
way  gained  access  to  the  living  tissues  through  the  blood,  is  true,  the 
leading  indications  for  treatment;  are,  to  prevent  the  further  introduction 
of  the  poison  ;  and  to  aid  in  either  neutralizing  or  expelling  that  which  is 
already  pervading  the  fluids  and  solids  of  the  body.  The  first  is  to  be  ac- 
complished by  placing  the  patient  and  his  immediate  surroundings  in  as 
good  sanitary  condition  as  possible.  The  second,  by  keeping  the  secretory 
and  eliminating  functions  as  near  naturally  active  as  possible,  and  giving 
internally  such  specific  or  antiseptic  medicines  as  experience  has  shown 
to  be  capable  of  exerting  some  influence  over  the  progress  of  the  disease. 
If  called  early,  and  the  lever  is  active,  with  coated  tongue,  dry  skin,  scanty 
and  high  colored  urine,  and  quiet  bowels,  I  endeavor  to  promote  the  ex- 
cretory functions  by  giving  every  three  or  four  hours  a  powder  containing 
the  compound  opium  and  ipecac  powder  and  nitrate  of  potassium,  each 
three  decigrams  (gr.  v.)  and  calomel  thirteen  centigrams  (gr.  ii),  until 
four  doses  have  been  taken,  and  follow  them  by  a  saline  laxative  sufficient 
to  cause  one  or  two  intestinal  evacuations.  After  this  the  bowels  seldom 
need  further  prompting,  and  the  action  of  the  skin  and  kidneys  may  be 
sufficiently  sustained  by  suitable  doses  of  the  spirits  of  nitrous  ether.  To 
exert  a  specific  action  upon  the  exciting  cause  in  such  a  way  as  to  lessen 
the  severity  and  duration  of  the  disease,  we  may  give  the  tuicture  of  the 


TREATMENT.  161 

chloride  of  iron,  the  sulphites  of  sodium  and  calcium,  or  the  dilute  sulph- 
urous acid,  in  suitable  doses  and  sufficiently  frequent  to  freely  impregnate 
the  blood.  In  far  the  larg-er  number  of  cases  I  prefer  the  tincture  of 
chloride  of  iron,  and  commence  giving  it  from  the  beginning  of  the  treat- 
ment in  doses  of  from  1.5  to  3.0  cubic  centimetres  (m.  xxv  to  xxx) 
well  diluted  with  sweetened  water,  and  repeated  every  three  or  four 
hours,  until  the  fever  begins  to  decline,  and  the  inflammation  ceases  to 
spread.  Then  the  doses  may  be  diminished  or  the  interval  between  them 
increased,  but  the  remedy  should  not  be  wholly  discontinued  until  con- 
valescence is  well  established.  In  many  cases  this  treatment  appears  to 
arrest  the  further  progress  of  the  disease  in  three  or  four  days.  There  are 
some  cases  in  which  this  preparation  of  iron  is  not  well  borne,  or  is  re- 
jected by  vomiting.  In  such  cases  I  have  substituted  the  sulphite  of 
sodium  in  doses  of  six  decigrams  (gr.  x),  with  0.3  cubic  centimetres 
(m.  V )  of  the  tincture  of  belladonna,  in  solution  with  mint- water,  re- 
peated just  as  often  as  in  other  cases  I  repeat  the  iron,  and  with  excellent 
effect.  In  the  epidemic  of  1863,  I  treated  some  of  the  worst  cases  that 
came  under  my  care,  both  in  the  hospital  and  out,  with  the  sulphites  of 
sodium  and  calcium,  very  satisfactorily. 

It  appeared  to  me  slower  in  developing  its  effects  than  the  iron,  but  none 
the  less  permanent.*  If  at  any  time  during  the  progress  of  an  attack  of 
er\-sipelas,  diarrhcea  supervenes,  it  can  be  best  controlled  by  giving  the 
emulsion  of  oil  of  turpentine  and  tincture  of  opium,  according  to  the 
same  formulae  that  I  gave  you  when  discussing  the  treatment  of  typhoid 
fever.  In  this  city  and  throughout  the  larger  part  of  the  great  interior 
valley  of  this  continent,  the  local  epidemics  of  erysipelas  have  been  mate- 
rially influenced  by  the  co-existing  presence  of  malaria,  imparting  to  the 
fever  a  more  remitting  type,  and  to  the  external  inflammation  a  more  per- 
sistent disposition  to  spread.  In  all  cases  occurring  under  such  circum- 
stances, the  sulphate  of  quinia  should  be  given  in  moderate  but  efficient 
doses,  in  conjunction  with  the  tincture  of  chloride  of  iron  or  the  sulphites. 
In  the  earlier  years  of  my  residence  here,  when  malarious  or  periodical 
fevers  were  much  more  prevalent  within  the  city  limits  than  in  recent 
years,  I  met  Avith  such  cases  of  erysipelas,  and  used  quinine  as  an  adjunct 
in  their  treatment,  with  the  best  results.  AVhen  cases  of  erysipelas  be- 
come comjDlicated  with  important  internal  inflammations,  such  complica- 
tion must  be  promptly  treated  by  the  same  remedies  that  would  be  indi- 
cated by  a  similar  grade  of  disease  in  the  same  parts  under  other  circum- 
stances. If  the  meninges  of  the  brain  or  other  serous  membranes  are 
attacked,  accompanied  by  a  high  temperature  and  a  firm  pulse,  one  free 
bleeding  by  venesection  in  the  first  stage  of  its  progress,  will  be  found 
promptly  beneficial  in  checking  the  progress  until  time  is  gained  for  other 
remedies  to  develop  their  action.  I  well  recollect  a  case  occurring  in  my 
practice  during  the  notable  epidemic  of  1843,  in  the  person  of  an  adult 
male,  of  rather  plethoric  habit,  and  sanguine  temperament.  The  general 
fever  was  active,  and  the  inflammation  attacked  the  face,  spreading  rapidly 
over  the  whole  face  and  head,  accompanied  by  much  tumefaction  and  ves- 
ication. On  the  third  day,  while  the  inflammation  was  extending  rapidly 
from  the  face  over  the  whole  scalp,  the  patient  became  wildly  delirious, 
with  contracted  pupils,  and  a  corded,  tense  pulse.  I  directly  opened  a 
vein  in  his  arm  and  let  the  blood  flow  from  a  good-sized  orifice,  to  the  extent 
of  more  than  one  litre  (fl.  |xxx),  with  the  most  tranquiJizing  effect.  The 
whole  subsequent  progress  of  the  case  was  modified,  and  the  patient  made 
a  good  recovery. 

*  See  Chicago  Medical  Examiner,  Vol,  IV,  pp.  161-2, 1863. 
11 


162  EEYSIPELAS. 

Thus  far  I  have  said  nothing-  in  regard  to  local  applications  to  the  in- 
flamed surfaces  in  erysipelatous  fever,  simply  because  I  regard  them  as 
capable  of  exercising  no  control  over  the  progress  of  the  disease.  When 
I  first  entered  the  ranks  of  the  profession,  nearly  half  a  century  since,  very 
much  importance  was  attached  to  local  applications  in  this  disease.  It 
was  thought  that  the  extension  of  the  inflammation  might  be  arrested  by 
deadening  the  whole  inflamed  surface  with  strong  applications  of  nitrate 
of  silver,  tincture  of  iodine,,  strong  solution  of  sulphate  of  iron,  and  even 
encircling  the  inflamed  surface  with  narrow  blisters.  Others  recommended 
the  constant  application  of  cold  lotions,  as  solutions  of  acetate  of  lead, 
alum,  and  poultices  made  ot  cranberries. 

During  the  first  ten  years  of  my  practice,  which  included  the  epidemic 
years  from  1841-46,  I  tried  all  these  expedients  faithfully,  until  I  became 
fully  convinced  that  none  of  them  exerted  rjiy  controlling  influence  what- 
ever over  either  the  local  inflammation  or  the  general  fever.  Conse- 
quently, during  the  last  thirty  years  I  have  used  no  local  applications  to 
erysipelatous  surfaces,  except  such  as  were  calculated  to  add  to  the  comfort 
of  the  patient  by  lessening  the  burning  pain  in  the  inflamed  surface.  For 
this  purpose,  keeping  the  surface  moistened  with  a  lotion  made  of  equal 
parts  of  glycerine  and  rose-water  succeeds  well,  and  is  pleasant  to  use. 
The  next  most  comfortable  application  is  cloths  kept  a  little  wet  with  a 
cold  solution  of  acetate  of  lead. 

A  few  years  since.  Dr.  J.  S.  Whitmire,  of  Metamora,  111.,  reported  to 
the  Illinois  State  Medical  Society  several  cases  of  severe  erysipelas,  in 
which  the  disease  was  speedily  arrested  by  the  hypodermic  injection  of  a 
few  drops  of  a  strong  solution  of  carbolic  acid  at  the  margin  of  the  inflamed 
surface. 

It  would  be  necessary  to  exercise  much  care  in  regard  to  the  quantity 
of  the  carbolic  acid  introduced  into  the  subcutaneous  tissue,  or  its  effects 
might  be  far  more  dangerous  to  the  patient  than  the  disease  it  is  intended 
to  cure.  Throughout  the  whole  course  of  the  disease,  proper  attention 
should  be  given  to  the  support  of  the  patient  by  nourishment.  Milk, 
beef-tea,  thin  wheat  flour  and  milk  gruel,  and  oatmeal  gruel,  constitute  the 
best  articles  of  nourishment.  They  should  be  given  in  small  quantities  at 
a  time,  but  repeated  sufficiently  often  to  afford  a  fair  degree  of  support, 
without  accumulating  too  much  in  the  stomach  at  one  time.  In  those 
comparatively  rare  cases  in  which  the  erysipelatous  inflammation  develops 
in  the  fauces,  pharynx,  and  tongue,  rendering  deglutition  difficult  or 
impracticable,  the  nourishment,  as  well  as  the  medicines,  must  be  admin- 
istered mostly  in  the  form  of  enemas.  In  the  more  malignant  and  typhoid 
grades  of  erysipelas,  many  recommend  the  free  use  of  wine,  brandy,  and 
other  alcoholic  liquids. 

I  have  seen  many  bad  cases  of  erysipelas  in  which  the  habitual  use  of 
alcoholic  liquids  appeared  to  have  been  the  chief  predisposing  cause;  but 
I  have  never  seen  one  in  which  the  use  of  these  liquids  had  any  beneficial 
effect,  either  in  sustaining  the  patient  or  in  curing  the  disease. 

Prophylaxis. — As  the  infection  or  specific  cause  of  erysipelas  is  capable 
of  adhering  to  clothing,  bedding,  sponges,  instruments,  and  even  the  hands 
of  the  attending  physician,  great  care  should  be  exercised  in  having  all 
such  things  as  have  been  in  contact  with  an  erysipelatous  patient  thor- 
oughly cleansed  and  disinfected,  before  allowing  them  to  be  used  by  others. 
Beds,  mattresses,  etc.,  can  be  most  easily  and  reliably  rendered  innocuous 
by  baking,  or  heating  them  to  a  high  temperature  in  dry  air.  And,  as 
practitioners,  you  should  ever  be  particularly  careful  not  to  carry  the  infec- 
tion on  your  hands  or  instruments  to  your  obstetric  patients.     Whether 


DIPHTHERIA.  163 

takino-  daily  two  or  three  moderate  doses  of  the  tincture  of  chloride  of  iron 
or  of  the  sulphite  of  soda  by  well  persons,  during  the  prevalence  of  a  severe 
epidemic,  would  prevent  their  being  attacked — on  the  same  principle  that 
moderate  daily  doses  of  quinine  often  protect  an  individual  from  attacks 
of  ao-ue  while  living  in  a  highly  malarious  atmosphere — remains  to  be 
determined  by  future  experience  and  observation. 


LECTUKE    XIX. 

Diphtheria.— Its  History,  Causes,  Symptoms,  Diagnosis,  Prognosis,  Pathology,  Treatment  and 
Sequelae. 

GENTLEMEN: — The  word  Diphtheria,  as  used  to  designate  a  particular 
form  of  disease,  is  of  recent  origin,  having  been  first  applied  to  that 
purpose  by  Bretonneau  in  a  valuable  paper  laid  before  the  French  Acad- 
emy of  Medicine,  in  1821.  While  the  name  is  thus  modern,  the  disease 
has  been  recognized  and  described,  with  varying  degrees  of  accuracy, 
from  a  very  early  period  in  medical  history.  The  Grecian  writers  alleged 
that  the  disease  originated  in  Egypt,  and  called  it  '■'•  Malum,  E gynticum^'''' 
in  the  days  of  Homer  and  Hippocrates.  An  epidemic  of  the  disease  in 
Rome  was  recognized  and  described  by  Macrobius  in  the  year  380,  A.  D. 
From  that  time  to  the  middle  of  the  sixteenth  century,  I  find  but  few 
allusions  to  the  disease.  At  the  latter  date,  1557,  it  appeared  in  Holland 
as  an  epidemic;  in  Germany,  in  1650;  in  France  and  Italy,  in  1749;  and 
in  England,  from  1760  to  1769.  While  the  descriptions  of  all  these  earlier 
epidemics  are  sufficiently  accurate  to  render  it  certain  that  the  writers 
were,  for  the  most  part,  describing  the  disease  now  called  diphtheria,  it  is 
equally  evident  that  they  often  confounded  with  it  scarlet  fever  and  vari- 
ous forms  of  sore  throat.  Perhaps  the  most  accurate  of  the  early  records 
is,  "An  Account  of  the  Putrid  Sore  Throat,"  as  it  prevailed  in  London,  by 
Dr.  John  Fothergill,  published  in  1769.  The  earliest  account  we  have  of 
this  disease  in  America  was  written  by  Dr.  Douglass,  of  the  Massachusetts 
Colony,  in  1736.*  It  undoubtedly  prevailed  in  New  York  in  1771,  and 
was  pretty  clearly  described  by  Dr.  Samuel  Bard.  From  that  time  to 
1831  we  find  nothing  in  the  medical  literature  of  our  country  which  could 
be  regarded  as  applying  to  true  diphtheria;  although  it  was  more  or  less 
prevalent  on  the  continent  of  Europe,  and  was  being  carefully  investigated 
by  Bretonneau,  at  Tours,  from  1818  to  1821. 

Dr.  John  Bell,  of  Philadelphia,  alludes  to  the  prevalence  of  an  epidemic 
sore  throat  in  that  city  in  1831,  which  was  evidently  true  diphtheria.  In 
1856  the  disease  prevailed  with  great  severity  in  San  Francisco  and  the 
adjacent  counties  in  California,  and  during  the  next  two  or  three  years 
epidemics  appeared  in  various  parts  of  New  England,  New  York,  and  a 
large  number  of  the  Middle  and  Western  States.  According  to  Dr.  L.  N. 
Beardsley,  of  Milford,  Connecticut,  the  disease  commenced  in  the  adjoin- 
ing town  of  Orange,  among  the  scholars  attending  a   select  school,  and 

*See  the  Practical  History  of  a  New  Epidemical  Eruptive  Miliary  Fever,  with  an  Angina  Ulcus- 
culosa,  which  prevailed  in  New  England  in  1735-3G.    By  Dr.  William  Douglass,  of  Boston. 


164  DIPHTHERIA. 

with  such  severity  that  "  fourteen  cases  out  of  fifteen,  of  those  "who  -were 
first  attacked,  proved  fatal."*  In  April,  1858,  it  made  its  appearance  in 
Albany,  N.  Y.,  and  caused  167  deaths  during  the  next  eight  months. f  The 
disease  began  to  attract  attention  in  this  city  in  1858,  and  prevailed  with 
considerable  severity  for  three  or  four  successive  years. 

During  the  same  period  of  time,  it  showed  itself  more  or  less  prevalent 
in  almost  every  inhabited  district  of  country  from  the  Atlantic  to  the 
Pacific  Ocean,  and  from  the  Lakes  to  the  Gulf  of  Mexico.  It  prevailed  in 
localities  the  most  diverse  in  all  their  local  conditions.  Elevated,  dry, 
thinly  populated  rural  districts  were  visited  as  freely,  and  often  as  fatally, 
as  the  lowest  alluvial  valleys,  or  the  most  densely  populated  cities.  It 
presented  every  gradation  of  severity,  from  fifteen  deaths  in  sixteen 
attacks,  as  reported  by  Dr.  Beardsley,  of  Connecticut,  to  onh'  four  deaths 
in  one  hundred  and  thirty-three  attacks,  as  reported  by  Dr.  Wm.  L.  Wells, 
of  Milwaukee,  Wis. J  For  additional  facts  regarding  the  prevalence  of 
this  disease  during  the  years  intervening  between  1858  and  1860,  and 
earlier,  I  refer  you  to  an  interesting  report  on  the  topography  and  epidem- 
ics of  New  York,  by  Dr.  Joseph  M.  Smith,  in  the  Transactions  of  the 
American  Medical  Association,  Vol.  xiii,  p.  251,  1860.  From  that  period 
to  the  present  it  is  not  probable  that  the  disease  has  been  entirely  absent 
from  all  parts  of  the  country  for  a  single  year.  We  find  it  occupj'ing  a 
place  of  more  or  less  prominence  in  nearly  all  the  annual  tables  of  mortal- 
ity in  our  cities,  and  accounts  of  its  prevalence  in  some  of  the  country 
districts  have  come  to  us  every  year.  It  seldom  prevails  in  the  same  rural 
district  more  than  two  or  three  years  in  succession,  without  a  period  of 
exemption.  And  in  the  larger  cities  it  presents  its  distinct  waves  of 
increase  and  decrease.  For  instance,  in  Philadelphia  the  number  of 
deaths  from  diphthpria  each  year  for  eight  successive  years  was,  in  1872, 
141;  1873,  106;  1874,  181;  1875,  656;  1876,  708;  1877,  458;  1878,  464; 
1879,  321.  In  this  city  (Chicago)  and  in  New  York,  the  statistics  of  mor- 
tality indicate  the  same  wave  of  increase  in  1875,  culminating  in  3  876, 
and  receding  through  1877-78-79.| 

Causes. —  The  predisposing  causes  or  circumstances  that  appear  to 
favor  the  prevalence  of  diphtheria,  are,  childhood  and  youth;  darajoness, 
with  frequent  changes  in  the  thermometric  conditions  of  the  atmosphere; 
overcrowding  of  houses  and  consequent  lack  of  ventilation;  the  presence 
of  the  products  of  the  decomposition  of  organic  matter,  whether  animal 
or  vegetable;  and  the  want  of  attention  to  personal  cleanliness  and  do- 
mestic hygiene. 

While  it  is  true,  that  during  the  epidemic  prevalence  of  diphtheria, 
persons  have  been  attacked  at  all  periods  of  life,  from  infancy  to  ripe  old 
age,  very  much  the  larger  number  of  cases  occur  in  childhood.  Of  the 
133  cases  reported  by  Dr.  Wells,  1()7  were  in  children  and  26  in  adults.  Of 
the  latter,  one  was  63  years  of  age;  while  the  great  majority  of  the  former 
were  between  the  ages  of  2  and  10  years.  Dr.  Willard,  of  Albany,  in 
giving  an  account  of  an  epidemic  in  that  city,  reports  179  deaths,  of  whicli 
only  thi'ee  were  adults,  all  the  remainder  being  children,  most  of  whom  were 
under  twelve  years  of  age.  From  the  statistics  of  the  severe  epidemic 
prevalence  of  this  disease  in  England  from  1857  to  1860,  it  would  appear 
that  more  than   85  per  cent,  of  all  the  deaths  were  of  children    under 

*  See  Boston  Medical  and  Surgical  Journil.  1858. 

fSee  Transactions  of  New  York  State  Medical  Society,  pp.  182-5, 18"9. 

X  See  Chicago  Medical  P^x.nminer,  Vol.  I.  lf-60,  p.  194. 

II  See  Transactions  of  College  of  Physicians  of  Philadelphia,  Thifd  Series.  VoL  V.  p.  38,  1881. 
Also  Report  of  Dr.  John  F.  Kagle,  of  New  York,  in  National  Board  of  Health  Bulletin,  for  Nov. 
12.  ISbl,  Vol3,No.20. 


CAUSES.  165 

the  ao-e  of  fifteen  years.*  It  is  probable  that  seventy-five  per  cent,  of  all  the 
cases  of  diphtheria  occur  in  children  under  twelve  years  of  age.  And  as 
one  attack  of  the  disease  does  not  destroy  the  susceptibility  of  the  system 
to  subsequent  ones,  there  must  be  something  in  the  conditions  of  child- 
hood that  acts  the  part  of  a  predisposing  influence. 

While  isolated  cases  of  diphtheria  occur  in  particular  houses  or  circum- 
scribed localities  at  all  seasons  of  the  year,  and  epidemics  have  occurred 
in  all  varieties  of  climate,  yet  it  remains  true  that  the  disease,  especially 
in  epidemic  forms,  prevails  much  the  most  frequent  and  severe  within  the 
temperate  zone,  and  during  the  sprint:  and  autumn  months,  when  atmos- 
pheric conditions  are  most  variable.  That  overcrowding  of  the  population, 
as  in  the  tenement  houses  in  our  cities,  with  neglect  of  ventilation,  and 
the  accumulation  of  vegetable  and  animal  matters  from  want  of  sewerage 
and  cleanliness,  act  as  strongly  predisposing  influences,  is  abundantly  shown 
by  the  behavior  of  the  disease  in  all  our  large  cities  during  its  special 
periods  of  prevalence  from  1856  to  1860,  from  1864  to  1867,  and  from  1875 
to  the  present  time.  For  instance,  in  New  York  city,  during  the  three 
months  ending  September  30th,  1881,  the  whole  number  of  deaths  from 
diphtheria  was  545  ;  of  which  405  took  place  in  tenement  houses,  leaving 
140  to  occur  in  all  other  dwellings.  During  the  last  five  months  of  the 
year  1877,  there  were  reported  to  the  health  officer  of  this  city  (Chicago), 
162  deaths  from  diphtheria,  occurring  in  122  dw^ellings.  The  health  officer 
caused  each  of  these  houses  to  be  very  thoroughly  examined  by  an  expert 
plumber  and  sewer  builder,  whose  report  showed  13  of  these  houses  to  be 
in  excellent  sanitary  condition  in  every  respect;  14  faulty  from  insufficient 
ventilation  only;  19  from  insufficient  ventilation  and  uncleanliness;  24 
from  insufficient  ventilation  and  uncleanliness,  both  of  persons  and  prem- 
ises; and  52  from  defective  sewerage  and  plumbingj-. 

Facts  of  similar  import  may  be  gathered  in  connection  with  the  preva- 
lence of  the  disease  in  all  large  cities;  and  they  justify  the  conclusion  that 
in  such  ago-regations  of  population,  those  persons  and  families  who  live  in 
poorly  ventilated,  uncleanly,  and  imperfectly  sewered  houses  and  premises, 
yield  a  larger  proportion  of  victims  of  diphtheria,  than  those  in  better 
sanitary  surroundings.  But,  as  I  have  already  pointed  out  to  you  in  pre- 
vious lectures,  this  conclusion  is  equally,  or  even  more  applicable  to  the 
prevalence  of  typhoid,  typhus,  and  all  other  acute  general  febrile  aff"ections 
of  kindred  type.  And,  consequently,  the  only  legitimate  deduction 
from  the  facts,  is,  that  the  diminished  power  of  vital  resistance  from  im- 
paired tone  of  health  caused  by  living  in  bad  sanitary  conditions,  causes  a 
more  ready  yielding  to  the  influence  of  the  essential  cause  or  causes  of 
diphtheria. 

On  the  other  hand,  in  villages  and  country  districts,  the  disease  has  pre- 
vailed in  its  epidemic  form  with  as  much  severity  and  fatality,  in  propor- 
tion to  the  population,  as  in  the  most  densely  populated  cities;  and  in 
such  districts  it  has  shown  little  or  no  preference  for  the  poor  or  uncleanly, 
but  has  invaded  dwellings  kept  in  the  most  perfect  sanitary  condition,  and 
rural  districts  usually  deemed  most  healthy.  For  instance,  Dr.  William 
C.  Wey,  of  Elmira,  N.  Y.,  after  carefully  noting  the  rise,  progress  and 
decline  of  an  unusual  prevalence  of  diphtheria  in  that  place  during  the 
years  1877-78-79-80,  says:  "  In  the  epidemic  which  has  so  severely  visited 
Elmira,  the  questions  of  filth  and  water-supply  from  unclean  sources,  as 
means  of  inducing  and  spreading  the  disease,  have  been  carefully  consid- 
ered.    In  some  cases  the  water-supply  has  been  found  corrupted;  in  many 

*See  Reynold's  System  of  Medicine.  Am.  Edition.  Vol.  I,  p.  62. 

tSee  Report  of  Department  ot  Health  of  the  City  of  Chicago,  1876-7,  p.  15. 


166  DIPHTHERIA. 

the  general  surroundings  have  been  unsanitary,  and  the  facilities  and  com- 
forts of  the  sick  and  attendants  limited  and  unsatisfactory.  As  a  matter 
of  course,  great  mortality  has  followed  in  the  train  of  neglect  and  poverty. 
In  other  cases  the  "water  supply  has  come  from  pure  sources,  the  sanitary 
conditions  of  the  people  and  their  manner  of  living  have  been  faultless, 
the  utmost  watchfulness  has  been  exercised  to  maintain  rigid  non-inter- 
course with  seats  of  the  disease,  and  \'et,  in  spite  of  care,  and  as  if  in 
defiance  of  it,  the  affect. on  has  appeared  with  as  much  malignity  as  in 
places  of  human  crowding  and  disregard  of  hygienic  precautions."* 

These  are  the  statements  of  one  of  the  most  experienced  and  intelligent 
practitioners  in  that  State.  To  precisely  the  same  import  are  the  facts  given 
by  Dr.  N.  B.  Bailey,  of  Brewster,  Putnam  Coinity,  N.  Y.,  in  an  account 
of  an  epidemic  of  diphtheria  that  prevailed  in  that  place  during  the  years 
1877-78,  published  in  the  same  volume  of  Transactions  from  which  I  have 
just  quoted.  My  own  personal  observations  lead  to  the  same  conclusions. 
I  have  met  with  the  disease  here,  in  this  city,  in  all  grades  of  severity, 
among  both  rich  and  poor,  in  the  stateliest  mansions  of  luxury,  and  in  the 
most  narrow,  dark,  damp  and  uncleanly  hovels  of  poverty  and  vice.  It 
has  visited,  from  time  to  time,  almost  every  county  in  this  and  neighboring 
States,  and  has  proved  as  malignant  and  fatal,  in  proportion  to  the  popu- 
lation, on  the  open  plains,  and  thinly  populated,  healthy,  rural  districts  in 
Northern  Illinois,  Wisconsin,  and  Minnesota,  as  in  the  most  unsanitary 
wards  in  the  city  of  Chicag^j.  At  most,  therefore,  bad  sanitary  conditions 
can  only  be  regarded  as  predisposing  influences,  and  we  must  look  in 
other  directions  for  the  efficient  cause  or  causes  on  which  the  disease 
depends. 

Many  of  the  most  eminent  observers  and  writers  of  the  present  time 
represent  the  essential  cause  of  tlie  disease  to  be  a  specific  contagium 
vivum,  or  organic  germ,  which  has  been  shown  to  exist  abundantly  in  the 
diphtheritic  exudation  or  membrane,  and  in  the  epitheiial  la3'er  of  the 
membrane  lining  the  fauces  and  otlier  parts  affected  by  the  local  manifes- 
tations of  disease.  By  some,  this  organic  germ  is  claimed  to  be  the 
"  Oidium  Albicans,"  a  fungus,  consisting  of  sporules  or  micrococci  and 
mycelium.f  In  1868  Buhl,  Hueter,  and  Oertel,  discovered  in  the  diphthe- 
ritic membranous  formations,  and  in  the  mucous  membrane  covered  by 
them,  various  species  of  bacteria,  the  most  important  of  which  were  an 
exceedingly  minute  spherical  variety,  called  by  Cohn,  micrococcus,  and  the 
bacteria  termo,  or  rod-shaped  bacteria.J  By  Oertel,  and  many  others, 
these  minute  organisms  are  regarded  as  the  essential  cause  of  the  diphthe- 
ritic disease,  and  they  claim  to  have  produced  well  characterized  diph- 
theria in  animals  by  inoculation  with  portions  of  the  membrane  from  the 
fauces. 

On  the  other  hand,  the  results  of  the  experiments  of  Burden-Sanderson, 
Avith  filtered  liquids;  the  failure  of  Trousseau  and  Peter,  to  induce  the 
disease  in  themselves  by  the  very  free  application  of  the  membranous 
substance  to  their  o\An  fauces;  and  the  entire  failure  of  Curtis  and  Satterth- 
waite,  and  H.  C.  Wood  and  Formad,  to  induce  the  disease  in  animals 
by  repeated  and  carefully  executed  inoculations  with  diphtheritic  matter, 
go  far  to  disprove  the  conclusions  of  Oertel  and  his  followers.  And  if  we 
add  to  these  the  further  fact  that  every  variety  of  germs  found  either  in 
the  membranous  exudations  of  diphtheria,  or  in  the  blood  and  tissues  of 
diphtheritic  patients,  have  also  been  found  in  the  miguet  or  curdy  exuda- 

*See  Transactions  of  the  New  York  State  Medinal  Society  for  1881,  p.  r43. 

+  See  Clinical  I^eclure  by  Dr.  Laycoek,  of  Edinburgh,  in  18.38. 

X  tee  Cyclopaedia  of  the  Fracdceof  Medicine,  by  Zienissen,  Vol.  I,  p.  588. 


SYMPTOMS.  167 

tions  upon  the  mucous  membrane  of  the  mouth  and  fauces  iti  young  chil- 
dren, in  the  white  exudations  upon  the  tonsils  and  fauces  in  the  last  stage 
of  consumption  and  other  wasting  diseases,  and  in  the  exudations  that 
sometimes  appear  on  diiferent  parts  of  the  mucous  membrane  in  typhoid, 
typhus,  and  other  low  forms  of  fever,  we  shall  find  it  much  more  in  accord- 
ance with  sound  principles  of  reasoning  to  conclude  that  these  minute 
organic  forms,  called  bacteria,  micrococci,  etc.,  are  simply  accompaniments, 
if  not  products,  of  certain  degenerative  organic  processes  that  take  place, 
to  a  greater  or  less  extent,  in  all  the  acute  febrile  and  inflammatory  affec- 
tions of  an  asthenic  type.  If  we  adhere  impartially  to  well  ascertained 
facts,  we  mvist  admit  that  diphtheria  often  makes  its  appearance  in  families, 
asylums,  and  schools,  as  well  as  at  the  beginning  of  epidemics,  under  such 
circumstances  that  it  is  impossible  to  trace  it  to  any  form  of  communica- 
tion with  previous  cases,  either  in  the  same  localities  or  elsewhere.  In 
other  words,  it  is  capable  of  spontaneous  development,  and  consequently 
does  not  depend  for  its  production  and  spread  upon  any  specific  conta- 
gious germs  or  virus  generated  in  the  bodies  of  the  sick.  I  have  seen 
many  cases  illustrative  of  this  fact;  and  the  same  is  strikingly  exemplified 
by  the  outbreak  of  the  disease  in  Brewster,  N.  Y.,  as  described  by  Dr. 
Bayley,  in  1878.* 

The  same  adherence  to  simple  facts,  however,  compels  us  to  admit  that 
in  very  many  cases  the  disease  appears  to  spread  by  an  infection  capable 
of  contaminating  clothes  and  furniture,  and  of  being  carried  by  them  from 
family  to  family,  and  from  one  locality  to  another.  Oertel  recognizes  both 
these  series  of  facts,  and  claims  that  when  it  develops  spontaneously,  it  is 
from  some  organic  niiasni ^  and  hence  he  includes  diphtheria  in  his  class 
of  "  miasmatic  contagious  diseases."  The  fact  that  this  disease  usually 
prevails  as  an  epidemic,  commencing  often  without  any  traceable  commu- 
nication with  previous  cases  or  known  contagious  influence,  and  attacking, 
simultaneously,  members  of  families  in  different  parts  of  a  city,  village,  or 
rural  district,  v/ho  have  neither  had  any  communication  with  each  other 
nor  witii  any  known  common  source  of  infection,  would  indicate  that  its 
essential  cause  consists  in  some  special  condition  of  the  atmosphere,  which 
the  older  writers  called  an  epidemic  constitution.  Its  nature  will  remain 
unknown  until  more  systematic  and  continuous  observations  are  made  and 
recorded,  concerning  all  appreciable  conditions  of  the  atmosphere  in  direct 
connection  with  records  of  the  prevalence  of  acute  general  diseases. 
When  this  is  done  through  a  series  of  years,  with  the  accuracy  now  attain- 
able by  the  aid  of  physics,  chemistry,  and  microscopy,  we  shall  have  such 
elements  for  comparison  as  will  throw  light  upon  this  and  many  other 
obscure  questions  connected  with  the  etiology  of  diseases. 

Symptoms. — For  the  clinical  stiidy  of  diphtheria  I  shall  group  the  vari- 
ous cases  met  with,  under  three  heads — namely  :  the  simple,  the  crouppus, 
and  malignant.  In  the  first  group  I  shall  include  all  the  cases  that  pre- 
sent so  moderate  a  degree  of  severity  as  to  pass  through  their  successive 
stages  with  a  natural  tendency  to  convalescence.  In  the  second  group  I 
shall  include  all  those  cases  in  which  the  local  inflammation  invades  the 
larynx  and  trachea.  In  the  third  group  will  be  included  all  such  cases  as 
by  the  gravity  of  the  general  morbid   conditions,  or  the   severity  of  the 

*See  Transactions  of  the  New  York  Stat;  Medical  Societv  for  1881.  p.  315.— Dr.  Bayley  says:  "In 
twenty-one  of  the  fifty  cases  of  which  I  have  notes,  the  disease  wa.s  developed  with' Tut  any  known 
previous  exposure  ;  and  especial  pains  were  taken  to  arrive  at  the  truth.  In  seven  of  these  cases 
there  could  be  no  mistake,  as  they  were  the  primary  ones,  and  no  members  of  these  families  (three 
in  number)  had  been  exposed  to  any  sore  throat  whatever.  Moreover,  these  seven  feU  il.  on  the 
same  days,  viz.:  December  21,  3d,  and  4tli ;  and  at  two  different  points,  separated  by  a  distance  of 
3,218  kilometers  (nearly  three  miles) ;  and,  further,  the  famdies  moved  in  veiy  diflferent  spheres, 
and  did  not  come  in  contact  with  each  other  in  any  manner." 


168  DIPHTHEEIA. 

naso-pharyngeal  and  glandular  inflammations  tend  strongly  towards  a  fatal 
result.  The  majority  of  cases  of  simple  diphtheria  are  developed  grad- 
ually; the  patient  feeling  for  one,  two,  or  three  days  a  gradually  increasing 
sense  of  weariness;  indisposition  to  mental  or  physical  activity;  vague  or 
ill-defined  pains  in  the  head,  back,  and  limbs;  with  indifference  to  food. 
Then  the  face  becomes  a  little  flushed,  the  lips  dry,  the  expression  of  coun- 
tenance dull,  the  pulse  moderately  accelerated,  with  an  increase  of  one  or 
two  degrees  of  temperature,  and  a  more  decided  sense  of  weakness;  and, 
in  addition  to  these  symptoms  of  a  moderate  general  fever,  there  is  observ- 
able a  little  undue  fullness  behind  and  beneath  the  angle  of  the  jaw,  with 
some  feeling  of  stifi"ness  and  soreness  in  swallowing.  On  examining  the 
fauces  at  this  stage  you  will  find  the  mucous  membrane  covering  the  ton- 
sils, arch  of  the  palate,  and  portions  of  the  pharynx,  presenting  a  tumefied 
and  dark  red  appearance,  with  some  spots  of  white,  or  yellowing  white, 
membranous  exudation  closely  adhering  to  it,  together  with  some  degree 
of  swelling  of  the  tonsils  and  neighboring  lymphatic  glands. 

In  a  smaller  number  of  the  cases  belonging  to  this  group,  the  attack  is 
more  abrupt,  and  accompanied  by  chilliness  or  even  a  decided  chill,  fol- 
lowed' by  a  more  active  general  fever,  but  the  same  local  symptoms  as  I  just 
described.  The  symptoms  thus  begun  usually  gradually  increase  during 
the  succeeding  three  or  four  days.  The  patches  of  inembrane  on  the 
inflamed  surface  of  the  fauces  increase  in  number  and  size,  until  in  many 
cases  they  coalesce  and  cover  nearly  the  whole  surface,  and  extend  with  the 
inflammation  into  the  posterior  nares.  During  the  same  time  the  tonsils 
and  lymphatic  glands  also  increase  in  size,  impeding  the  free  opening  of 
the  mouth,  and  rendering  deglutition  more  difficult.  The  fauces  also  become 
troubled  with  an  excess  of  tenacious  mucus,  which  in  young  children 
often  causes  much  rattling  in  the  throat  and  some  cough.  The  urinary 
secretion  is  moderately  diminished,  and  in  a  small  proportion  of  cases  con- 
tains some  albumen,  and  the  bowels  usually  remain  quiet  unless  disturbed 
by  laxative  medicine. 

This  class  of  cases  usually  reach  the  climax  of  activity  in  both  general 
and  local  symptoms  in  from  three  to  five  days  after  the  first  development 
of  local  symptoms.  The  swelling  of  the  glands  of  the  neck  and  parts 
within  the  fauces  ceases  to  increase;  the  membranous  exudation  soon 
appears  more  yellow  and  shows  signs  of  loosening  or  disintegration;  the 
saliva  or  mucus  in  the  mouth  and  fauces  becomes  more  opaque,  more  easily 
dislodged,  the  breath  more  offensive,  and  generally  some  discharge  from 
the  nostrils.  While  these  local  changes  are  taking  place,  the  general 
febrile  symptoms  also  diminish  ;  and  in  the  inildest  variety  of  cases  by  the 
end  of  the  first  week,  the  temperature  has  returned  to  the  natural  standard, 
the  pulse  becomes  soft  and  weak,  but  natural  in  frequency;  the  cutaneous 
and  urinary  secretions  natural,  and  the  membranous  exudation  and  swell- 
ing both  in  the  fauces  and  lymphatic  glands  disappear,  leaving  the  patient 
fairly  convalescent,  yet  much  debilitated.  In  the  more  severe  cases  belong- 
ing to  the  first  group,  the  morbid  phenomena  reach  their  climax  in  the  same 
length  of  time,  and  the  same  subsequent  charges  take  place,  but  the  sub- 
sidence of  the  glandular  swellings  and  the  disintegration  of  the  membran- 
ous exudations  progress  slower,  and  are  accompanied  by  more  copious  and 
troublesome  discharges  from  the  mouth  and  nostrils,  and  greater  offensive- 
ness  of  the  breath.  The  patient  also  exhibits  more  dullness,  with  paroxysms 
of  restlessness,  especially  when  the  fauces  and  nostrils  become  obstructed 
by  the  mucous  or  muco-purulent  discharge,  as  is  apt  to  be  the  case  in 
infants  and  young  children.  The  pulse  becomes  more  weak,  the  bodily 
temperature  returns  more  slowly  to  the  natural  standard,  although  the  skin 


SYMPTOMS.  169 

and  extremities  may  even  feel  unduly  cold,  and  the  patient  is  lono^er 
troubled  with  difficulty  of  deglutition,  and  more  tendency  of  food  and 
drink  to  regurgitate  through  the  nostrils.  Yet,  in  nearly  all  of  these  cases 
the  disease  cotnpletes  its  cpurse,  and  convalescence  is  established  by  the 
middle  or  latter  part  of  the  second  week.  In  some,  however,  tho  breaking 
up  and  disappearance  of  the  false  membrane  is  accompanied  and  followed 
by  superficial  ulcerations  in  the  tonsils  and  other  parts  of  the  throat;  and, 
in  a  smaller  number,  one  or  more  of  the  inflamed  lymphatic  glands  suppu- 
rate, forming  abscesses  in  the  neck.  These  occurrences  may  postpone  the 
establishment  of  convalescence  until  some  time  during  the  third  week 
from  the  commencement  of  the  attack. 

The  second  or  croupous  group  of  cases,  including  all  those  in  which  the 
diphtheritic  inflammation  invades  the  larynx,  will  be  presented  to  you  under 
two  aspects  :  one,  in  which  the  inflammation  enters  the  larynx  apparently 
by  extension  from  the  pharynx,  and  generally  manifests  itself  first  between 
the  fourth  and  seventh  days  after  the  commencement  of  the  disease,  or 
even  after  convalescence  has  fairly  commenced;  the  other,  in  which  the 
inflammation  attacks  the  larnyx  primarily,  giving  rise  to  hoarseness  of 
voice,  stridulous  breathing  and  croupal  cough,  from  the  beginning  of  the 
patient's  sickness.  In  both,  the  general  symptoms  are  the  same  as  in 
ordinary  diphtheria. 

In  all  the  cases  in  which  the  local  disease  develops  in  the  larynx  by 
extension  from  above  downward,  and  does  not  commence  until  several 
days  after  the  beginning  of  the  general  diphtheritic  disease,  there  can  be 
no  difficulty  in  making  the  diagnosis.  But  when  the  larynx  is  invaded 
coincidently  with  the  beginning  of  the  sickness,  there  is  often  much  diffi- 
culty in  keeping  a  clear  line  of  distinction  between  the  diphtheritic 
disease  and  the  ordinary  sporadic  pseudo-membranous  laryngitis.  And 
many  writers  of  the  present  day  regard  them  as  identical,  and  do  not 
attempt  to  distinguish  the  one  from  the  other.  In  all  the  cases  that  have  come 
under  my  observation,  however,  the  diphtheritic  laryngitis  has  been  accom- 
panied by  some  redness  and  swelling  of  the  tonsils  and  other  glands  in 
the  neck;  a  soft,  weak  pulse;  more  dullness  of  expression,  and  earlier 
symptoms  of  exhaustion.  In  all  these  cases  the  inflammation  in  the  larynx 
is  accompanied  b}'  a  rapidly  increasing  exudation,  which  solidifies  into  a 
thick,  firm  layer  of  false  membrane  over  all  the  intei'ior  of  the  larvnx,  the 
cartilages  at  the  opening  of  the  glottis,  and  often  downward  through  the 
treachea  and  into  the  larger  bronchial  tubes.  The  voice  becomes  early 
suppressed,  the  cough  rough,  stridulous  and  sufl^ocative;  the  breathing 
difficult,  and  accompanied  by  a  tiglit,  wheezing  sound  in  the  neck  at  first, 
but  subsequently  accompanied  by  mucous  rattle.  To  these  local  symptoms 
of  direct  obstruction  in  the  larynx,  there  is  added  a  soft,  quick,  weak  pulse, 
somewhat  purplish  or  leaden  color  of  the  lips,  and  fullness  or  bloating  of  the 
face;  coolness  of  the  extremities,  with  moderate  increaseof  temperature  in  the 
head  and  trunk  of  the  body;  drowsiness,  with  temporary  paroxysms  of 
restlessness  and  tossing;  often  difficulty  of  deglutition,  and  scantiness 
of  urine.  In  very  severe  cases  the  dyspnoea  and  rattling  in  the  throat 
and  larynx  increases  every  hour,  with  frequent  paroxysms  of  choking, 
strangling  cough,  during  which,  more  or  less  of  a  thick,  ropy  mucus  is 
forced  out,  containing  shreds  of  the  false  membrane;  after  which,  for  a 
brief  time,  the  breathing  is  easier.  But  the  obstruction  soon  accumulates 
again,  causing  the  sense  of  suffocation  and  strugsling  lor  breath  to  be 
renewed,  until  the  imperfect  oxygenation  and  decarbonization  of  the  blood 
renders  it  no  longer  capable  of  sustaining  the  sensibility  of  the  brain  and 
nervous    centers,    when   the    patient    becomes   somnolent    or  stupid,    the 


170  DIPHTHERIA. 

breathing  frequent,  very  difficult,  and  accompanied  by  coarse  mucous  rat- 
tliuo-  in  the  air  passages;  blueness  of  the  lips;  coldness  and  blueness  of 
the  extremities;  a  small  and  very  weak  pulse;  and,  finally,  relaxation  of 
the  sphincters,  a  general  clammy  sweat,  and  death  from  asphyxia.  The 
fatal  result  is  reached  in  some  of  these  cases  in  five  or  six  hours;  in  a 
much  larger  number,  however,  it  is  deferred  from  two  to  five  days.  If  the 
tumefaction  of  the  parts  within  the  larnyx  and  the  membranous  formations 
are  not  sufficient  to  destroy  life  in  from  three  to  five  days,  the  latter  begin 
to  loosen  and  disintegrate,  and  in  the  paroxysms  of  coughing  more  shreds 
and  patches  of  the  membrane  are  dislodged  and  thrown  out  with  a  more 
opaque,  muco-purulent  expectoration. 

The  tightness  and  constriction  in  the  breathing  diminishes;  the  color  of  the 
skin  and  expression  of  countenance  improve;  the  pulse  becomes  slower; 
the  mind  more  active;  and  in  three  days,  or  from  seven  to  nine  from  the 
commencement  of  the  laryngeal  trouble,  all  bad  symptoms  have  disap- 
peared, leaving  the  patient  convalescent  but  much  debilitated.  In  some 
cases  of  diphtheritic  laryngitis,  the  membrane  is  detached  and  thrown  out, 
in  the  severe  paroxysms  of  coughing,  in  large  pieces,  presenting,  when 
inflated,  more  or  less  of  a  complete  model  of  the  interior  of  the  larynx. 
Many  years  since  I  saw  a  case  in  consultation  with  my  colleague.  Dr. 
HoUister,  in  which  the  patient,  a  boy  aged  seven  years,  in  a  violent  par- 
oxysm of  coughing  expelled  a  perfect  tubular  cast  of  the  larynx  and  tra- 
chea, measuring  seven  inches  in  length  to  the  bifurcation,  and  extending 
beyond  to  the  primary  division  of  the  bronchial  tubes,  having  thirteen  divis- 
ions on  one  side  and  eleven  on  the  other,*  The  expulsion  was  followed 
by  a  great  degree  of  immediate  relief;  but,  as  frequently  happens,  the 
relief  was  only  temporary.  Fresh  exudations  took  place  on  the  inflamed 
membrane,  and,  extending  lower  into  the  bronchial  tubes,  renewed  the 
dyspnoea,  and  proved  fatal  before  the  end  of  the  next  twenty-four  hours. 

In  the  third,  or  malignant  group  of  cases,  the  onset  of  the  attack  is  gen- 
erally abrupt,  and  attended  by  appearances  of  a  chill  or  cold  stage,  which 
is  followed  by  a  more  rapid  rise  of  temperature  of  the  body;  a  more  rapid 
development  of  inflammation  and  swelling,  both  in  the  fauces  and  glands 
of  the  neck,  oi'ten  causing  in  a  very  few  hours  great  difficulty  of  deglu- 
tition, inability  to  open  the  mouth  widely,  and  the  speedy  formation  of  a 
thick,  tough,  yellowish  membrane  over  the  whole  arch  of  the  palate,  ton- 
sils, and  pharynx.  The  pulse  is  freqtient,  soft,  and  weak;  breathing  noisy 
from  the  existence  of  tenacious  mucus  in  the  throat  and  nostrils,  and  more 
fre(4uent  than  natural;  the  expression  of  countenance  dull,  with  a  dark  or 
purplish  flush;  extremities  often  coo),  with  leaden  color  under  the  nails; 
urine  scanty,  and  often  containing  some  albumen;  and  the  mind  inclined 
to  drowsiness,  except  in  momentary  paroxysms  of  restless  tossing  or  of 
efi"orts  to  clear  the  mucus  from  the  throat.  Sometimes  the  attacks  of  this 
variety  are  so  severe,  and  the  tumefaction  of  the  tissues  within  and  behind 
the  angle  of  the  jaw  so  great,  that  the  blood  is  obstructed  in  its  return 
from  the  brain,  causing  stupor,  inability  to  swallow,  extreme  frequency 
and  feebleness  of  pulse,  and  death  in  from  twelve  to  eighteen  hours  after 
the  beginning  of  the  attack.  In  other  cases,  the  obstruction  to  the  cere- 
bral circulation  is  less,  and  life  is  prolonged  from  one  to  five  days.  In 
such,  during  the  second  day,  the  inflammation  and  exudation  extend  into 
the  nostrils  posteriorly,  and  sometimes  into  the  eustachian  tubes,  and  even 
into  the  middle  ear.  During  the  third  and  fourth  days  the  false  mem- 
branes begin  to  disintegrate,  the  mucus  in  the  fauces  and  nostrils  becomes 
more  abundant,  more  opaque  or  muco-purulent,  decidedly  offensive,  and 

*See  Chicago  Medical  Examiner,  Vol.  I,  pp.  05-6, 1800. 


DIAGNOSIS.  171 

gives  occasion  to  much  noise  and  difficulty  of  breatliing.  The  inflamed 
mucous  membrane  also  shows  commencing-  ulceration,  and  in  many  cases 
gangrene.  The  patient  loses  strength  rapidly,  and  usually  dies  from  com- 
plete exhaustion  before  the  end  of  the  fifth  day. 

I  have  now  given  you  a  sunnnary  of  the  more  important  symptoms  of 
the  different  grades  of  diphtheria.  You  observe  that  it  is  a  disease  vary- 
ing greatly  in  its  degree  of  severity  in  different  seasons,  and  in  different 
cases  the  same  season.  So  true  is  this,  that  I  have  in  some  years  attended 
a  large  number  of  cases  with  less  than  two  per  cent,  of  deaths;  while  in 
other  years,  with  no  greater  numbers,  the  proportion  of  croupal  and  malig- 
nant cases  was  so  great  that  the  deaths  averaged  from  ten  to  fifteen  per 
cent.  It  is  not  rare  that,  in  the  more  severe  epidemics  of  this  disease,  all 
the  children  in  a  family  are  destroyed  within  a  few  days.  I  remember 
being  called  to  visit,  in  consultation,  a  Scandinavian  family  in  the  north- 
west part  of  the  city,  where  I  found  three  children  lying  side  by  side  on 
the  same  table,  dressed  for  burial,  and  a  fourth  one  dying,  leaving  only 
the  nursing  intant  in  its  mother's  arms. 

Thus  far  I  have  spoken  of  the  diphtheritic  membranous  exudations  as 
appearing  only  in  the  thioat  and  parts  in  immediate  connection  with  it. 
The  same,  however,  may  attack  the  vagina  and  vulva,  the  lips,  the  wing 
of  the  nose,  the  conjunctiva  of  the  eye,  and  any  sore  or  raw  surface 
in  any  part  of  the  body.  I  saw  one  well  marked  case,  in  which  a  thick 
layer  of  false  membrane  covered  one-third  of  the  upper  lip,  accompanied 
by  considerable  tumefaction;  and  another  in  which  a  lady,  recovering  from 
an  extirpation  of  a  cancerous  tumor  from  one  breast,  while  there  was  still 
a  healthy  granu'ating  surface  unhealed,  was  attacked  with  the  ordinary 
general  symptoms  of  diphtheria,  accompanied  with  a  moderate  degree  of 
inflammation  and  exudation  in  the  fauces.  Simultaneous  with  the  appear- 
ance of  the  latter,  the  uncicatrized  surface  on  the  breast  became  com- 
pletely covered  with  a  thick  layer  of  false  membrane,  which  remained 
about  three  days,  and  as  it  disintegrated  and  disappeared,  it  was  accom- 
panied by  an  abundant  sero-purulent  and  offensive  discharge,  with  a  com- 
plete destruction  of  all  the  previously  healthy  granulations.  After  the 
diphtheritic  disease  had  disappeared,  the  raw  surface  on  the  breast  gradu- 
ally resumed  a  healthy  apjoearance,  and  subsequently  progressed  to  com- 
plete cicatrization. 

Diagnosis. — From  catarrhal  sore  throat,  diphtheria  is  distinguished  by 
the  character  of  the  general  fever;  the  coincident  inflammation  of  the 
mucous  membrane  of  the  fauces  and  tonsils,  with  tumefaction  of  some  of 
the  lymphatic  glands  near  the  angle  of  the  jaws;  and  still  more,  by  the 
appearance  of  more  or  less  diphtheritic  exudation  on  some  part  of  the 
inflamed  structures.  The  diagnostic  differences  between  diphtheria  and 
ordinary  sporadic  croup  or  active  pseudo-membranous  laryngitis,  I  pointed 
out  when  giving  the  symptoms  of  the  croupous  variety  of  diphtheria,  and 
need  not  repeat  them.  From  scarlet  fever,  diphtheria  is  distinguished  by 
the  much  less  sudden  and  severe  onset  of  the  fever,  the  presence  of  diph- 
theritic membranous  exudations,  and  the  absence,  generally,  of  any  exan- 
thematous  eruption  upon  the  skin.  In  some  epidemics  of  diphtheria  quite 
a  proportion  of  the  cases  will  be  accompanied  by  a  moderate  amount  of  a 
fine  red  exanthematous  rash,  causing  the  surface  to  much  resemble  mild 
cases  of  scarlet  fever.  But  the  milder  grade  of  general  fever,  and  the 
coincident  existence  of  white  patches  of  diphtheritic  mem!)rane  in  the 
fauces,  will  usually  enable  the  practitioner  to  keep  the  diagnosis  correct. 
It  has  undoubtedly  happened,  however,  when  both  these  general  febrile 
diseases  were  prevailing  in  the  same  community,  that  they  have  manifested 


172  DIPHTHERIA. 

a  disposition  to  commingle  the  chiracteristic  symptoms  of  both  in  the 
same  patient,  thereby  causing  doubt  and  sometimes  controversy  concern- 
ing the  diagnosis.  It  is  more  proper  to  regard  such  cases  as  presenting 
the  combined  or  simultaneous  presence  of  the  causes  of  both  diseases,  in 
the  same  manner  as  we  recognize  the  coincident  action  of  the  causes  of 
typhoid  and  periodical  fevers,  producing  what  has  been  styled  typho- 
malarial  disease. 

Prognosis. — The  prognosis  has  been  pretty  fully  indicated  by  the  clin- 
ical history  I  have  just  detailed  to  you.  Ail  the  milder  cases  tend  towards 
spontaneous  recovery  in  from  seven  to  fourteen  days.  The  more  malignant 
and  the  croupous  groups  of  cases  manifest  a  strong  tendency  to  end  in  the 
death  of  the  patient,  and  are  always  productive  of  a  high  ratio  of  mortality. 

Pathology. — I  regard  diphtheria  as  a  general  febrile  affection,  arising 
from  some  cause  or  combination  of  causes  by  which  the  properties  of  the 
blood  and  of  the  organized  structures  are  so  changed  as  to  render  the 
fibrin  more  disposed  1x)  solidify  or  coagulate  than  natural,  and  to  lessen  the 
tone  and  contractibility  of  the  muscular  structures,  with  special  tendency 
to  develop  asthenic  inflammation  of  greater  or  less  severity  in  the  mucous 
membrane  of  the  throat  and  adjacent  lymphatic  glands.  That  the  general 
disease  is  one  of  a  typhoid  or  adynamic  character,  and  the  local  inflamma- 
tions asthenic,  is  proved  by  the  generally  soft,  compressible  pulse,  universal 
muscular  weakness,  liability  to  syncope  from  moderate  exertion,  and  the 
aplastic  character  of  all  exudations.  By  the  latter  I  mean  the  uniform 
tendency  of  all  the  membranous  exudations,  however  thick  or  tough  they 
may  be,  to  undergo  degeneration  and  dissolution,  never  taking  on  perma- 
nent organization  or  becoming  a  bond  of  union  by  adhesively  uniting  sur- 
faces that  may  be  in  contact  with  each  other.  This  view  is  further 
corroborated  by  the  frequent  occurrence  of  muscular  paralysis  as  a  sequel 
of  the  disease. 

Treatment. — From  these  views  of  the  pathology  of  diphtheria  I  deduce 
four  well  defined,  rational  indications  to  be  fulfilled  by  treatment:  First, 
to  arrest  the  further  infection  and  deterioration  of  the  blood.  Second,  to 
improve  the  general  tonicity  of  the  tissues  by  increasing  the  vital  affinity. 
Third,  to  sustain  the  nuti'itive  and  excretory  functions  as  near  their  natural 
condition  as  possible.  Fourth,  to  mitigate  the  violence  of  such  local  inflam- 
mations as  may  exist  in  each  individual  case.  To  fulfill  the  first  of  these 
indications,  the  chief  reliance  has  been  placed  on  the  internal  use  of  chlo- 
rine, bromine,  iodine,  and  their  salts,  such  as  the  chlorates  of  potassium 
and  sodium;  and  to  these  have  been  added  more  recently,  the  sulphurous 
acid  and  the  sulphites  of  sodium  and  calcium,the  benzoate  of  sodium, 
the  sulpho-carbolate  of  sodium,  and  the  permanganate  of  potassium.  Of 
these,  T  think  the  aqueous  solution  of  iodine,  the  chlorate  of  potassium 
and  the  benzoate  of  sodium  are  the  most  important.  To  fulfill  the  second  in- 
dications, I  rely  principally  upon  a  judicious  use  of  quinia,  iron,  strychnia, 
pure  air  and  nourishment;  even  when  temporary  stimulants  are  needed,  car- 
bonate of  ammonium  and  camphor  are  the  most  reliable.  Many  recommend 
strongly  the  use  of  some  one  of  the  alcoholic  class  of  drinks,  and  mention 
the  extraordinarily  large  doses  borne  by  diphtheritic  patients  without  intoxi- 
cating effects.  So  far  is  this  from  affording  a  reason  for  their  use,  that  I 
should  construe  it  in  the  opposite  direction.  Both  the  general  susceptiWlity 
of  the  tissues  and  the  sensibilitv  of  the  nervous  svstem  are  blunted  or 
below  the  normal  standard,  and  consequently,  anaestheti'cs  like  alcohol,  are 
neither  indicated  nor  readily  responded  to  when  given.  The  same  prin- 
ciple or  therapeutic  rule  applies  here,  that  I  explained  more  fully  when 
speaking  to  you  in  relation  to  the  treatment  of  typhoid  fever. 


TREATMENT.  173 

If  you  can  succeed  well  in  fulfilling  the  first  and  second  indications  as 
DOW  explained,  the  fulfil. meut  of  the  third  follows  as  a  necessary  result. 
Yet,  when  called  early,  and  you  find  the  skin  hot  and  dry;  urine  scanty; 
tongue  coated;  and  bowels  inactive,  you  can  give  a  small  alterative  dose 
of  calomel  with  bicarbonate  of  sodium,  every  three  or  four  hours,  until 
three  doses  are  taken;  and  if  the  bowels  do  not  move  in  three  hours  after 
tlie  third  dose,  give  a  mild  laxative,  and  it  will  generally  produce  a  favor- 
able efl'ect.  The  action  of  the  skin  and  kidneys  may  be  further  sustained 
by  suitable  doses  of  spirits  of  nitrous  ether  and  liquor  ammonii  acetatib. 
To  fulfill  the  fourth  indication,  namely — to  lessen  the  severity  of  the  local 
ir.fiammation  in  the  fauces,  air  passages,  and  glands  of  the  neck,  a  great 
variety  of  local  applications  have  been  used.  During  the  severe  epidem- 
ics in  this  country,  occurring  between  1856  and  1864,  nitrate  of  silver  in 
all  gradations  of  strength,  from  the  solid  stick  to  a  solution  of  0.33  grains 
(gr.  V.)  to  30.0  cub.c  centimeters  (fl.  ^i.)  of  water,  was  extensively  and 
perseveringly  used  locally,  with  the  expectation  of  arresting  the  mem- 
branous exudation  and  of  limiting  the  extent  of  the  inflammation.  After  an 
abundant  experience,  its  use  was  abandoned  by  nearly  all  the  more  ac  urate 
observers  as  either  useless  or  positively  injurious.  Applications  of  strong 
solutions  of  sulphate  of  copper,  tincture  of  iodine,  and  tincture  of  the 
chloride  of  iron,  were  tried  with  no  better  results,  and  the  profession  gen- 
erally had  come  to  regard  local  applications  of  any  kind  as  a  matter  of 
secondary  importance,  until  Oertel  and  others  again  promulgated  the  doc- 
trine that  diphtheria  is  primarily  a  local  disease,  produced  by  the  direct 
action  of  bacterial  germs  on  the  mucous  membrane  of  the  fauces  and  air 
passages,  and  through  which  they  entered  the  blood,  and  secondarily,  pro- 
duced general  infectious  fever.  Under  this  teaching  the  early  and  thor- 
ough local  application,  not  of  caustics,  but  of  sirong  antiseptics  or  germi- 
cides, as  carbolic,  salicylic,  benzoic,  and  sulphurous  acids,  were  brought 
prominently  to  the  notice  of  the  profession,  and  received  the  unqualified 
commendation  of  many  practitioners.  During  the  past  ten  or  twelve  years 
diphtheria  has  prevailecl  with  average  severity  in  most  of  our  large  cities 
and  in  many  coimtry  districts,  affording  abundant  opportunities  lor  test- 
ing the  virtues  of  this  class  of  remedies.  And,  aided  by  the  coincident 
extravagant  ideas  in  regard  to  the  uses  of  antiseptics  in  the  practice  of 
medicine  and  surgery  generally,  they  were  enthusiastically  applied  in 
every  form,  and  every  degree  of  strength;  in  solution,  with  the  swab  and 
the  syringe;  in  spray,  with  the  atomizers;  and  in  vapor,  by  inhalations.  As 
might  be  expected,  the  results,  as  reported  at  the  various  medical  society 
meetings  and  through  the  medical  press,  have  been  varied.  As  a  general 
1  ule,  those  who  met  the  disease  in  a  mild  form  reported  great  success. 
Those  who  met  the  disease  in  its  more  severe  and  malignant  aspects, 
reported  the  usual  ratio  of  mortality,  and  pronounced  the  germicide 
treatment  useless.  A  middle  class  of  practitioners,  like  a  member  of  the 
Illinois  State  Society,  reported,  with  enthusiasm,  that  the  thorough  appli- 
cation of  pretty  strong  solutions  of  carbolic  acid  had  aborted  every  case 
that  had  come  under  his  treatment  before  the  inflammation  and  exudation 
had  entered  the  posterior  nares  or  the  larynx.  But  unfortunately  the  dis- 
ease had  extended  beyond  these  limits  in  so  many  cases  before  coming 
under  treatment,  that  the  actual  ratio  of  mortality  to  the  whole  number  of 
cases  treated,  was  the  same  as  usual. 

So,  gentlemen,  if  you  will  diligently  examine  the  statistics  of  cases  and 
mortality  in  all  the  cities  and  municipalities  in  which  such  statistics  have 
been  kept,  for  the  past  ten  years,  in  which  germicidal  theories  and  prac- 
tice have  predominated,  with  the  same  class  of  statistics  for  the  preceding 


174  DIPHTHEr.TA. 

ten  years,  you  will  find  no  evidence  that  such  practice  has  resulted  in 
diminishing,  in  any  degree,  the  ratio  of  mortality  below  that  of  the  former 
decade.  Having  already  stated  to  you  that  I  regard  diphtheria  as  pi-ima- 
rily  a  general  febrile  afl'ection,  developing  certain  local  inflammations  of 
peculiar  character  during  its  progress,  and  having  now  explained  the  sev- 
eral objects  to  be  accomplished  in  its  treatment,  it  only  remains  for  me  to 
indicate  more  definitely  which  of  the  remedies  mentioned  for  the  several 
purposes  I  deem  best,  and  their  mode  of  use  as  adapted  to  the  several 
stages  of  the  disease.  In  the  milder  cases  of  simple  diphtheria,  very  little 
medication  is  either  necessary  or  projoer.  For  such,  I  direct  a  diet  of 
milk  and  farinaceous  articles,  rest,  as  Iresh  good  a-r  as  possible,  a  moder- 
ate, comfortable  temperature  of  the  room,  and  the  following  prescriiDtion 
for  medicine: 

^      Potassii  Chlorate  10.0  grams.  3iiss 

Acidi  Muriatic!  4.0  c.  c.  3i 

Tincturae  Belladonnas  10.0  c.  c.  3iiss 

Aquae  260.0  c.  c.  ?viii 

Mix.  Give  from  two  cubic  centimeters  (fl.  3ss.)  to  eight  (fl.  3ii),  or  from 
half  a  teaspoonful  to  a  dessert  spoonful,  according  to  the  age  of  the 
patient,  every  two  or  three  hours,  without  further  dilution.  The  applica- 
tion of  this  solution  to  the  fauces  and  throat,  is  made  much  more  complete 
and  easy  by  swallowing  it,  than  bv  any  process  of  swabbing,  sponging  or 
gargling;  while  its  introduction  into  the  system  constitutes  one  of  the  best 
means  for  fulfilling  the  first  indication  for  general  treatment.  The  solution 
of  the  chlorate  of  potassium  with  the  mineral  acid,  combines  the  properties 
of  an  efficient  antiseptic  and  tonic,  while  the  influence  of  the  belladonna 
on  the  vessels  of  the  mucous  membrane  and  glands  of  the  throat  and  neck 
tends  to  lessen  both  tumefaction  and  membranous  exudation. 

During  the  last  thirty  years  I  have  treated  very  many  cases  of  mild 
diphtheria,  without  any  other  medication  than  the  use  of  the  formula  just 
given.  If.  at  any  time  during  its  use,  the  efi^ects  of  the  belladonna  accu- 
mulate sufficient  to  perceptibly  dilate  the  pupils,  the  dose  should  either  be 
diminished  or  given  at  longer  intervals.  In  cases  of  greater  severity,  yet  not 
positively  malignant,  I  give  the  same  formula  in  the  same  manner  during 
the  first  three  days  after  the  commencement  of  the  disease.  If  the  patient 
has  been  previously  healthy  and  well  nourished,  and  the  pulse  and  tem- 
perature rise  pretty  actively,  with  scantiness  of  secretions,  I  give  in  addi- 
tion during  the  first  day,  an  alterative  dose  of  calomel  at  intervals  of  once 
in  two  or  three  hours  until  three  doses  have  been  taken;  and,  if  nec- 
essary, follo"\v  them  by  a  mild  laxative  or  warm  water  enema.  After 
the  bowels  have  moved,  I  direct  a  solution  of  iodine  0.33  grams  (gr.  v.) 
and  iodide  of  potassium  2.0  grams  fgr.  xxx.)  in  45  cubic  centimetres 
(5jss)  of  water,  to  be  given  in  doses  suited  to  the  age  of  the  patient, 
every  six  hours.  During  the  same  early  stage,  if  the  tonsils  and  glands 
behind  and  below  the  angle  of  the  jaw  commence  to  swell  actively,  I  keep 
the  external  parts  closely  covered  with  cloths  wet  in  an  infusion  of  aconite 
leaves  and  chloride  of  ammonium,  30  grams  (fj)  of  the  former,  and 
15  grams  (fss.)  of  the  latter  to  one  litre  (Ojj)  of  boiling  water.  "When, 
from  any  cause  it  may  be  difficult  to  keep  the  wet  cloths  applied  properly, 
the  following  liniment  may  be  used  instead: 

I^     Olei  OlivjB  90.0  c.  c.     |iii. 

Olei  Terebinthinae  15.0  c.  c.       ^ss. 
Chloroformi  15.0  c.  c.       ^ss. 


TREATMENT.  175 

]\rix,  and  apply  to  all  the  external  swollen  parts  every  three  hours,  or 
oTteii  enouo-h  to  keep  the  surface  moiat.  If,  under  the  remedial  ag-ents  I 
have  now  mentioned  the  case  progresses  favorably,  and  when  the  time  for 
the  membranous  exudations  to  begin  to  loosen  and  disintegrate  comos, 
which  is  generally  from  the  third  to  the  fifth  day,  the  breath  and  saliva 
do  not  become  offensive,  and  the  swelling  of  the  glands  does  not  increase 
further,  there  need  be  no  essential  change  in  the  treatment  except  to  lessen 
the  frequency  of  doses  as  the  disease  declines,  and  an  early  convalesceno*^ 
will  be  reached.  But  if,  at  the  stage  just  mentioned,  the  breath  becomes 
oifensive,  the  saliva  more  abundant,  and  mixed  with  more  or  less  muco- 
purulent or  sanious  discharge  from  the  throat  and  nostrils,  with  more  dull- 
ness of  expression  and  a  solter  pulse,  I  immediately  exchange  the  chlorate 
of  potassium  and  belladonna  solution  for  the  tincture  of  chloride  of  iron 
and  quinine,  given  in  moderate,  but  frequently  repeated  doses,  and  require 
more  diligence  in  giving  nourishment.  The  solution  of  iodine  may  gener- 
ally be  given  with  benefit  two  or  three  days  longer.  Under  the  influence 
of  the  quinine,  iron,  and  simple  nourishment,  the  patient  will  pass  the 
crisis  of  the  disease  with  only  a  moderate  amount  of  ulceration  and  suppu- 
rative action  in  the  inflamed  membranes,  and  the  general  febrile  symptoms 
will  gradually  decline  until  convalescence  is  established.  In  some  of  the 
more  severe  and  malignant  cases,  the  crisis  of  the  disease  is  marked  by 
great  weakness,  a  more  copious  flow  of  offensive  muco-purulent  matter  from 
the  mouth  and  nostrils,  and  more  extensive  destruction  of  the  inflamed  struc- 
tures by  ulceration,  and  sometimes  by  gangrene.  In  such  cases,  I  continue 
the  use  of  the  quinine  and  iron,  and,  in  addition,  give  carbonate  of  ammo- 
nium and  camphor,  in  moderate  but  frequently  repeated  doses,  and  add  to 
what  nourishment  is  taken  by  the  mouth,  the  use  of  nutritive  enemas. 
Unfortunately,  in  many  of  these  bad  cases,  deglutition  is  so  impaired  that 
neither  medicines  nor  nourishment  can  be  swallowed  in  sufficient  quantity 
to  effect  the  needed  support.  Even  in  such,  much  can  be  done  to  sustain 
them  until  the  throat  begins  to  improve,  by  a  judicious  use  of  milk,  beef 
tea,  and  other  items  of  nourishment  in  the  form  of  enemas,  and  most  of 
the  medicines  required  can  be  added  to  the  enemas.  Further  support  may 
also  be  given  by  inunction  of  cod-liver  oil,  in  which  may  be  suspended  a 
small  amount  of  strychnine.  To  a  litre  (Oii.)  of  cod-liver  oil  may  be  added 
0.2  grams  (gr.  iii)  of  strychnine.  This  may  be  well  shaken  and  applied 
sufficient  to  anoint  nearly  the  whole  surface  of  the  body  three  times  a  day. 
In  the  cases  that  present  a  strongly  malignant  aspect  from  the  beginning, 
I  give  the  quinine  and  tincture  of  chloride  of  iron,  alternated  with  the  car- 
bonate of  ammonium  and  camphor  at  once;  and  during  the  first  twenty-four 
hours  apply  freely  over  the  trunk  of  the  body  the  cod-liver  oil,  holding  in 
solution  a  small  proportion  of  iodine;  and,  after  the  first  day,  the  strych- 
nine my  be  added  in  the  proportion  already  stated. 

During  the  last  few  years,  I  have  used  a  solution  of  the  benzoate  of 
sodium  as  a  substitute  for  the  chlorate  of  potassium,  and  belladonna  solu- 
tion, in  the  early  stage  of  the  disease.  Ten  grams  (3iiss.)  may  be 
dissolved  in  120  cubic  centimetres  (fl.  Tiv)  of  water;  of  which  four  cubic 
centimetres,  or  one  teaspoonful  may  be  given  to  an  adult  every  two  hours. 
It  appears  to  exercise  much  influence  in  limiting  the  amount  of  the  mem- 
branous exudation,  and  is  particularly  well  adapted  to  the  early  stage  of 
the  more  active  sthenic  class  of  cases.  Again,  in  the  second  stage  of  the 
disease,  if  the  muco-purulent  discharge  from  the  nostrils  becomes  copious 
and  offensive,  or  irritating  to  the  parts  with  which  it  comes  in  contact,  it 
will  do  good  to  have  the  nostrils  syringed  out  freely  at  least  twice  in  the 
twenty-four  hours,  with  a  weak  solution   of  carbolic  acid  and   sulphate  of 


176  DIPHTHERIA. 

zinc  or  of  permanganate  of  potassium.  If  an  anodyne  is  required  at  night  to 
aid  in  procuring  rest,  I  know  of  none  better  than  a  powder  containing  the 
compound  powder  of  opium  and  ipecac,  0.33  grams  (gr.  v)  and  pulverized 
gum  camphor  0.13  grams  (gr.  ii.)  for  an  adult,  and  proportionably  less  for 
children. 

I  have  now  given  you  an  outline  of  that  course  of  treatment  of  the 
several  stages  and  grades  of  severity  of  this  disi  as  ',  which  has  been,  in 
my  hands,  the  most  beneficial  to  my  patients,  leading  to  the  highest  ratio 
of  recoveries  and  leaving  the  smallest  ratio  of  important  sequelae.  One 
variety  of  cases,  however,  has  been  omitted  from  this  outline,  namely,  the 
croupous  or  laryngo-tracheal.  When  the  diphtheritic  inflammation  in- 
vades the  larynx,  whether  primarily,  with  the  beo inning  of  the  attack,  or 
secondarily,  by  extension  from  the  pharynx,  I  give,  as  early  as  possible, 
an  emetic  dose  of  the  sub-sulphate  of  mercury,  and  repeat  it  at  intervals 
of  from  two  to  six  hours,  until  the  stage  of  increasing  exudation  has  passed. 
Thirteen  centigrams  (gr.  ii.)  of  the  sub-sulphate  given  in  the  form  of  pow- 
der, will  generally  produce  prompt  and  free  vomiting  in  children  from 
three  to  five  years  of  age.  For  older  patients  the  dose  should  be  increased, 
and  for  younger  ones  diminished.  In  the  interval  between  the  emetics,  I 
give  during  the  first  twelve  hours,  a  small  dose  of  calomel  and  bicarbonate 
of  sodium  every  two  hours.  To  children  from  three  to  five  years  old,  six 
centigrams  (gr.  i.)  of  calomel  and  twelve  centigrams  (gr.  ii.)  of  the 
sodium,  may  be  given  at  a  dose.  During  the  same  period  of  time,  a  solu- 
tion of  lactic  acid,  0.33  cubic  centimetres  (min.  v.)  to  30.  c.c.  (fl.  |i.)  of 
water  should  be  frequently  thrown  into  the  fauces  in  the  form  of  spray 
from  an  atomizer,  and  the  liniment  I  have  previously  mentioned,  containing 
oil  of  olive,  oil  of  turpentine  and  chloroform,  applied  freely  to  the  front  and 
lateral  parts  of  the  neck  externally.  After  the  first  four  or  five  doses  of 
the  calomel  and  sodium  have  been  given,  they  are  omitted,  and  I  give, 
instead,  a  solution  of  lactate  of  iron,  4  grams  (3i.)  to  120  cubic  centimetres 
of  water  (fl.  fiv.)  of  water,  of  which  2  c.c.  (fl.  3S3.)  or  half  a  teaspoonful, 
may  be  given  every  two  hours.  If  the  invasion  of  the  larynx  has  been 
secondary,  several  days  after  the  commencement  of  the  general  disease,  I 
omit  the  calomel  and  sodium  powders,  and  commence  the  use  of  the  solu- 
tion of  the  lactate  of  iron,  alternated  with  quinine,  at  once.  In  all  other 
respects  their  management  is  the  same  as  I  have  just  indicated. 

Sometimes  a  mild  anodyne  and  expectorant  influence  is  needed  to 
lessen  the  violent  spasmodic  quality  of  the  cough  and  aid  in  promoting 
rest — especially  in  the  later  stages  of  the  disease.  For  such  purpose  I 
know  of  nothing  better  than  an  equal  mixture  of  the  compound  syrup  of 
squills  and  camphorated  tincture  of  opium,  given  in  doses  suited  to  the 
age  of  the  patient.  If  a  judicious  use  of  the  remedies  I  have  just  detailed 
should  fail  to  relieve  the  patient,  and  suffocation  be  impending,  the  only 
alternative  is  a  resort  to  tracheotomy,  which  almost  always  afibrds  a  sur- 
prising degree  of  temporary  relief,  but  is  very  generally  followed  by  an 
extension  of  the  inflammation  into  the  bronchial  tubes  and  the  ultimate 
death  of  the  patient.  During  all  the  treatment  of  the  croupous  cases  the 
temperature  of  the  room  should  be  kept  a  little  above  the  usual  standard 
of  healthy  comfort,  and  the  air  constantly  impregnated  with  aqueous 
vapor.  Some  place  much  reliance  on  the  inhalation  of  the  vapor  of  hot 
water,  in  which  quicklime  is  undergoing  the  process  of  slacking.  I  have 
seen  it  perseveringly  tried  many  times,  but  with  very  little  effect.  I 
regard  it  of  far  less  importance  than  the  lactic  acid  spray,  and  even  less 
beneficial  than  the  old-fashioned  remedy,  consisting  of  the  free  inhalation 
of  the  vapor  from  a  hot  infusion  of  hops  in  vinegar. 


SEQUELS.  177 

Co)ivalescenc€, — Due  attention  should  be  given  to  the  management  of  the 
period  of  convalescence  from  all  grades  of  diphtheria.  To  secure  a  proper 
action  of  the  skin  and  kidneys,  and  promote  the  renewal  of  a  healthy  tone 
and  sensibility  in  the  muscular  and  nervous  structures,  the  patient  should  be 
kept  much  at  rest;  well  protect.3d  from  sudden  atmospheric  changes  by 
flannel  underclothes;  judiciously  supplied  with  fresh,  dry  air,  and  plain, 
nutritious,  and  easily-digestible  food.  In  the  convalescence  from  severe 
cases,  the  taking  of  a  small  dose  of  strychnine  or  nux  vomica,  with  a  solu- 
ble salt  of  iron  at  each  regular  meal-time,  will  be  of  much  benefit,  both  in 
hastening  the  return  of  strength  and  in  lessening  the  risk  of  paralysis. 

Prophylaxis. — The  best  means  of  preventing  the  spread  of  diphtheria 
is  to  isolate,  as  far  as  practicable,  all  cases  as  they  occur,  and  maintain 
essentially  the  same  sanitary  regulations  as  I  mentioned  for  the  preven- 
tion of  typhus  and  typhoid  fevers. 

Sequehe. — Congestion  of  the  cortical  texture  of  the  kidneys,  and  gen- 
eral dropsy  occasionally  occur  as  a  sequel  of  diphtheria,  though  much  less 
frequently  than  after  scarlet  fever.  For  the  treatment  of  such  cases  I 
refer  you  directly  to  the  lecture  on  the  sequelae  of  the  fever  just  named. 
The  most  frequent  and  troublesome  of  the  affections  that  are  liable  to 
arise  during  the  convalescence  from  diphtheria  is  some  form  of  paralysis. 
In  most  cases  it  is  limited  to  the  muscles  of  the  fauces  and  pharynx,  and 
is  only  sufficient  to  simply  give  the  voice  a  decided  nasal  quality,  and 
make  deglutition  a  little  difficult;  but  is  sometimes  so  complete  as  to 
render  swallowing  altogether  impossible.  During  the  prevalence  of  the 
disease  in  this  city  in  1858-9,  I  saw  a  case  of  this  kind  with  the  late  Dr. 
J.  A.  Collins.  The  patient  was  a  boy  about  eight  years  of  age;  and  it  was 
necessary  to  feed  him  liquid  nourishment  through  a  stomach-tube  for  two 
weeks,  before  he  regained  the  power  to  swallow  anything. 

While  the  paralysis  more  frequently  attacks  the  muscles  of  the  fauces 
and  throat,  it  may  manifest  itself  in  any  one  or  more  of  the  voluntary 
muscles  in  any  part  of  the  body  and  extremities.  Or  it  may  attack  one 
set  of  muscles  after  another,  until,  like  rheumatism,  it  has  passed  in  suc- 
cession over  a  large  proportion  of  the  voluntary  muscles  of  the  system. 
A  case  of  this  kind  was  brought  to  the  Mercy  Hospital  two  years  since. 
It  was  in  the  person  of  a  young  man  who  had  passed  through  a  moderately 
severe  attack  of  diphtheria,  and  recovered  so  far  that  he  had  begun  light 
out-door  work. 

He  first  lost  the  power  of  speech  and  deglutition.  In  a  few  days  these 
functions  began  to  improve,  when  he  lost  all  voluntary  motion  of  the  mus- 
cles of  one  side  of  his  face  and  eye.  Just  as  he  was  regaining  control 
over  these,  the  paralysis  involved  the  muscles  of  both  upper  and  lower 
extremities,  and  was  so  near  complete  that  he  could  neither  feed  himself 
nor  stand  on  his  feet.  It  was  at  this  stage  of  his  disease  that  he  was 
brought  into  the  hospital.  The  paralysis  following  diphtheria,  whether 
partial  or  complete,  appears  to  be  a  simple  loss  of  nervous  force  or  mus- 
cular contractility,  and  is  not  accompanied  by  any  inflammatory  or  febrile 
symptoms,  or  even  local  pain  and  soreness.  It  very  generally  tends 
towards  recovery,  and  probably  never  ends  fatally,  except  in  very  rare 
instances,  when  it  attacks  the  muscles  of  respiration  or  of  the  heart.  No 
case  has  terminated  fatally  or  failed  to  recover,  within  the  circle  of  my 
own  practice.  The  only  remedies  necessary  are  rest,  good  air,  nutritious 
and  easily-digestible  food,  and  muscular  and  nerve  tonics. 

Of  the  latter,  we  have  none  better  adapted  to  these  cases  or  more 
promptly  curative  than  strychnine,  citrate  of  iron,  and  the  hypophosphites. 
To  an  adult  or  patient  over  fifteen  years  of  age,  I  give  a  pill  or   capsule 

12 


178  PERIODICAL   FEVERS. 

containing'  strychnine,  two  milligrams  (gr.  1-30),  and  citrate  of  iron,  thir- 
teen centigrams  (gr.  ii),  before  each  meal-time;  and  four  cubic  centi- 
meters (£1.  3i)  of  either  the  syrup  of  the  lacto-phosphate  of  calcium  or  of 
the  compound  syrup  of  the  hypophosphite  of  sodium,  calcium,  and  iron, 
half  an  hour  after  each  meal.  Of  course,  proportionately  less  doses  must 
be  given  to  younger  children. 

Under  such  management  the  patients  usually  make  a  good  recovery  in 
from  one  to  four  weeks.  The  daily  application  of  mild  currents  of  elec- 
tricity or  galvanism  has  also  proved  beneficial. 


LECTURE    XX. 

Periidieal  Fevers— Their  History,  Causes,  Varieties,  and  General  Pathology. 

GENTLEMEN: — I  now  invite  your  attention  to  the  second  group  or 
family  of  acute  general  diseases,  usually  styled  periodical  fevers.  The 
individual  fevers  included  in  this  group  are  fewer  in  number  and  much 
more  closely  allied  to  each  other  than  those  constituting  the  first  division, 
under  the  general  name  of  continued  fevers.  They  are  really  varieties  or 
different  grades  of  one  acute  general  disease,  arising  from  the  same  efficient 
cause,  prevailing  at  the  same  times  and  places,  and  readily  convertible  from 
one  into  the  other. 

History. — The  periodical  fevers  have  been  known  and  described,  from 
the  earliest  records  of  medicine,  under  the  names  of  paludal  fever,  marsh 
fever,  endemic  fever,  ague,  bilious  remittent,  and  periodic  fever.  They 
have  often,  also,  been  named  from  the  locality  or  country  where  they  pre- 
vail, as  the  African,  Bengal,  Mediterranean,  Walcheren,  Chagres,  Pan- 
ama fever,  etc.  At  the  present  time  they  are  very  generally  designated 
as  periodical  or  malarial  fevers.  Their  prevalence  appears  to  be  limited 
by  certain  meteorological  and  topographical  conditions,  independent  of 
the  social  or  sanitary  condition  of  the  people.  For  instance,  a  certain 
degree  and  duration  of  summer  heat,  acting  upon  a  soil  containing  a  suf- 
ficient amount  of  moisture  and  decomposable  vegetable  matter,  appear  to 
be  conditions  necessary  to  the  development  and  spread  of  these  fevers. 
If  you  go  so  far  north  or  south  of  the  equator,  or  ascend  a  mountain  range 
so  high,  that  you  do  not  get  a  mean  summer  temperature  equal  to  16.9°  C. 
(60°  F.)  for  two  consecutive  months,  you  will  find  no  prevalence  of  peri- 
odical fevers.  If  there  are  any  exceptions  to  this  rule,  they  are  few  and 
unimportant.  On  the  other  hand,  if  you  have  the  longest  and  most  intense 
summer  heat,  without  the  presence  of  both  moisture  and  decomposable 
vegetable  matter  in  the  surface  and  sub-soils,  you  will  find  no  prevalence 
of  this  variety  of  disease.  Consequently,  its  chief  prevalence  is  vpithin  the 
temperate  and  tropical  zones,  and  on  moist,  alluvial,  or  tertiary  forma- 
tions, at  moderate  elevations  above  the  level  of  the  sea.  In  Europe  the 
regions  most  subject  to  the  prevalence  of  periodic  fevers  are  the  whole 
western  coast  of  Italy,  including  Tuscany,  the  Pontine  Marshes,  the  Cam- 
pagna  of  Rome,  and  the  environs  of  Naples;  on  the  low  lands  along  the 
southwestern  coast  of  Spain  and  Portugal;  the  southern  coast  of  France; 


HISTORY.  179 

the  o^reater  part  of  European  Turkey,  includino;  Bulgaria,  Albania,  etc.; 
that  part  of  Russia  bordering  on  the  Baltic  and  Black  Seas,  and  in  the 
valleys  of  the  Danube,  Dnieper,  Don,  and  Volga  rivers;  the  plains  of 
Hungary,  Croatia,  and  Slavonia;  that  part  of  Lower  Austria  along  the 
Danube;  the  Baltic  coast  of  Prussia;  the  western  coast  of  Holland,  includ- 
ing the  marshy  plains  on  the  Rhine  and  its  tributaries;  and  that  part  of 
Sweden  bordering  on  the  Baltic  and  along  the  river  Angermann,  as  far 
north  as  62°  20'  N.  latitude.  The  latter  is  said  to  be  the  most  northern 
point  of  its  prevalence  in  Europe.  Iceland,  Norway,  the  greater  part  of 
Denmark,  the  British  Islands,  Switzerland,  and  all  mountainous  districts 
of  Central  Europe  are  quite  exempt  from  the  prevalence  of  these  fevers. 
In  Asia,  the  great  alluvial  valleys  of  the  Indus  and  the  Ganges,  the  whole 
south  and  southwestern  coast  of  China,  the  coasts  of  Syria  and  x\sia  Minor, 
on  the  shores  of  the  Red  Sea  and  Persian  Gulf  in  Arabia,  on  the  islands 
of  Ceylon  and  Sumatra,  and  in  Farther  India,  periodical  fevers  are  very 
prevalent  and  severe.  The  same  is  true  in  reference  to  all  the  western 
and  northern  coast  of  Africa  bordering  on  the  Atlantic  and  Mediterranean, 
the  valley  of  the  Nile  in  Lower  Egypt,  and  along  the  banks  of  the  Gambia, 
Niger,  and  Senegal  Rivers.  In  America,  this  variety  of  fever  is  endemic, 
and  often  severe  in  many  of  the  islands  of  the  West  Indies,  and  on  the  low, 
alluvial  lands  bordering  all  sides  of  the  Gulf  of  Mexico,  which  includes  the 
northern  coast  of  South  America,  the  eastern  coast  of  the  Isthmus,  Central 
America,  and  Mexico,  and  the  southern  coast  of  the  United  States,  from 
the  mouth  of  the  Rio  Grande  to  Key  West.  In  addition  to  that  part  of  the 
Southern  States  bordering  on  the  Gulf  of  Mexico,  this  country  presents 
four  principal  malarious  districts:  First,  all  the  low,  alluvial  lands  border- 
ing on  the  Atlantic  from  Florida  to  Rhode  Island,  in  width  extending  from 
the  foot  of  the  Alleghany  Mountains  to  the  seashore.  Second,  the  country 
bordering  on  the  great  interior  lakes  on  our  northern  border,  wliich 
includes  the  northwestern  part  of  New  York,  the  northern  border  of  Ohio, 
Indiana,  Illinois,  and  the  whole  peninsula  of  Michigan.  Third,  the  great 
interior  valley  lying  between  the  western  foot  of  the  Alleghany  Mountains, 
on  the  east,  and  the  eastern  slope  of  the  Rocky  Mountains,  on  the  west, 
and  extending  from  Lake  Superior  and  the  elevated  plateau  west  of  that 
lnke,  on  the  north,  to  the  Gulf  of  Mexico,  on  the  south.  The  plateau  of 
which  I  speak,  lying  west  of  Lake  Superior  and  Lake  of  the  Woods,  is 
only  from  1,500  to  1,800  feet  above  the  level  of  the  ocean;  but  it  consti- 
tutes the  great  hydrographical  axis  of  the  continent,  separating  the  waters 
that  flow  eastward  through  the  Great  Lakes  and  the  St.  Lawrence  to  the 
Atlantic,  from  those^flowing  north  to  the  Arctic  Ocean,  and  those  flowing 
south  through  the  Mississippi  to  the  Gulf  of  Mexico;  and  constitutes  the 
northern  limit  of  the  prevalence  of  the  malarial  fevers.  The  fourth  district 
embraces  the  Pacific  slope,  extending  from  the  foot  of  the  Sierra  Nevada 
]\rountains  to  the  coast,  and  extending  from  Mexico,  on  the  south,  to 
Alaska,  on  the  north.  Besides  the  extensive  districts  I  have  mentioned, 
there  are  many  smaller  valleys  along  rivers  or  on  the  borders  of  lakes,  in 
almost  every  State  where  periodical  fevers  abound,  more  or  less.  The 
parts  of  our  country  most  nearly  exempt  are  the  hilly  and  mountainous 
region  extending  from  the  northern  part  of  Georgia  and  Alabama  to  the 
northeast,  until  it  reaches  the  southwestern  part  of  Maine,  embracing  the 
Cumberland,  Alleghany,  Catskill,  and  Adirondack  ranges  of  mountains, 
and  the  White  and  Green  Mountains  of  New  Hampshire  and  Vermont; 
and  the  great  mountain  ranges  intervening  between  the  western  border  of 
the  Mississippi  valley  and  the  Pacific  slope,  extending  parallel  with  the 
Pacific  coast  from  Mexico  to  the  Arctic  regions. 


180  PERIODICAL    FEVERS. 

This  latter  immense  mountain  district,  where  it  is  crossed  by  the  Union 
Pacific  Railroad,  is  made  up  of  lour  nearly  parallel  ranges,  called  the 
Rocky  Mountains  proper,  the  Wahsatch,  the  Hum  bolt,  and  the  Sierra  Ne- 
vadas,  between  which  are  the  great  elevated  basins  called  the  Green  River, 
the  Salt  Lake,  and  the  Humbolt  Valleys. 

Causes  of  Periodical  Fevers.  — The  fact  that  this  variety  of  fevers  is 
limited  in  its  prevalence  by  certain  geographical  and  topographical 
boundaries,  shows  that  its  essential  cause  arises  from  some  conditions 
pertaining  to  the  soil  itself.  As  I  have  already  stated,  these  conditions 
relate  to  the  temperature,  moisture,  and  decomposable  vegetable  matter. 
Where  these  exist  in  proper  proportions,  something  is  brought  into  ex- 
istence, or  excited  to  activity,  which  is  capable  of  exerting  such  influence 
upon  the  human  system  as  to  cause  the  development  of  those  pathological 
cliange's  and  symptoms  which  constitute  periodic  or  malarial  fevers.  As 
it  requires  not  merely  an  elevation  of  temperature,  but  the  maintenance  of 
such  elevation  for  at  least  two  months,  it  brings  the  time  for  beginning 
the  active  development  of  the  specific  agent  or  influence  past  the  climax 
of  summer-heat,  and  continues  it  until  the  temperature  falls  too  low  in  the 
autumn.  Hence,  the  chief  prevalence  of  these  fevers  in  this  city,  as  well 
as  in  all  the  middle  and  northern  parts  of  this  country,  is  during  August, 
September,  and  October.  In  some  seasons  they  begin  to  prevad  earlier, 
and  in  others  continue  quite  prevalent  through  the  month  of  November. 
In  those  locations  where  the  circumstances  are  highly  favorable  for  gen- 
erating the  specific  cause,  it  is  quite  common  to  have  a  moderate  prevalence 
of  the  intermittent  form  of  the  disease  during  the  first  continuous  warm 
weather  of  spring.  Irregular  and  relapsing  cases  are  met  with  occasion- 
ally at  all  seasons  of  the  year. 

That  the  local  conditions  I  have  enumerated  as  favorable  for  the  preva- 
lence of  these  fevers,  give  rise  to  the  development  of  a  specific  materies 
raorbi,  which  constitutes  their  efficient  cause,  is  clearly  indicated  by  the 
following  facts:  First,  persons  previously  healthy  are  often  attacked  wilh 
some  form  of  the  fever,  as  the  result  of  spending  only  one  or  two  days,  at 
the  proper  season,  in  localities  where  the  favorable  conditions  are  highly 
concentrated,  as  on  some  parts  of  the  coast  of  Africa,  the  campagna  of 
Rome,  or  the  swamps  of  Louisiana.  Second,  persons  living  in  districts 
where  the  fevers  are  actively  prevailing,  are  found  to  greatly  lessen  their 
liability  to  an  attack  by  refraining  from  going  out  after  the  atmospheric 
vapor  begins  to  condense  in  the  form  of  dew  in  the  evening,  and  until 
after  it  has  again  been  dissipated  and  risen  above  the  lower  strata  of  the 
atmosphere  in  the  morning.  Third,  families  living  on  hillsides,  so  situated 
that  the  fog  or  vapor  arising  from  a  neighboring  marsh  or  moist  alluvial 
plain,  is  waited  by  the  atmospheric  currents  or  prevailing  winds  against 
them,  have  often  been  found  to  suffer  more  than  their  neighbors  lower 
down  the  hillside  and  nearer  to  the  marsh.  So,  also,  families  and  whole 
settlements  which  had  been  for  many  years  entirely  exempt  from  this  va- 
riety of  sickness,  have  become  sorely  afilicted  every  season,  after  the 
cutting  away  of  a  grove  or  strip  of  forest  trees,  which  had  intervened 
between  them  and  a  more  or  less  extensive  marsh.  Fourth,  repeated 
instances  have  occurred  in  which  the  drinking  of  water  from  springs,  rills, 
and  wells  supplied  or  percolating  from  a  neighboring  marsh  or  rich  alluvial 
soil,  has  caused  attacks  of  the  disease.  On  the  other  hand,  locations  pre- 
viously highly  infested  with  the  disease,  have  been  rendered  quite  exempt 
by  thorough  drainage  and  cultivation.  So  true  is  this,  that  large  portions 
of  our  country,  in  which  malarious  fevers  prevailed  severely  during  the 
first  two  generations  after  their  settlement,  have  now  become  nearly 
exempt  from  such  prevalence. 


CAUSES.  181 

These  and  kindred  facts  not  only  prove  that  a  specific  material  substance 
of  some  kind  is  produced,  but  that  it  is  capable  of  being  held  suspended 
in  water  and  in  aqueous  vapor,  and  that  its  diffusion  in  the  atmosphere  is 
governed  by  the  same  laws  as  govern  the  diffusion  of  the  latter.  From  a 
very  early  period  this  substance,  or  materies  morhi^  has  been  called  ma- 
laria^ marsh-miasm,^  koino-miasm,  etc.,  under  the  belief  that  it  was  a 
subtle  gas  evolved  by  the  action  of  heat  on  moist,  decomposing  vegetable 
matter  in  the  soil.  Until  a  recent  period  this  theory  was  generally 
accepted  by  the  profession,  although  the  suf)posed  gas  successfully  eluded 
every  effort  of  the  chemist  to  isolate  and  identify  it.  Suggestions  were 
made  from  time  to  time,  that  the  special  agent  is  an  organic  germ,  either 
animal  or  vegetable.  One  of  the  earliest  and  ablest  advocates  of  the 
theory  that  malaria  is  a  species  of  fungus  or  vegetable  germ,  was  J^r.  J.  K. 
Mitchell,  for  many  years  one  of  the  faculty  of  Jefferson  Medical  College, 
who  gave  the  results  of  his  observations  and  experiments  in  an  interesting 
little  volume,  published  in  1849.  In  1866,  Dr.  J.  H.  Salisbury,  of  Cleve- 
land, published  the  results  of  his  investigations,  claiming  that  the  active 
agent  is  a  vegetable  organism  of  the  algoid  class,  called  palmella.  Several 
years  since,  Dr.  John  Bartlett,  of  this  city,  reported  to  the  Chicago  Medi- 
cal Society  the  results  of  an  interesting  series  of  investigations,  somewhat 
confirmatory  of  the  conclusions  of  Dr.  Salisbury.  And  within  the  last  two 
years,  Drs.  Klebs  and  Tommasi  Crudeli  have  published  the  results  of  a 
still  more  extended  series  of  observations  near  Rome,  in  which  they  claim 
to  have  proved  that  the  essential  cause  of  periodical  fever  is  a  low  form  of 
vegetable  organism  which  they  call  baciUus  malaria?,.  They  made  a 
watery  extract  from  the  marshy  soil  of  a  malarious  region,  containing 
these  germs,  and  by  injecting  it  into  rabbits,  produced  symptoms  which 
they  regarded  as  diagnostic  of  malarial  fever.  These  gentlemen  certainly 
succeeded  in  killing  the  rabbits,  but  the  symptoms  preceding  their  death 
were  by  no  means  identical  with  those  of  any  variety  of  malarious  fever. 
Moreover,  the  known  readiness  with  which  rabbits  a,nd  guinea  pigs  are 
affected  by  the  injection  of  almost  any  organic  material  into  their  blood  or 
tissues,  renders  them  wholly  unfit  for  use  in  such  investigations.  During 
the  past  year.  Dr.  G.  M.  Sternberg,  of  the  U.  S.  A.,  at  the  request  of  the 
National  Board  of  Health,  has  been  still  furth<^r  pursuing  the  same  line 
of  investigation  as  the  Italian  physicians,  with  additional  observations 
concerning  both  the  specific  characters  of  the  so-called  bacillus  inalarim^ 
and  the  range  of  temperature  that  rabbits  may  undergo  when  under  no 
unnatural  influence.  From  the  facts  given  in  his  report  recently  pub- 
lished,* I  am  satisfied  that  the  evidence  thus  far  developed  is  wholly 
insufficient  to  justify  the  conclusions  arrived  at  by  Klebs  and  Tommasi 
Crudeli.  On  the  contrary,  the  disease  they  produced  in  their  rabbits 
differs  in  no  essential  symptoms  or  post  mortem  appearances  from  that 
produced  in  the  same  species  of  animal  by  the  injection  of  healthy  human 
saliva  or  any  other  organic  material  capable  of  undergoing  septic  changes; 
and  their  bacillus  malaria  differs  in  no  recognizable  specific  characters 
from  bacilli  found  in  almost  any  foul  water,  under  the  influence  of  a 
summer  temperature.  The  real  nature  and  origin  of  the  specific  cause  of 
periodic  fevers  is,  therefore,  still  a  mystery.  The  circumstances  or  condi- 
tions necessary  for  its  production,  and  the  laws  governing  its  diffusion, 
have  beep  well  ascertained,  as  I  have  already  stated  to  you  ;  and  we  may 
properly  call    it  malaria,  without    intending  thereby   to   imply  anything 

*  See  Experimental  Investiirations  by  George  M  Sternberg,  Surgeon  U.  S.  A.,  relating  to  the  Eti- 
ology of  Malarial  Fevers.    National  Board  of  Health  Bulletin,  Ap,,endix  No.  2. 


182  PERIODICAL    P'EVEES. 

concerning  its  nature,  until  further  investigations  shall  result  in  its  more 
perfect  identification.  Age  and  sex  appear  to  exert  little  or  no  influence 
over  the  liability  to  attacks  of  malarial  fever. 

Varieties.  —  All  the  varieties  of  periodical  or  malarious  fever  may  be 
conveniently  grouped  under  three  heads,  viz.:  Intermittent,  Remittent, 
and  Pernicious.  The  first  includes  all  those  cases  characterized  by  par- 
oxysms of  fever  of  brief  duration,  with  an  interval  of  time  between  them, 
during  which  all  febrile  symptoms  are  absent.  The  second  includes  all 
such  cases  as  are  characterized  by  active  paroxysms  of  fever,  with  a  regu- 
lar interval  between  them,  during  which  the  febrile  symptoms  are  greatly 
diminished  but  not  entirely  absent.  Instead  of  a  complete  intermission, 
as  in  the  first  variety,  there  is  only  a  ^'emission.  The  third  includes  all 
such  cases  as  are  characterized  by  a  dangerous  degree  of  depression  during 
the  first  stage  of  the  paroxysm. 

In  all  the  varieties  the  paroxysms  recur  at  stated  periods  of  time,  with 
a  near  approach  to  regularity.  In  some  cases  they  return  at  a  given  time 
every  day;  in  others  every  second,  third,  fourth,  fifth,  sixth,  or  seventh 
day  ;  and  are  technically  called  respectively,  quotidians,  tertians,  quartans, 
quintans,  sextans,  and  septans.  Cases  are  also  known  in  which  the  pj^.rox- 
ysms  return  every  fourteenth  day.  Very  much  the  larger  number  of  cases 
of  the  intermittent  varietv  present  a  febrile  paroxysm  every  day  or  every 
second  day.  The  next  most  numerous  cases  have  a  paroxysm  every 
seventh  or  fourteenth  day.  In  the  remittent  variety  the  paroxysms 
very  generally  recur  every  day.  In  the  pernicious  cases,  if  the  patient 
does  not  die  in  the  first  paroxysm,  they  may  take  either  the  intermittent  or 
remittent  type,  but  much  the  larger  number  present  the  characteristics  of 
the  former.  Most  writers  mention  cases  in  which  two  paroxysms  occur  in 
one  day,  and  call  them  double  quotidians,  double  tertians,  etc.  According 
to  my  experience,  such  cases  are  exceedingly  rare.  I  have  already  made 
frequent  mention  of  the  words  paroxysm,  interval,  intermission,  and 
remission.  A  -paroxysm  of  malarial  fever  consists  of  three  stages,  each 
presenting  a  distinct  group  of  symptoms,  and  following  each  other  in  a 
))retty  uniform  order  ;  namely,  the  algid  or  cold  stage,  the  hot  or  pyretic 
stage,  and  the  declining  or  sweating  stage.  The  interval  is  the  length  of 
time  from  the  comihencem.ent  of  one  paroxysm  to  the  beginning  of  the 
next.  The  intermission  is  the  length  of  time  from  the  end  of  one  parox- 
ysm to  the  beginning  of  the  next.  The  remission  is  the  period  of  time 
from  the  decline  of  one  paroxysm  to  the  accession  of  the  next,  and  applies 
only  to  the  remittent  variety  of  fever. 

G-eneral  Pathology. — A  study  of  the  general  pathology  of  periodical 
fevers  necessarily  involves  a  consideration  of  the  modus  operandi  of  their 
specific  cause,  called  malaria.  This  agent  evidently  gains  access  to  the 
human  system  chiefly  through  the  lungs,  by  inhalation  with  the  air  and 
aqueous  vapor,  and  to  some  extent  also,  through  the  stomach  with  water 
and  other  liquids,  capable  of  holding  it  in  solution.  When  received  into 
the  blood  through  either  channel  in  sufficient  quantity  to  produce  general 
disturbance,  it  acts  upon  the  properties  of  the  tissues  as  an  irritant,  increas- 
ing the  general  susceptibility,  and  at  the  same  time  impairing  the  force  of 
vital  affinity,  while  it  exerts  a  special  local  influence  over  the  functions  of 
the  vasomotor  nervous  system.  The  irritant  effect  gives  to  the  febrile 
movement  the  same  rapidity  of  development  and  active  excitement  that 
Vjelongs  to  the  febriculas,  while  the  impaired  tonicity  of  the  tissues  favors 
congestions  or  the  undue  accumulation  of  blood  in  the  more  vascular 
structures,  such  as  the  spleen,  lungs,  liver,  and  mucous  membranes;  and 
and  at  the  same   time  the  special  action  on  that  part  of  the  vasomotor 


GENEKAL    PATHOLOGY  li^O 

nerves  controlling  the  peripheral  circulation  is  such  that  the  vessels  of  the 
surface  becoine  much  contracted,  causing  it  to  appear  pale,  shrunken,  and 
cold.  But  the  rapid  accumulation  of  heat  in  the  internal  hyperaemic 
structures  soon  increases  the  temperature  of  the  blood  to  such  a  degree 
that  it  overcomes  the  contraction  of  the  peripheral  vessels,  and  not  only- 
carries  the  increase  of  heat  throughout  the  whole  system,  but  ultimately 
cooperating  with  the  impairment  of  vital  affinity,  causes  that  relaxation 
which  constitutes  the  sweating  stage,  and  ends,  for  the  time  being,  the 
febrile  excitement.  If  the  relaxation  is  complete,  allowing  a  free  exuda- 
tion or  sweating  from  the  cutaneous  surface,  the  exciting  cause  appears  so 
far  removed  that  all  active  phenomena  cease,  constituting  the  intermission. 
If  the  relaxation  be  only  partial  or  imperfect,  allowing  only  a  lowering  of 
temperature  with  slight  moisture  of  the  surface,  it  constitutes  only  a  remis- 
sion between  the  paroxysms.  The  first  represents  the  intermittent,  and 
the  second  the  remittent  variety  of  periodical  fever.  But  when,  from  the 
intensity  of  the  action  of  the  malaria  or  some  peculiarity  in  the  condition 
of  the  patient,  the  vital  affinity  becomes  so  impaired  as  to  greatly  retard 
all  molecular  changes,  and  not  only  the  vasomotor  function  of  the  per- 
iphery, but  of  the  whole  system,  is  perverted,  the  active  generation  of  heat 
fails  internally  as  well  as  externally,  allowing  the  cold  stage  to  continue, 
with  shrinking,  blueness,  and  coldness  of  the  surface;  a  rapidly  failing 
pulse;  unsteady  respiration;  entire  suspension  of  innervation  and  secretion, 
and  death  within  a  few  hours. 

Such  cases  constitute  the  true  algid  variety  of  pernicious  intermittents. 
When  the  extreme  impairment  of  the  vital  affinity  is  coupled  with  such  an 
alteration  of  the  vasomotor  influence  as  causes  paralysis  or  relaxation  of 
the  vessels  of  the  mucous  membrane  of  the  alimentary  canal,  as  well  as  of 
the  cutaneous  surface,  giving  rise  to  copious,  thin  or  serous  dischai'ges  by 
vomiting  and  purging — which  often  ends  in  complete  collapse  and  death 
during  the  first  paroxysm — it  constitutes  the  choleraic  variety  of  the  per- 
nicious cases.  Sometimes,  on  the  accession  of  a  paroxysm,  the  extreme 
failure  of  vasomotor  influence  is  limited  mostly  to  the  pulmonary  vessels, 
including  an  engorgement  of  the  vascular  capillary  network,  so  complete 
as  to  cause  rapid  exudation  and  compression  or  filling  up  of  the  air-cells, 
and  consequent  speedy  death  of  the  patient  by  suffocation. 

A  similar  but  less  intense  impairment  of  the  vital  affinity  and  vasomotor 
nerve  influence,  limited  mostly  to  the  brain  or  cerebro-spinal  nerve  cen- 
ters, causes  the  pernicious  cases  styled  in  your  text-books  Soporose  or 
cerebro-spinal  intermittents.  Such  are  the  morbid  processes  which  con- 
stitute the  essential  pathology  of  the  different  varieties  of  malarial  fever. 
If  the  patient  lives  through  the  first  and  second  paroxysms,  as  in  the 
ordinary  variety  of  intermittent  and  remittent  cases,  and  the  disease  con- 
tinues its  natural  course,  other  important  pathological  changes  take  place, 
with  greater  or  less  rapidity,  during  the  further  progress  of  each  case. 
The  active  disturbance  of  those  elementary  properties  of  the  tissues  on 
which  the  molecular  changes  constituting  nutrition,  disintegration,  and 
secretion  depend,  with  the  renewed  hypergemia  of  the  digestive  and  assim- 
ilative organs  at  each  returning  paroxysm,  arrests  or  greatly  retards  the 
formation  of  nevv  organizable  constituents  of  the  blood,  especially  the  red 
corpuscles  and  albumen;  and  at  the  same  time  the  disintegration  and  waste 
of  those  already  existing  are  increased,  both  by  the  heat  and  excitement 
of  the  paroxysms,  and  sweating  or  other  evacuations  at  their  close.  Con- 
sequently, the  blood  becomes  rapidly  impoverished  of  its  red  corpuscles, 
albumen,  and  some  of  its  salts,  while  the  fibrin,  white  corpuscles,  and 
extractive  matter   remain  in  nearly  natural   proportion.     In   addition  to 


184  PERIODICAL   FEVERS. 

these  changes,  the  microscope  shows  the  existence,  in  the  serum  of  the 
blood,  of  many  small  black  specks  or  granules,  apparently  derived  from 
the  hteraatin  of  the  disintegrated  red  corpuscles. 

This  same  pigment  or  coloring  matter  is  found  staining  the  walls  of  the 
blood-vessels  quite  generally,  giving  rise  to  a  somewhat  characteristic 
change  of  color  in  the  liver  and  spleen,  and  doubtless  contributing  to  the 
formation  of  that  sallow  hue  of  the  surface  generally  presented  by  persons 
subject  to  protracted  ague.  The  extreme  degree  to  which  the  blood  is 
deprived  of  its  red  corpuscles  in  some  cases  of  protracted  intermittents, 
was  shown  by  some  of  the  analyses  made  by  myself  in  1H52.* 

In  one  instance,  the  blood  taken  from  a  vein  in  the  arm  of  a  laboring 
man  who  had  had  a  paroxysm  of  simple  intermittent  fever  every  day  for 
about  ten  weeks,  yielded,  on  very  careful  analysis,  only  49.19  per  1,000,  or 
a  little  less  than  Jive  per  cent,  of  red  corpuscles  ;  64.84,  or  less  than  6.5 
per  cent,  of  albumen,  and  1.38  or  0.13  per  cent,  of  fibrin.  In  another  case, 
also  analyzed  in  November,  1852,  the  blood  taken  from  the  arm  of  a  labor- 
ing man  aged  23  years,  who  had  suffered  from  quotidian  ague  six  weeks, 
gave  82.79  per  1,000,  or  8.2  per  cent,  of  red  corpuscles  ;  69.68,  or  near  7 
per  cent,  of  albumen  ;  and  2.48,  or  near  0.25  per  cent,  of  fibrin.  Both  the 
specimens  of  blood  I  have  alluded  to  were  also  subjected  to  a  careful  ex- 
amination with  the  microscope.  The  red  corpuscles  appeared  to  me  slightly 
distended  or  more  globular  than  natural,  and  some  of  them  had  a  corru- 
gated or  shrivelled  appearance,  as  if  undergoing  disintegration.  The  white 
corpuscles  were  less  numerous  than  in  healthy  blood.  There  were  also 
many  minute  dark  granules  floating  in  the  serum.  Between  the  years  1856 
and  1859,  Dr.  Joseph  Jones,  then  Professor  of  Medical  Chemistry  in  the 
Medical  College  of  Georgia,  at  Augusta,  made  a  large  number  of  analyses 
of  blood  from  patients  laboring  under  different  grades  of  malarial  fever, 
the  results  of  which  he  gave  in  a  lengthy  and  important  paper  presented 
to  the  American  Medical  Association  in  May,  1859.  So  far  as  relates  to 
the  alteration  of  the  relative  proportion  of  the  constituents  of  the  blood,  his 
analyses  led  to  the  same  results  as  my  own.f 

In  addition  to  his  chemical  analyses,  Dr.  Jones  embraced  opportunities 
more  frequently  presented  in  the  intensely  malarious  district  in  which  he 
then  lived,  for  making  minute  post  mortem  examinations  of  many  fatal 
cases  of  remittent  and  pernicious  intermittent  fevers,  and  found  the  serum, 
or  liquor  sanguinis,  of  a  decided  yellow  color  ;  unusually  extensive  and 
numerous  fibrinous  clots  in  the  cavities  of  the  heart  and  larger  blood- 
vessels, of  such  firmness  and  freedom  from  colored  corpuscles  as  to  indicate 
their  formation  before  death  ;  and  in  most  cases  enlargements  and  altera- 
tions in  the  color  of  the  liver  and  spleen.  He  states  that  the  blood  in  the 
liver  and  spleen  does  not  change  to  a  brighter  hue  on  exposure  to  the 
oxygen  of  the  air,  as  in  other  parts  of  the  body,  and  that  in  the  many 
cases  examined  for  that  purpose,  he  uniformly  found  the  liver  containing 
an  increase  of  animal  starch  or  glucogene,  but  no  grape  sugar. 

In  nearly  all  the  cases  of  death   from  the  remittent  type  of  fever,  the 

*See  Report  on  the  Changes  which  take  place  in  the  Blood  in  the  Continued  and  Periodical 
Fevers,  read  to  the  Illinois  State  Medical  Society  in  June,  1857.  By  N.  S.  Davis,  M.  D.,  etc.  Pub- 
lished in  the  Transactions  of  the  Society  for  1857,  andasointho  Northwestern  Med.  and  Surg. 
Journal,  Vol.  VI,  New  Series,  pp.  389-398. 

t  The  following  are  the  conclusions  of  Dr.  Jones,  in  his  own  words  :  1.  The  careful  comparison 
of  the  table  of  the  changes  of  the  blood  in  malarial  fever,  with  the  formula  of  the  blood,  established 
by  laborious  investigations,  reveals  the/act  that  the  colored  blood-corpusc  es-  are  diminished  during  mala- 
rial/ever. 2.  The  careful  comparison  of  these  analyses  with  each  other,  reveals  the  faci  that  the 
ex  ent  aid  rapidity  of  the  diminution  of  the  colored  cor  uscles  corresponds  to  the  severity  and  extent  oi 
the  disease.  3.  Our  researches  show  that  the  fixed  saline  constituents  of  the  blood-corpuscles  are 
often  diminished  in  malarial  lever.  See  Transactions  of  the  American  Medical  Association,  Vol. 
XII,  pp.  379  and  385.    1859. 


PATHOLOGY.  185 

mucous  membrane  of  the  stomach  and  duodenum  was  found  congested 
with  blood  ;  and  in  some  instances  the  same  changes  were  found  in  the 
ilium,  accompanied  by  tumefaction  of  the  glands  of  Peyer.  Without 
occupying  your  time  with  further  details,  I  will  close  this  part  of  the  sub- 
ject by  submitting  the  following  brief  propositions  :  — 

1st.  The  essential  cause  of  periodical  fevers  gaining  access  to  the  blood, 
chiefly  through  the  lujigs  and  stomach,  by  its  presence,  exerts  an  excitant 
or  irritative  influence  on  the  susceptibility  of  all  the  organized  tissues  of 
the  body,  while  it  so  modifies  the  vital  affinity  as  to  impair  their  tonicity 
and  lessen  the  natural  molecular  changes  constituting  assimilation,  nutri- 
tion, and  secretion  ;  and  at  the  same  time  so  modifies  the  action  of  the 
vasomotor  nerves  as  to  induce  contraction  of  the  peripheral  or  cutaneous 
vessels,  while  those  of  the  viscera  and  internal  structures  remain  un- 
affected or  dilate  from  the  general  impairment  of  tonicity. 

2nd.  When  the  cause  acts  feebly,  but  persistently,  through  considerable 
periods  of  time,  the  pathological  conditions  just  stated  will  not  be  de- 
veloped in  sufficient  degree  to  present  the  active  yjhenomena  of  fever,  but 
will  so  retard  hferaatosis  and  nutrition  as  to  cause  spana?mia,  or  impover- 
ishment of  blood  corpuscles,  imperfect  secretions,  and  want  of  niuscular 
and  nervous  force,  —  a  condition  often  called  malarial  cachexite. 

3d.  When  the  cause  acts  with  sufficient  intensity  to  actively  develop  the 
morbid  impressions  indicated  in  the  first  proposition,  the  coincident  con- 
traction of  the  vessels  of  the  periphery,  and  suspension  of  heat-production 
there,  with  the  undue  excitability  and  rapid  accumulation  of  blood  and 
heat  in  the  more  v^ascular  and  relaxed  internal  organs,  speedily  presents 
all  the  phenomena  of  the  first  or  cold  stage  of  the  febrile  paroxysm.  But 
such  a  disparity  in  circulation  and  temperature  between  the  external  and 
internal  parts  of  the  body,  must  of  necessity  be  of  short  duration.  Either 
the  irritative  quality  of  the  exciting  cause  will  predominate,  and  the  rap- 
idly increasing  temperature  and  blood-pressure  internally  will  increase  the 
force  and  frequency  of  the  action  of  the  heart  and  larger  blood-vessels,  and 
soon  cause  the  vessels  of  the  periphery  to  relax  and  become  hot  and  turgid 
with  blood,  constituting-  the  second  or  hot  stage  of  the  paroxysm  ;  or,  that 
quality  of  the  exciting  cause  which  impairs  the  play  of  vital  affinity  will 
so  far  predominate  that  when  the  first  stage  of  the  paroxysm  is  induced, 
there  is  not  sufficient  tone  or  molecular  attraction  in  the  cardiac  and  in- 
voluntary muscular  structures  to  maintain  efficient  contractions.  Conse- 
quently the  circulation  will  grow  more  feeble,  the  respirations  more 
irreg-ular  and  inefficient  ;  natural  secretory  actions  will  cease;  the  capillary 
circulation  will  be  retarded  as  much  in  the  internal  structures  as  in  the 
cutaneous  surface  ;  the  blood,  with  its  rapidly  disintegrating  red  cor- 
puscles, will  accumulate  in  the  spleen,  liver,  and  sometimes  the  lungs  ; 
and  in  a  few  hours  the  patient  dies  in  what  is  called  a  pernicious  or 
congestive  paroxysm. 

4th.  When  the  irritative  influence  predominates  and  the  hot  stage  of  the 
paroxysm  readily  supervenes,  the  rapid  increase  of  heat  in  the  tissues,  and 
the  equally  rapid  increase  of  effete  matter  in  the  blood,  both  from  retarded 
eliminations  and  morbid  changes  in  the  corpuscular  elements  of  the  blood 
itself,  soon  begin  to  neutralize  the  excessive  excitability,  and  in  a  few 
hours  the  cutaneous  vessels  become  entirely  relaxed,  permitting  copious 
sweating,  with  a  coincident  resumption  of  more  natural  secretions  in  the 
internal  organs,  and  accompanied  by  an  entire  subsidence  of  fever  or  an  in- 
termission. In  other  cases  the  cutaneous  relaxation  and  sweating  is  only 
partial,  accompanied  by  an  equally  imperfect  subsidence  of  the  fever  or  a 
remission.     But   in   either   case,  if  not  interfered  with  by  treatment,  the 


186  PEEIODICAL    FEVERS. 

intermission  or  remission  continues  only  for  a  definite  limited  time,  when 
the  susceptibility  to  the  action  of  the  special  cause  is  regained,  and  the 
successive  stages  of  another  paroxysm  supervene;  and  this  regular  succes- 
sion of  morbid  phenomena  may  continue  without  any  definite  self- 
limitation. 

otli.  When  the  morbid  phenomena  just  named  are  permitted  to  recur  fi-om 
day  to  day,  the  high  excitement,  coupled  with  vascular  hypergemia  of  the 
abdominal  viscera,  that  is  renewed  with  the  access  of  each  paroxysm,  tends 
strongly  to  establish  either  sub-acute  inflammation  in  the  spleen,  liver, 
gastro-intestinal  mucous  membrane,  and  lungs,  or  a  rapid  enlargement  of 
the  two  first-named  organs,  partly  from  excessive  accuuiulation  of  the 
corpuscular  elements  of  the  blood,  and  partly  from  actual  hypertrophy  of 
their  tissue.  In  the  meantime,  the  blood  itself  is  undergoing  rapid  impov- 
erishment of  its  red  corpuscles,  both  from  their  more  active  destruction 
and  the  continued  interference  with  the  natural  processes  by  which  they 
are  reproduced. 

Such,  gentlemen,  are  my  views  of  the  modus  operandi  oi  malaria,  as  the 
efl&cient  cause  of  periodical  fevers;  and  of  the  pathological  conditions  and 
processes  that  characterize  the  several  stages  and  varieties  of  this  very 
important  group  of  acute  general  diseases.  A  consideration  of  their  clin- 
ical history  and  treatment  must  be  reserved  for  another  hour. 


LECTURE  XXI. 

Periodical  Fevers  Continued— lutennittent,  Remittent — Their  Symptoms,  Di.  gnosis,  Proe;nosis 
ana  Treatm^ent. 

G1ENTLEMEN: — The  active  febrile  symptoms  in  almost  all  cases  of 
r  malarial  fever,  are  preceded  by  feelings  of  indisposition,  consisting  in 
dull  pains  in  the  head,  back,  and  limbs,  more  especially  during  a  certain 
part  of  each  day  ;  variable  appetite  ;  undue  sensitiveness  to  atmospheric 
changes  ;  and  more  or  less  derangement  of  the  secretory  functions  gener- 
ally. These  prodromic  symptoms  may  continue  from  two  days  to  as  many 
weeks.  For  both  convenience  and  accuracy,  I  shall  describe  the  symp- 
toms of  each  variety  of  the  fever  separately. 

IrdermitUnU. — The  symptoms  of  intermittent  fever  are  naturally 
divided  into  those  belonging  to  the  paroxysm  and  those  of  the  intermis- 
sion. As  I  stated  to  you  in  the  preceding  lecture,  the  paroxysm  is  made 
up  of  three  stages,  and  each  of  these  is  characterized  by  a  distinct  group 
of  symptoms.  The  cold  stage  is  ushered  in  by  feelings  of  coldness  and 
general  depression  ;  shrinking  and  paleness  of  the  skin,  and  a  leaden  hue 
of  the  lips  and  nails  ;  the  coldness  being  first  in  streaks  along  the  spine, 
soon  deepens  into  general  shivering  and  muscular  tremliling,  with  chatter- 
ing of  the  teeth  ;  a  small  and  variable  pulse  ;  short  and  irregular  respira- 
tory movements  ;  often  increased  secretion  of  limpid  urine,  and  dull  pains 
in  the  head,  back,  and  limbs.  In  many  cases  there  is  frequent  sighing,  and 
a  very  uncomfortable  sense  of  oppression  in  the  epigastrium,  with  a  general 
feeling  of  weariness.     While  the  patient  thus  feels  depressed,  as  if  from 


INTERMITTENT.  187 

intense  cold,  the  application  of  the  clinical  thermometer  shows  the  actual 
reduction  of  temperature  to  be  limited  to  the  surface  of  the  body  and  ex- 
tremities, while  it  is  two  or  three  degrees  above  the  natural  standard  in 
the  mouth  and  rectum.  The  average  duration  of  the  cold  stage  is  from 
thirty  to  forty-five  minutes.  In  some  cases  it  is  no  more  than  ten  or 
fifteen  minutes,  and  may  be  absent  altogether.  On  the  other  hand,  it  has 
been  observed  to  last  two  and  three  hours  in  some  rare  instances.  The 
transition  from  the  cold  to  the  hot  stage  is  generally  gradual,  though 
occupying  not  more  than  ten  or  fifteen  minutes.  The  patient  first  be- 
comes more  quiet,  takes  deeper  and  more  regular  inspirations,  his  shivering 
ceases,  irregular  streaks  of  warmth  come  and  go  along  the  spine,  like  the 
streaks  of  cold  at  the  beginning  of  the  cold  stage  ;  then  warmth  appears 
in  the  cheeks,  the  leaden  hue  disappears  from  the  lips  and  nails,  and  soon 
the  whole  surface  becomes  warm,  the  skin  smooth,  the  face  flushed,  the 
pulse  and  respirations  full  and  uniform,  but  more  frequent  than  natural. 
In  the  meantime,  the  patient  has  been  gradually  throwing  off  his  extra 
coverings  and  calling  for  the  removal  of  the  hot  things  that  had  been 
applied  to  his  surface  and  extremities,  until  he  complains  of  the  excess  of 
heat  as  much  as  he  did  of  the  cold  a  short  time  previous. 

The  hot  stage  thus  fairly  established,  is  characterized  by  general  heat 
and  dryness  of  the  surface;  flushed  face  and  rather  excited  expression  of 
countenance;  pulse  full,  and  from  90  to  100  in  frequency;  respirations 
moderately  accelerated;  the  lips  red  and  dry;  tongue  generally  coated 
with  a  thin,  rather  yellowish-white  fur;  the  urinary  secretion  now  scanty 
and  high-colored;  and  the  patient  complains  of  much  heat,  thirst,  restless- 
ness, throbbing  pains  in  the  head,  with  some  general  soreness  of  the  flesh 
and  sensitiveness  to  light  and  noise;  some  tenderness  and  distress  in  the 
epigastrium,  and,  not  unfrequently,  active  vomiting,  especially  after  taking- 
drinks  freely.  The  temperature  continues  to  rise  after  the  accession  of  the 
hot  stage,  and  generally  reaches  its  climax  for  that  paroxysm  in  about  one 
hour  after  the  disappearance  of  cold  from  the  surface  and  extremities, 
when  it  ranges  between  40°  and  41°  C.  (104°  and  106°  F.)  in  the  axilla. 

AH  the  symptoms  mentioned  usually  continue  with  but  little  change 
from  two  to  four  hours,  when  the  patient  begins  to  rest  more  quiet,  and 
complains  less  of  headache  and  thirst.  Soon  a  slight  moisture  appears  on 
the  forehead,  in  the  axilla,  and  in  the  palms  of  the  hands,  and  in  half  an 
hour  more  the  whole  surface  is  covered  with  a  copious  sweat,  which  may 
continue  from  two  to  four  hours,  during  which  time  the  patient  usually 
sleeps  quietly.  The  sweat  is  generally  copious  enough  to  wet  thoroughly 
all  the  clothing  in  contact  with  the  patient. 

The  sweat  contains  an  unusual  amount  of  organic  matter,  fat  acids,  and 
salts  ;  and  gives  a  strongly  acid  reaction  ;  and  during  its  progress  all  the 
active  symptoms  of  the  hot  stage  disappear,  leaving  the  pulse,  respiration, 
and  temperature  natural,  and  the  patient  comfortable,  except  a  sense  of 
weakness  and  weariness  on  attempting  any  exercise,  and  sometimes  a  light 
coating  on  the  tongue  and  indifference  to  food. 

The  urea,  urates  and  chlorides,  which  had  been  largely  in  excess  in 
the  urine  during  the  hot  stage,  rapidly  decline  during  the  sweating,  and 
fall  below  the  natural  proportion  in  the  intermission.  From  the  descrip- 
tion I  have  given,  you  will  perceive  that  the  three  stages  united  make  the 
entire  length  of  a  paroxysm  from  five  to  nine  ho\irs,  leaving  from  fifteen  to 
nmeteen  hours  for  the  intermission  in  the  quotidian,  and  from  thirty-nine 
to  fourty-three  hours  in  the  tertian  variety.  At  the  end  of  the  intermis- 
sion the  cold  stage  again  commences,  and  is  followed  by  the  same  succes- 
sion of  stages,  and   characterized  by  the   same   symptoms  as  in  the  first 


188  PERIODICAL    FEVERS. 

paroxysm.  The  recurrence  of  paroxysms  and  intermissions  may  thus  con- 
tinue with  a  near  approach  to  regularity,  both  in  time  and  symptoms,  if 
not  interfered  with  by  treatment,  for  an  indefinite  period  of  time,  during 
which  the  blood  is  steadily  becoming  more  and  more  impoverished  of  its 
red  corpuscles  and  nutritive  constituents,  the  epigastrium  more  con- 
stantly tender  to  pressure,  and  the  liver  and  spleen,  from  the  repeated 
congestions,  considerably  enlarged  ;  and  the  skin  of  a  sallow  color,  from 
the  combined  effect  of  altered  blood  corpuscles  and  retained  coloring  matter 
of  bile.  When  the  disease  thus  continues  for  several  weeks,  it  is  called 
chronic  ague,  and  is  sometimes  accompanied  by  such  a  degree  of  impover- 
ishment of  the  blood  and  impairment  of  the  tone  of  the  tissues  as  to  in- 
duce general  dropsical  infiltration,  or  oedema  of  the  areolar  tissues.  In 
some  cases  of  intermittent  fever  each  succeeding  paroxysm  commences  a 
little  earlier  than  the  preceding  one,  and  its  hot  stage  continues  longer, 
thereby  shortening  the  intermission.  Such  cases,  if  not  interfered  with, 
are  liable  to  become  converted  into  the  remittent  form  during  the  second 
week  of  their  progress.  On  the  other  hand,  there  are  cases  in  which 
each  succeeding  paroxysm  begins  from  one  to  two  hours  later  than  the 
one  preceding. 

These  often  terminate  spontaneously  in  convalesence  during  the  sec- 
ond or  third  week  of  their  progress.  Besides  these  variations  in  the  pro- 
gress and  termination  of  different  cases  of  intermittent  fever,  you  will 
meet  with  occasional  variations  in  the  order  and  phenomena  of  the  sev- 
eral stages  of  the  paroxysm  itself.  In  some,  the  cold  stage  will  be  want- 
ing, or  so  slight  as  to  be  hardly  noticeable.  In  others,  the  hot  stage  will 
be  disproportionately  long,  and  the  sweating  stage  less  profuse.  These 
constitute  what  Dr.  D.  Drake  called  inflammatory  intermittents.  The 
paroxysm  may  commence  in  any  part  of  the  day;  but  in  far  the  larger 
number  of  cases  it  begins  between  six  and  eleven  o'clock  A.  m.  In  the 
intermissions  between  the  paroxysms,  the  patient  often  feels  no  other 
consciousness  of  being  ill,  than  a  sense  of  debility,  or  getting  easily  tired 
on  exercise  of  body  or  mind.  In  some  cases,  however,  the  tongue  remains 
coated  and  the  secretions  unnatural,  with  a  sense  of  fullness  in  the  epi- 
gas.ricand  hypochondriac  regions,  from  congestion  or  enlargement  of  the 
liver  and  spleen.  In  highly  malarial  districts,  cases  are  met  with  in  which 
there  are  no  open  paroxysms  of  fever,  and  yet  the  patients  grow  pale, 
lose  their  a])petite,  and  experience  a  sense  of  heaviness,  and  dull  pains  in 
the  head,  back,  or  limbs  during  a  part  of  each  day.  Although  these  cases 
present  no  marked  chills  or  heat  of  surface,  yet  the  thermometer  in  the 
mouth  or  under  the  tongue  shows  a  rise  of  two  or  three  degrees  of  tem- 
perature each  day.     These  are  called  latent  intermittents. 

When  a  similar  condition  of  the  system,  depending  on  malarial  influence, 
exists  coincidently  with  other  diseases  of  an  inflammatory  character,  the 
intermittent  is  said  to  be  mashed.  Cases  also  frequently  occur,  in  which 
a  severe  paroxysm  of  neuralgia  recurs  at  a  stated  period  each  day  or  every 
second  day,  and  appears  to  take  the  place  of  the  febrile  exacerbation. 

Remittent  Fever.  —  The  remittent  variety  of  malarial  fever  prevails  in 
the  same  localities,  at  the  same  seasons  of  the  year,  and  under  the  same 
circumstances  as  the  intermittent  variety.  Its  prodromic  or  forming 
stage  is  the  same  ;  and  its  first  paroxysm  is  ushered  in  by  the  same  well 
marked  cold  stage  or  chill,  followed  by  a  hot  stage,  presenting  every 
characteristic  symptom  of  the  hot  stage  of  an  intermittent,  except  that  it 
continues  much  longer,  being  usually  from  twelve  to  eighteen  hours  ;  and 
instead  of  terminat.ng  in  a  full,  copious  sweat,  with  entire  disappearance 
of  febrile  phenomena,  it  subsides  only  so  far  that  the  skin  becomes  moist, 


EEMITTENT.  189 

the  pains  cease,  and  the  patient  sleeps,  but  the  pulse  continues  from  ten 
to  fifteen  beats  per  minute  faster  than  natural,  and  the  temperature  from 
one  to  three  degrees  higher. 

Hence  it  is  called  a  remission  or  diminution  of  the  fever,  instead  of  an 
intermission.  About  the  same  hour  that  the  initial  chill  occurred,  which 
is,  in  most  cases,  between  seven  and  eleven  o'clock  a.  m.,  the  febrile  par- 
oxysm recommences,  and  continues  through  the  same  length  of  time,  and 
presents  the  same  active  symptoms  as  the  fii'st,  except  that  the  cold  stage 
is  less  marked;  and  after  the  first  two  days  amounts  only  to  a  brief  period 
of  coldness  of  the  extremities,  a  little  blueness  of  the  lips  and  nails,  pale- 
ness of  countenance,  and  a  desire  for  more  clothing  or  covering  on  the 
bed.  The  paroxysms  thus  commenced,  in  remittent  cases  usually  recur 
every  day;  and  as  the  hot  stage,  or  period  of  high  irritative  excitement,  is 
protracted,  and  the  subsidence  only  partial,  the  patient  becomes  more 
rapidly  exhausted;  the  tenderness  and  sense  of  oppression  in  the  epi- 
gastric and  hypochondriac  regions,  more  severe  and  constant ;  the  urinary 
secretions  more  scanty  and  high  colored  ;  the  tongue  more  thickly  coated 
and  mouth  more  dry  ;  the  mind  more  likely  to  be  wandering  or  delirious 
durino-  the  height  of  each  paroxysm  ;  and  t)e''ore  the  end  of  the  first  week 
the  skin  is  apt  to  become  more  or  less  yellow,  with  physical  signs  of  en- 
largement of  the  liver  and  spleen.  When  this  variety  of  fever  is  not 
materially  modified  by  treatment,  the  cases  are  found  to  progress  in  three 
directions.  In  the  more  severe  attacks,  especially  in  the  warmer  climates, 
the  initial  chill  is  severe,  and  the  hot  stage  characterized  by  intense 
throbbino-  pain  in  the  head,  with  more  or  less  delirium  ;  great  epigastric 
distress,  with  frequent  vomiting  of  yellow  or  green  fluid;  very  scanty 
urine  ;  severe  engorgement  of  the  liver  and  spleen,  indicated  by  enlarge- 
ment of  those  organs;  a  rapid  pulse,  and  temperature  of  41°  to  43°  C.  (106° 
to  110°  F.);  and  a  remission  characterized  by  much  weakness  and  little  or 
no  perspiration.  Under  the  daily  renewal  of  such  paroxysms,  the  patient 
becomes  rapidly  prostrated  ;  the  remissions  less  marked  ;  the  pulse  more 
rapid,  but  soft  ;  mind  more  continuously  wandering  ;  mouth  and  tongue 
dry  with  sordes  ;  skin  and  eyes  yellow  ;  epigastric  and  hypochondriac  re- 
gions full  ;  sometimes  spontaneous  diarrhoea  ;  and  somewhere  between  the 
fifth  and  ninth  days  entire  suppression  of  urine,  involuntary  intestinal 
discharges,  complete  collapse,  and  death.  Some  of  these  cases  are  accom- 
panied by  petechial  or  hemorrhagic  spots  on  the  surface,  or  by  more  copious 
discharges  of  blood  from  the  stomach  and  bowels,  or  both.  Late  in  the 
autumn,  and  in  the  spring,  these  severe  cases  are  often  accompanied  by  a 
dangerous  degree  of  pneumonic  engorgement  of  the  lungs. 

Cases  of  the  same  class  but  a  little  less  severe,  often  occur,  in  which  the 
hot  stage  of  the  paroxysm  becomes  more  and  more  prolonged,  until  the 
daily  remission  is  nearly  oblitei'ated,  and  all  the  symptoms  approximate 
closely  to  those  of  severe  typhoid  fever;  and  in  the  latter  part  of  the  sec- 
ond, or  during  the  third  week,  they  exhibit  the  dry,  brown  tongue,  sub- 
sultus,  mental  wandering,  and  imperfect  control  over  the  sphincters,  that 
indicates  the  near  approach  of  a  fatal  result.  Another,  milder,  class  of 
cases  are  met  with  in  which  the  hot  stage  of  each  returning  paroxysm  is 
shorter  than  the  preceding  one,  and  the  remission  more  distinct.  The 
tendency  of  such  is  to  terminate,  about  the  end  of  the  first  week,  in  a  full 
sweating  stage  and  complete  intermission,  to  be  followed  by  ordinary  par- 
oxysms of  intermittent  fever,  either  of  the  quotidian  or  tertian  form.  A 
still  milder  class  of  cases  run  about  the  same  covirse  as  the  last  mentioned, 
and  terminate  in  a  full  intermission  and  permanent  convalescence. 

Pathological  Anatomy. — The   pathological   changes  in  the  blood  and 


190  PERIODICAL    FEVEES. 

different  organs  of  the  body  were  so  fully  stated  in  the  jDreceding  lec- 
ture, when  discussing  the  general  pathology  of  malarial  fevers,  that  onlv  a 
few  words  need  be  added  here.  The  post  mortem  appearances  presented 
in  fatal  cases  of  intermittents  and  remittents  are  nearly  the  same.  Leav- 
ing the  pernicious  or  truly  malignant  cases  for  separate  consideration,  I 
may  state  that  the  chief  changes  observable  on  post  mortem  examinations 
are  the  diminution  of  the  red  corpuscles  and  appearance  of  black  pigment 
granules  in  the  blood;  the  app'earance  of  the  latter  in  many  of  the  organs 
and  tissues  of  the  body,  but  more  especially  in  the  spleen,  liver,  and  mar- 
row of  the  bones;  the  decided  congestion  and  tumefaction  of  the  spleen, 
liver  and  mucous  membrane  of  the  stomach  and  duodenum;  and  some- 
times a  moderate  degree  of  tumefaction  of  the  solitary  and  aggregated 
glands  of  the  ilium,  the  latter  presenting  what  has  been  called  the  shaven 
beard  appearance. 

When  death  has  taken  place  early  in  the  progress  of  the  general 
disease,  the  liver  and  spleen  present  a  dark  bluish  color,  and  their  en- 
largement is  caused  chiefly  by  the  accumulation  of  dark  blood.  ^Yhen 
the  course  of  the  disease  has  been  more  protracted,  these  organs  are  more 
dense  from  some  hypertrophy  or  hyperplasia  of  the  connective  tissue  and 
increase  of  lymphoid  cells,  and  the  color  of  the  spleen  is  lighter  or  nearer 
slate  color,  and  that  of  the  liver  more  of  the  olive  yellow,  varying  from 
light  olive  to  the  bronzed  hue.  In  the  more  protracted  cases  some  degree 
of  the  fatty,  waxy  and  amylaceous  molecular  degenerations  can  also  be 
found  in  the  parenchyma  of  many  of  the  organs,  but  in  much  less  degree 
than  in  the  continued  fevers,  as  the  typhoid  and  typhus. 

Diagnosis. — The  unmixed  or  uncomplicated  cases  of  either  intermittent  or 
remittent  fever  are  easily  distinguished  from  all  other  general  febrile  affec- 
tions when  they  have  progressed  far  enough  to  pass  one  or  more  paroxysms. 
The  well  marked  initial  chill,  followed  by  a  high  irritative  grade  of  fever, 
with  its  rapid  rise  of  temperature,  continuing  from  three  to  eighteen  or 
twenty  hours  with  an  equally  rapid  decline,  nearly  or  qiute  to  the  standard 
of  health,  the  same  to  be  repeated  at  intervals  nearly  regular  as  to  time, 
every  day  or  every  second  day,  constitute  an  assemblage  of  symptoms  so 
different  from  those  of  all  the  other  fevers,  that  no  other  diagnostic  marks 
are  needed.  It  is  only  when  the  specific  causes  of  yellow  fever,  or  of 
typhoid  or  typhus  are  actively  prevalent  at  the  same  time  and  in  the  same 
places  with  the  malarial  fevers,  that  you  will  meet  with  cases  in  which  the 
symptoms  of  different  types  of  fever  become  so  blended  in  the  same  case, 
as  to  lead  you  into  errors  or  uncertainties  regarding  the  diagnosis  of  individ- 
ual cases.  That  such  blending  is  not  only  possible,  but  of  frequent  occur- 
rence in  all  places  naturally  malarious,  into  which  the  causes  of  ^^ellow  and 
typhoid  fevers  are  introduced,  either  by  commerce  or  by  accumulations  of 
population,  I  have  already  abundantly  shown  in  the  lectures  on  those  dis- 
eases. And  at  the  same  time  I  pointed  out  the  most  available  means  for 
maintaining  the  line  of  differential  diagnosis  in  such  cases,  and  will  not 
repeat  them  here.* 

Those  protracted  cases  of  remittent  fever,  in  wdiich,  during  the  third 
week,  the  fever  becomes  more  continuous,  with  mental  wandering,  dry, 
brown  tongue,  some  degree  of  subsultus,  and  perhaps  diarrhoea,  if  pre- 
sented to  you  for  the  first  time  in  that  condition,  with  no  one  present  to 
give  a  correct  history  of  the  case,  might  cause  you  to  hesitate  or  feel  un- 
certain in  regard  to  the  question  as  to  whether  it  was  malarial  or  true 
typhoid.     But  even  in  such  cases,  there  is  a  more  yellow  shade  of  color  in 

*  See  pp.  90-91  and  145  of  this  Vol. 


TREATMEXT.  191 

the  skin  and  eyes,  greater  paleness  of  the  prolabia  from  impoverishment 
of  the  red  corpuscles  of  the  blood,  and  less  abdominal  tympanites,  than  in 
the  corresponding  stage  of  typhoid  fever. 

Prognosis. — Excluding  the  cases  of  a  decidedly  pernicious  character, 
periodical  fevcjrs,  whether  intermittent  or  remittent  in  form,  are  not  at- 
tended by  a  high  ratio  of  mortality.  And  in  such  cases  as  do  terminate 
iatally,  death  is  generally  caused  by  the  supervention  of  local  inflamma- 
tions in  some  of  the  important  organs,  and  not  from  the  gravity  of  the 
general  disease.  Yet,  if  either  from  neglect  or  inefficiency  of  treatment, 
the  fever  is  allowed  to  run  an  unusually  protracted  course,  the  progressive 
impoverishment  of  the  blood  and  impairment  or  perversion  of  molecular 
changes  in  the  tissues,  may  cause  fatal  exhaustion.  As  a  rule,  the  ratio  of 
mortality  is  much  greater  in  warm  or  tropical  climates,  than  in  the  tem- 
perate or  colder  regions.  It  is  much  greater  in  some  years  than  in  others 
in  the  same  locality.  Neither  age,  sex,  color  or  nationality,  appear  to 
have  any  influence  over  the  liability  to  be  attacked,  or  over  the  resulting 
mortality.  One  attack  does  not  in  any  degree  lessen  the  susceptibility  to 
subsequent  attacks,  but  rather  the  reverse.  The  disease  is  not  in  any 
degree  contagious;  neither  is  its  cause  portable  or  capable  of  being  car- 
ried from  place  to  place. 

Treatmeni. — There  are  three  distinct  objects  to  be  accomplished  in  the 
treatment  of  all  non-malignant  cases  of  periodical  or  malarial  fevers, 
namely:  first,  to  palliate  or  lessen  the  more  important  symptoms  during  the 
paroxysms;  second,  to  interrupt  or  prevent  their  recurrence;  and,  third, 
to  aid  in  restoring  the  proper  proportion  of  the  constituents  of  the  blood, 
and  the  natural  condition  of  the  properties  of  the  tissues,  and  thereby 
more  certainly  prevent  relapses.  The  several  stages  of  a  paroxysm  of  an 
ordinary  intermittent  fever  are  so  brief,  that  very  little  treatment  of  a  pos- 
itive character  is  needed.  The  patient  should  be  placed  in  bed  as  soon 
as  the  cold  stage  is  felt  approaching,  well  covered,  with  the  addition 
of  bottles  of  hot  water,  hot  bricks,  or  otrier  means  of  dry  warmth  to.  the 
extremities;  and  if  any  medicine  is  administered  internally,  from  two  to 
three  cubic  centimeters  of  chloroform  (min.  xxx  to  xlv)  given  at  once,  well 
diluted  with  sugar  and  water,  will  be  more  likely  to  lessen  the  severity 
and  duration  of  the  cold  stage  than  any  other  remedy.  The  common  cus- 
tom of  allowing  the  patient  to  drink  freely  of  hot,  pungent,  or  stimulating 
drinks  during  the  cold  stage,  is  worse  than  useless.  By  filling  the  stom- 
ach with  such  liquids,  you  are  much  more  likely  to  provoke  vomiting  and 
increase  the  epigastric  distress  as  the  hot  stage  supervenes,  than  you  are 
to  lessen  the  severity  of  the  chill.  Dr.  Mackintosh  of  Edinburgh  recom- 
mended free  bleeding  at  the  beginning  of  the  cold  stage  ;  Dr.  Wright,  of 
Chatham,  Illinois,  recommended  hypodermic  injections  of  sulphate  of  mor- 
phia; and  many  others  have  given  a  full  dose  of  opium,  for  the  same 
purpose.  While  there  is  abundant  evidence  that  either  of  these  remedies, 
will  in  many  cases,  greatly  lessen  the  severity  of  the  cold  stage,  the  danger 
of  producing  either  direct  or  secondary  bad  eflects,  more  than  counterbal- 
ances all  the  benefit  they  can  produce  in  ordinary  cases  of  malarial 
fever.  When  the  hot  stage  supervenes,  and  the  skin  becomes  hot 
and  dry,  frequent  sponging  of  the  surface  with  cold  water;  the  ap- 
plication of  cold  cloths  to  the  bead;  cooling  drinks  in  small  quan- 
tities but  frequently  repeated;  and  moderate  doses  of  an  efficient 
arterial  sedative,  will  contribute  most  to  mitigate  the  severity  of  the 
febrile  excitement,  lessen  the  tendency  to  kindle  up  inflammatory  compli- 
cations, and  add  to  the  comfort  of  the  patient.  The  Lest  sedatives  for 
this  purpose   are  aconite    and   veratruin  viride.      From  0.06  to  0.12  cubic 


192  PERIODICAL    FEVERS. 

centimeters  (min.  i  to  ii)  of  the  strong  tincture  of  either  may  be  given 
every  hour  until  the  liot  stage  begins  to  decline,  when  it  should  be  sus- 
pended. This  is  all  the  treatment  necessary  so  far  as  relates  directly  to 
the  paroxysms  of  ordinary  intermittents.  But  in  remittents,  in  which  the 
hot  stage  is  more  protracted,  and  the  symptoms  of  gastric  irritation  and 
visceral  congestions  are  more  prominent,  it  is  better  to  give  the  arterial 
sedative  in  larger  doses,  at  intervals  of  once  in  two  hours,  and  at  the  in- 
termediate hour  give  a  powder  composed  of  calomel  0.13  grams  (gr.  ii) 
and  bicarbonate  of  sodium  0.33  grams  (gr.  v).  These,  like  the  sedative, 
should  be  discontinued  on  the  decline  of  the  paroxysm,  and  if  the  bowels 
fail  to  move  during  the  next  twelve  or  eighteen  hours,  a  laxative  should  be 
given  sufficient  to  effect  that  object.  During  the  sweating  stage,  or  de- 
cline of  the  paroxysm,  no  special  treatment  is  required  except  rest  and 
dry  clothes  when  it  is  ended.  To  accomplish  the  second  object  I  have 
named  as  important,  namely,  to  prevent  the  recurrence  of  the  paroxvsras, 
requires  the  use  of  the  class  of  remedies  called  anti-periodics.  Of  these 
the  sulphate  of  quinia  is,  undoubtedly,  the  most  reliable,  in  the  great 
majority  of  cases.  But  the  other  alkaloids  of  the  Peruvian  bark,  the  ac- 
tive principles  of  the  bark  of  the  cornus  florida,  the  salix  alba,  etc.,  pos- 
sess sufficient  efficacy  to  be  used  with  advantage  in  many  cases;  more 
especially  in  such  patients  as  are  affected  unpleasantly  by  the  quinine. 
It  is  probable  that  quinia  and  all  the  vegetable  alkaloids  possessing  anti- 
periodic  properties,  produce  their  curative  influence  by  directly  antagoni- 
zing the  effects  of  the  malaria  on  the  properties  of  the  tissues  and  the 
function  of  the  vaso-motor  nerves.  In  the  preceding  lecture  I  stated  that 
the  essential  or  direct  pathological  conditions  produced  by  malaria,  were, 
an  increase  of  the  susceptibility  of  the  living  structures,  a  diminution  or 
impairment  of  the  vital  affinity,  and  such  an  influence  on  the  vaso-motor 
centres  as  to  induce  active  contraction  of  the  whole  system  of  peripheral 
or  cutaneous  vessels.  The  sulphate  of  quinia,  however,  when  used  in  fair 
doses,  directly  diminishes  the  susceptibility,  while  it  increases  the  force  of 
affinity  in  the  tissues,  and  so  impresses  the  vaso-motor  centres  as  to  favor 
relaxation,  if  not  temporary  paralysis,  of  the  vessels  of  the  surface.  In 
small  doses  its  influence  on  the  vital-affinity  and  consequent  tonicity  of 
the  tissues  predominates,  and  hence  when  thus  administered  it  has  been 
regarded  as  a  tonic.  In  large  doses  its  effect  in  directly  diminishing  the 
susceptibility  or  excitability  of  the  structures  and  modifying  the  vaso- 
motor function,  caused  it  to  be  claimed,  in  former  times,  as  a  powerful 
sedative,*  and  more  recently  as  an  anti-pyretic.  That  it  is  capable  of 
producing  these  effects,  even  to  a  degree  destructive  of  life,  is  fully  proved 
by  experiments  on  animals,  by  accidental  experiments  on  the  human  sub- 
ject, and  by  clinical  observations  at  the  bed-side,  f  It  is  only  a  few  days 
since,  that  I  saw  a  patient  with  typhoid  fever,  evidently  complicated  with 
malarial  influence,  in  which  the  exhibition  of  moderately  full  doses  of 
quinine  for  three  or  four  days  in  succession,  had  induced  great  impair- 
ment of  hearing  and  vision,  and  a  dangerous  degree  of  depression,  with 
insomnia,  and  what  the  family  called  "sinking  spells." 

Some  practitioners  have  attributed  to  quinine  important  germicide  prop- 
erties ;  but  I  do  not  think  its  effects  on  the  human  system  are,  in  any 
degree,  dependent  on  its  power  to  destroy  bacteria  or  micrococci.  The 
arsenical   preparations   have  long   been  known   to  possess   valuable  anti- 

*See  paper  in  the  American  Journal  of  Medical  Sciences  for  July,  1844,  by  Wm.  M.  Boling,  M, 
D.,  of  Montgomery,  Ala. 

t  See  papi.r  on  the  '•  Poisonous  Properties  of  Quinia,"  by  Wm.  O.  Baldwin,  M.  D..  of  Montgom- 
ery. Alabama,  in  the  Ame' lean  Journal  of  Medical  Sciences,  1847.  Also  in  the  Medical  Gazette, 
New  York,  fur  October  22d,  1S81. 


TREATMENT.  193 

periodic  or  anti-malarial  properties.  The  most  efficacious  of  these  prepa- 
rations, is  the  Liquor  Potassii  Arsenitis.  More  recently  it  has  been  found 
that  the  sulphites  or  hypo-sulpliites  of  sodium,  calcium  and  magnesium, 
when  given  in  large  doses  and  continued  for  several  days  in  succession, 
are  capable  of  arresting  the  progress  of  ordinary  periodical  fevers.  These 
undoubtedly  act  as  antiseptics,  neutralizing  the  malarial  poison  in  the 
system. 

My  own  experience  would  indicate  that  they  are  much  slower  and  less 
certain  in  their  influence  in  preventing  the  recurrence  of  fever  paroxysms 
tlian  the  quinine  or  its  kindred  substances.  As  I  have  already  stated, 
abundant  experience  has  shown  that  sulphate  of  quinia  is  the  most  relia- 
ble of  all  the  remedies  hitherto  used  for  the  interruption  of  the  paroxysms 
or  active  phenomena  of  periodical  fever,  in  the  great  majority  of  cases. 
The  next  question  of  practical  importance  is,  in  what  doses,  and  at  what 
times  in  relation  to  the  paroxysms,  can  it  be  administered  with  the  greatest 
certainty  of  success  and  the  least  liability  to  produce  unpleasant  or  inju- 
rious effects  upon  the  patient  ?  It  is  pretty  generally  agreed  that,  in  all 
ordinary  cases,  from  0.66  to  1.33  grams  (g-r.  x  to  xx)  given  during  each  of 
the  first  and  second  days,  followed  by  from  0.5  to  0.8  grams  (gr.  viii  to  xii) 
on  the  third,  fourth  and  fifth  days,  is  sufficient  to  fairly  interrupt  the  further 
recurrence  of  the  paroxysms.  But  concerning  the  best  mode  and  time  of 
administering  the  quantities  I  have  named,  you  will  find  wide  differences 
of  opinion,  even  among  the  most  eminent  and  experienced  in  the  profes- 
sion. Some  prefer  to  give  0.066  or  0.130  grams  (gr.  i  or  ii)  every  one  or 
two  hours,  until  the  required  quantity  for  the  day  has  been  taken;  while 
others  give  the  whole  amount  in  one  or  two  doses.  Some  limit  the  ad- 
ministration to  the  time  of  the  intermission  or  remission,  and  others  ad- 
minister the  remedy  as  freely  in  the  hot  stage  of  the  paroxysm  as  at  any 
other  time.  My  own  clinical  experience  has  fully  satisfied  ine  that  in  this, 
as  in  most  other  matters  relating  to  the  treatment  of  disease,  the  adherence 
to  a  medium  course  which  avoids  both  extremes,  is  attended  by  the  highest 
degree  of  success  with  the  smallest  ratio  of  casualties  or  unpleasant  effects. 
Consequently,  I  prefer  to  divide  the  whole  amount  to  be  given  in  the 
tvi'enty-four  hours  into  three  doses,  and  give  one  on  the  decline  of  a  par- 
oxysm, another  in  the  middle  of  the  intermission  or  remission,  and  the 
third  an  hour  before  the  access  of  the  next  expected  paroxysm.  My 
reasons  for  preferring  this  method  are:  first,  as  it  is  during  the  intermission 
or  time  between  the  paroxysms,  that  the  exciting  cause  (whatever  its 
form  or  nature  may  be)  is  being  re-developed  in  the  system  and  is  re-accu- 
mulating its  influence  upon  the  properties  of  the  blood  and  tissues, 
which  is  to  eventuate  in  the  re-establishmcTit  of  another  paroxysm;  so 
the  remedy  that  is  expected  to  either  neutralize  or  counterpoise  the  action 
of  this  agent,  should  be  most  actively  present  in  the  system  at  the  same 
time  if  we  would  afford  it  the  best  opportunity  for  successful  action. 
Second,  from  the  sweating  stage  or  decline  of  one  paroxysm  to  the  time 
for  beginning  the  next,  the  stomach  is  less  irritable,  and  consequently  very 
much  less  likely  to  reject  the  medicine  by  vomiting,  and  the  nervous  cen- 
tres less  likely  to  be  unpleasantly  disturbed,  than  in  the  stage  of  high 
excitement  during  the  paroxysm.  Third,  the  end  sought,  namely  the  effec- 
tual arrest  of  the  active  paroxysms  of  the  disease,  is  obtained  with  greater 
uniformity  by  so  administering  the  remedy  that  its  effects  are  continued 
evenly  through  the  intermission,  and  are  existing  in  full  activity  at  the 
time  a  paroxysm  might  be  expected  to  recur.  I  think  the  same  reasons 
apply  to  the  administration  of  all  the  anti-periodic  vegotaVjle  alkaloids. 
It  is  true,  however,  that   the   use  of  the    quantity  of  quinine  I  have   iudi- 

13 


194  PERIODICAL    FEVERS. 

cated  durino'  the  first  five  days  of  the  treatment,  will  very  generally  arrest 
the  progress  of  simple  intermittents,  whether  the  amount  to  be  given  each 
day  is  administered  in  one  dose  or  divided  into  ten  or  fifteen.  And  if 
the  treatment  I  have  suggested  for  mitigating  the  severity  of  the  hot 
stage  of  the  paroxysm  be  judiciously  applied  in  the  remittent  cases,  it  will 
carry  the  decline  as  near  an  intermission  as  possible,  and  make  the  action 
of  the  anti-periodic  almost  as  certain  to  arrest  the  progress  of  the  disease 
as  in  the  simple  intermittents. 

In  addition  to  the  measures  I  have  already  indicated,  the  practitioner 
should  always  give  careful  attention  to  the  functions  of  the  abdominal 
viscera,  including  the  kidneys.  Local  irritations  and  perversions  of  func- 
tion should  be  relieved  by  mild  anodynes  and  alteratives;  and  secretion, 
especially  of  the  kidneys,  well  sustained  by  diuretics,  when  indicated  by 
scantiness  of  the  urine.  Due  attention  to  these  items  need  not  interfere 
in  any  degree  with  the  prompt  and  proper  use  of  the  anti-periodics.  When 
you  have  fairly  interrupted  the  further  recurrence  of  febrile  paroxysms, 
whether  it  has  required  three  or  five  or  seven  days,  the  disease  under  which 
your  patient  is  laboring  is  by  no  means  completely  cured.  The  blood  is 
still  deficient  in  red  corpuscles;  the  tone  of  the  nervous  and  muscular 
structures  is  still  below  the  normal  standard;  and  the  molecular  changes 
required  for  healthy  secretory  action  in  the  important  secretory  organs, 
are  unsteady  from  the  altered  affinity  between  the  secretory  cells  and  the 
elements  of  the  blood.  Consequently,  if  the  treatment  is  suspended  here, 
as  is  too  often  the  case,  the  patient  is  left  in  the  most  favorable  condition 
for  a  relapse.  It  is  better,  therefore,  that  you  should  always  give  careful 
attention  to  the  third  object  of  treatment,  which  I  stated  to  be  the  restor- 
ing of  the  constituents  of  the  blood  to  their  natural  proportion,  and  the 
properties  of  the  tissues,  regulating  molecular  movements,  to  their  natural 
condition.  For  this  purpose,  as  soon  as  the  active  paroxysms  of  the  fever 
are  interrupted,  the  patient  needs  to  be  continued  on  a  plain,  nutritious 
diet;  he  may  begin  passive,  moderate  exercise  in  the  open  air,  but  should 
be  careful  to  avoid  fatigue  of  mind  orbodv;  avoid  exposure  to  the  damp- 
ness of  the  morning  and  evening,  while  the  dew  is  rising  or  falling;  and 
take  such  medicines  as  will  promote  the  general  tonicity  of  the  tissues, 
and  the  reproduction  of  the  red  corpuscles  of  the  blood,  and  maintain 
healthy  action  of  the  more  important  secretory  organs.  One  of  the  best 
combinations  for  accomplishing  these  objects,  is  the  following: 

5-     Quiniae  Sulphatis 
Ferri  Citratis 
Extracti  Hyosciami 
Extracti  Nucis  VomicEe 

Mix.  Divide  into  thirty  gelatine  capsules  or  pills,  of  which  one 
should  be  given  before  each  meal  time,  for  the  first  week  ;  one  before 
breakfast  and  dinner  the  second  week  ;  and  one  before  breakfast  only 
during  the  third  week. 

Another  excellent  formula,  which  I  have  used  for  many  years  as  a  sub- 
stitute for  the  one  just  given,  is  as  follows  : 

^     Extracti  Cornus  Floridas  4.00  grams  3i. 

Ferri  Sulphatis  2.00       "  3ss. 

Extracti  Hyosciami  2.00       "  3ss. 

Strychnise  Sulphatis         0.06       "  gr.  i. 

Mix.     Divide  into  thirty  gelatine  capsules  or  pills,  of  which  one  may 


4.00  grams 

3i. 

4.00       " 

3i. 

2.00       " 

3ss. 

0.6(>       " 

gr.  X. 

TREATMENT.  195 

bo  given  just  as  often,  and   continued  in  the   same   manner  as  those  of 
the  preceding  formula. 

Your  knowledge  of  the  therapeutic  action  of  the  several  ingredients  in- 
cluded in  these  formulas,  enables  you  to  see  that  I  have  in  each  a  soluble 
salt  of  iron  to  aid  in  the  formation  of  red  corpuscles  ;  tonic  doses  of  an 
anti-periodic  and  nerve  tonic  in  the  quinine  and  nux  vomica  of  the  one, 
and  the  cornus  florida  and  strychnia  of  the  other,  to  hasten  the  recovery 
of  a  natural  degree  of  general  tonicity  ;  and  hyosciamus  to  soothe  the  sen- 
sitiveness of  tlie  gastric  mucous  membrane  and  of  the  tissues  generally. 
Seeing  thus  clearly  the  therapeutic  elements  you  need  to  combine  to 
eiFect  the  improvements  needed  by  your  patient,  an  adequate  knowledge 
of  materia  medica  and  therapeutics  will  enable  you  to  make  a  score  of 
formulae,  each  capable  of  accomplishing  the  objects  you  desire,  but  with  a 
variable  degree  of  efficiency.  If  the  patient  for  which  you  are  prescrib- 
ing has  already  become  quite  pale  from  impoverishment  of  the  blood,  he 
may  derive  much  benefit  from  some  of  the  phosphatic  compounds.  Four 
cubic  centimetres,  or  a  teaspoon ful,  of  the  syrup  of  lacto-phosphate  of 
calcium,  or  of  iron  ;  or  the  same  quantity  of  the  compoutid  syrup  of  hypo- 
phosphites  of  sodium,  calcium  and  iron,  may  be  given  after  each  meal,  in 
addition  to  the  capsules,  or  pills,  before  the  meals.  Again,  in  many  of 
the  patients  you  will  find  a  constant  tendency  to  constipation,  which  may 
be  readily  obviated  by  adding  to  either  of  the  formulas  T  have  given,  such 
proportion  of  gum  aloes  and  pilulae  hydrargyri  as  will  give  from  0.015  to 
0.020  grams  {gr.  ^  to  ^)  in  each  capsule  or  pill.  In  cases  presenting  enlarge- 
ments of  the  spleen  or  liver,  or  both,  continuing  after  the  patient  is  well 
recovered  in  other  respects,  I  have  found  no  remedy  more  certainly  bene- 
ficial than  the  chloride  of  ammonium,  given  in  doses  of  from  0.33  to  0.50 
grams  (gr.  v  to  viii),  three  or  four  times  a  day.  It  was  recommended  for 
this  purpose  by  Dr.  John  Eberle,  in  his  work  on  the  practice  of  medicine, 
more  than  half  a  century  since.  It  may  be  most  conveniently  adminis- 
tered in  solution  with  syrup  of  liquorice.  The  practice  of  giving  patients, 
while  convalescing  from  malarious  fevers,  various  compounds  called 
"SiWers,"  which  was  much  in  vogue  in  former  times,  and  is  by  no  means 
wholly  abandoned  yet,  is  a  very  pernicious  one,  and  should  be  condemned 
by  every  intelligent  phj'^sician.  These* compounds  are  usually  made  up 
of  some  bitter  barks  or  roots  mascerated  in  wine,  whisky,  or  diluted  alco- 
hol, and  of  such  strength  that  patients  usually  take  a  table-spoonful  or 
two,  from  one  to  three  times  a  day.  The  barks  and  roots  generally  used 
are  moderately  tonic  and  unobjectionable  ;  but  the  amount  of  alcohol 
taken  in  all  such  preparations  is  sufficient  to  produce  a  perceptible  dimin- 
ution of  the  interchange  of  carbonic  acid  gas  for  oxygen  by  the  blood  in 
the  lungs,  and  to  retard  capillary  circulation  by  its  anaesthetic  influence  on 
the  vaso-motor  nerves  ;  effects  that  much  more  than  counter-balance  all 
the  good  derived  from  the  bitter  principles  incorporated  with  it.  The  time 
has  been  when  it  was  supposed  that  alcoholic  liquors  were,  in  themselves, 
more  or  less  preventive  or  prophylactic,  of  malarious  attacks.  But  experi- 
ence, both  in  civil  and  military  life,  has  shown  the  fallacy  of  that  opinion. 
If  there  are  any  who  still  entertain  such  a  belief,  or  are  in  doubt  on  the 
subject,  I  would  refer  them  to  the  results  of  an  experiment  tried  on  a 
large  scale  in  connection  with  our  army  of  the  Potomac  during  the  late 
war,  as  related  by  Dr.  Frank  H.  Hamilton,  of  New  York,  in  his  "  Treatise 
on  Military  Surgery  and  Hygiene,"  from  page  70  to  75,  inclusive.  Having 
said  what  I  deem  necessary  in  regard  to  the  ordinary  intermittent  and 
remittent  varieties  of  malarial  fever,  I  must  reserve  the  consideration  of 
the  more  malignant  or  pernicious  variety  of  cases  for  another  lecture  hour. 


196  PERNICIOUS    FEVEES. 


LECTURE  XXII. 

Periodical  Fevers  Continued— Pernicious  Fevers;  their  Varieties,  Symptoms,  Pathology  and 
Treatment. 

GENTLEMEN  :  The  word  pernicious  is  now  quite  generally  used  to 
designate  a  class  of  cases  of  malarial  fever,  which,  though  differing 
much  from  each  other,  yet  exhibit  a  common  tendency  to  destroy  life 
within  a  short  period  of  time.  These  cases  were  formerly  called  malignant 
by  some,  and  congestive  by  others.  They  were  much  more  prevalent  during 
the  first  two  or  three  generations,  after  the  settlement  of  the  more  highly 
malarious  districts  of  our  country  than  at  the  present  time. 

Dr.  Drake  tells  us  they  are  found  most  frequent  between  the  parallels 
of  thirty-one  and  thirty-three  degrees,  which  includes'  that  belt  in  the 
Southern  States  comprising  the  rice  fields,  the  cane  brakes,  and  the 
borders  of  streams  and  bayous  opening  into  the  Gulf  of  Mexico.  Accord- 
ing to  Dr.  Drake,  the  next  most  common  place  to  find  them  is  along  the 
Red  River  region  of  Louisiana,  and  the  southern  border  of  Lake  Michi- 
gan, from  Chicago  around  to  St.  Joseph.  In  the  early  settlement  of  the 
country  they  were  quite  common  in  the  latter  region,  but  with  increase 
of  population  and  its  consequences  they  have  become  rare. 

In  Europe  they  have  long  been  familiar  with  this  variety  of  malarial 
fever,  in  some  portions  of  Holland,  Turkey  and  Austria,  and  also  on  the 
western  coast  of  Africa.  These  are  the  regions  where  it  most  frequently 
occurs,  and  consequently  where  its  peculiarities  are  most  familiar  to  the 
profession. 

You  will  remember  that  in  speaking  of  the  modus  operandi  of  malaria 
on  the  human  system,  I  deviated  from  the  opinions  most  commonly 
expressed  on  this  subject,  which  are,  that  malaria,  whether  organic  or  inor- 
ganic, produces  its  primary  impression  xipon  the  nervous  structures 
through  the  medium  of  the  blood.  Instead  of  this,  I  claimed  that  its 
presence  in  the  blood  produced  a  primary  and  direct  effect  on  the  ele- 
mentary properties  common  to  all  the  tissues  ;  namely,  susceptibility  and 
vital  affinity;  and  that  the  nervous  disturbance  was  only  a  part  of  this 
more  general  action,  I  further  explained  that  it  primarily  caused  an 
increase  of  the  general  susceptibility  or  excitability,  coincident  with  a 
decided  diminution  of  the  vital  affinity  by  which  the  tonicity  of  the  tissues 
and  the  atomic  movements  are  controlled.  In  speaking  yesterday  of  the 
symptomatology  of  periodical  fevers,  I  explained  that  the  difference 
between  the  ordinary  and  the  pernicious  paroxysm  was  the  more  profound 
depression  of  the  vital  affinity  in  the  latter.  Owing  either  to  the  intensity 
of  the  exciting  cause  (malaria)  or  some  peculiarity  of  the  individual,  the 
depression  of  that  property  is  so  great  as  to  endanger  an  actual  arrest  of 
capillary  circulation  and  molecular  changes  as  they  occur  in  the  processes 
of  secretion,  nutrition,  and  disintegration;  and  hence  the  extreme  danger 
of  actual  suspension  of  life  in  the  paroxysm.  Or,  if  reaction  does  take 
place,  it  is  liable  to  be  incomplete,  leaving  the  circulation,  molecular 
changes,  and  temperature  of  some  of  the  parts  still  depressed,  even 
through  the  intermission.  The  essential  pathology  of  the  pernicious  chill 
therefore  is,  that  the  play  of  vital  affinity  is  so  far  overcome  as  to  make 


VARIETIES.  197 

the  restoration  of  the  natural  atomic  or  molecular  relations  between  the 
constituents  of  the  blood  in  the  capillaries  and  the  organized  tissues 
extremely  difficult.  This  being  the  essential  feature  of  the  disease,  it  is 
necessarily  dangerous,  because  whenever  the  properties  of  the  tissues 
become  so  involved  that  they  lose  their  inherent  power  to  attract  new 
atoms  from  the  blood  and  return  old  ones,  as  in  the  natural  processes 
of  secretion,  nutrition,  etc.,  there  is  not  only  imminent  danger  of  the  ces- 
sation of  life,  but  tiiere  is  also  great  difficulty  in  obtaining  any  effect  from 
the  administration  of  remedies. 

In  some  cases  in  which  reaction  takes  place,  it  is  not  complete  or  uniform 
in  all  parts  of  the  body  and  extremities.  The  parts  most  frequently  left 
pale  and  cold  after  the  general  reaction,  are  the  fingers,  toes,  tip  of  the 
nose,  and  lobe  of  the  ear.  Such  failure  in  any  part,  however  limited, 
should  be  regarded  as  indicating  the  return  of  another  and  still  more  dan- 
gerous paroxvsm. 

Owing  to  the  different  degrees  of  intensity  in  the  action  of  the  malarial 
poison,  or  to  the  difference  in  the  susceptibility  of  the  several  groups  of  or- 
gans, or  to  both,  the  cases  classed  as  pernicious  present  considerable  diversity 
in  their  symptoms  and  progress.  For  clinical  purposes  they  may  all  be  ar- 
ranged in  five  groups,  namely:  the  comatose,  the  spasmodic,  the  pulmonary, 
the  choleraic  and  the  algid.  This  number  might  be  reduced  by  uniting  the 
first  two  groups  in  one,  calling  it  the  cerebro-spinal.  In  the  first  group 
here  mentioned,  the  force  of  the  morbid  impression  falls  upon  the  brain, 
or  more  particularly  upon  the  cerebral  hemispheres,  and  so  far  suspends 
their  function  as  to  render  the  patient  unconscious  or  comatose  from  the 
very  beginning  of  the  paroxysm.  As  these  cases  progress  the  coma  may 
become  hourly  more  profound,  the  face  pale,  the  temperature  low,  pulse 
feeble,  respiration  irregular,  and  pupils  dilated,  until  death  supervenes. 
Dr.  Hertz,  in  Ziemssen's  Cyclopsedia,  speaks  of  cases  that  are  not  only 
perfectly  unconscious,  but  have  reached  a  stage  of  apparent  suspension 
of  the  functions  of  life  so  as  to  appear  dead.  He  speaks  of  a  man  who 
was  actually  supposed  to  be  dead,  and  taken  to  the  morgue  for  examina- 
tion; but  some  signs  of  life  being  discovered  he  was  returned  to  his  bed, 
where  subsequent  reaction  took  place  and  he  recovered.  Such  cases  of 
a|)parent  death  are  rare.  In  some  of  the  cases  in  which  a  comatose  con- 
dition presents  itself,  a  partial  reaction  soon  takes  place,  in  which  the  face 
becomes  deeply  suffused,  the  head  and  trunk  hot,  pulse  more  full,  and  res- 
piration hurried.  In  some  of  these  cases  the  coma  gives  place  to  wild  de- 
lirium, which  may  end  either  in  the  supervention  of  sleep  and  an  intermis- 
sion, or  the  return  of  coma,  general  paralysis  and  death. 

For  practical  or  therapeutical  purposes  it  is  important  to  distinguish  the 
cases  in  which,  at  least,  partial  reaction  occurs,  from  those  just  previously 
described.  The  one  is  accompanied  by  febrile  reaction,  with  fullness  of 
the  cerebral  vessels,  while  the  other  remains  cold,  the  pulse  weak,  vacil- 
lating and  irregular,  yet  both  are  comatose.  In  the  second  group  of  cases, 
which  I  called  spasmodic^  the  force  of  the  disease  appears  to  fall  upon  the 
spinal  cord  and  medulla  oblongata.  In  these,  the  paroxysm  is  ushered  in, 
not  with  coma,  but  with  severe  muscular  contractions,  either  continuous 
as  in  tetanus,  or  paroxysmal,  as  in  convulsions. 

The  latter  generally  occurs  in  children,  while  in  adults  the  muscular  con- 
tractions are  more  continuous,  causing  the  muscles  at  the  back  of  the  neck 
and  upper  part  of  the  spine,  on  one  or  both  sides  to  become  rigid,  retract- 
ing the  head,  and  giving  the  patient  much  the  same  aspect  as  in  cerebro- 
spinal meningitis.  A  case  of  this  kind,  in  the  person  of  a  young  woman, 
came  under  my  care  many  years  since  in  the  Mercy  Hospital.     I  saw  her 


198  PEENICIOUS    FEVERS. 

first  immediately  after  her  admission,  when  in  the  paroxysm!  She  ap- 
peared entirely  unconscious;  the  head  retracted  and  turned  to  the  left  from 
rigid  contraction  of  the  muscles  on  the  posterior  and  left  side  of  the  neck; 
face  and  skin  generally  congested  and  bluish;  extremities  cold;  pulse  soft 
and  variable  in  beat;  respirations  increased  in  frequency  but  variable;  and 
pupils  nearly  natural.  As  I  could  get  no  history  of  the  case  I  regarded  it 
as  one  of  congestion  of  the  cerebro-spinal  centres,  and  directed  treatment 
accordingly.  On  returning  to  the  hosjoital  a  few  hours  later,  I  was  sur- 
prised to  find  the  patient  conscious,  the  rigid  muscles  relaxed,  the  head 
freely  movable,  and  the  patient  comparatively  comfortable.  1  then  learned 
sufficient  facts  concerning  the  history  of  the  attack  to  satisfy  me  that  it  was 
altogether  of  malarial  origin,  and  at  once  commenced  giving  0.33  gram 
(gr.  v)  doses  of  quinine  every  two  hours,  and  continued  until  2.00  grams 
(gr.  xxx)  had  been  taken,  when  the  time  was  lengthened  to  six  hours. 
No  furtlier  paroxysms  recurred,  and  the  patient  soon  recovered.  There  is 
much  danger  in  this  class  of  cases  that  the  muscles  of  respiration  may 
become  so  involved  in  the  rigid  contractions  as  to  suspend  the  motions  of 
the  chest,  and  of  course  suspend  also  the  life  of  the  patient. 

In  the  third  group  of  cases  the  force  of  the  disease,  instead  of  falling 
upon  the  brain  or  spinal  cord,  is  manifested  chiefly  in  the  respiratory  or- 
gans, and  the  patient,  on  going  into  the  paroxysm  or  chill  with  its  general 
phenomena  of  depression,  feels  great  oppression  across  the  chest;  the 
breathing  becomes  laborious,  the  finger-nails  blue,  the  lips  leaden, 
and  the  pulse  frequent  and  feeble,  with  impairment  of  circulation  in 
the  cutaneous  surface.  While  the  mind  remains  clear,  though  often 
inclined  to  drowsiness,  the  stagnation  in  the  pulmonary  capillaries  and 
consequent  dyspnoea  increases  rapidly.  At  first  there  is  a  universal  mix- 
ture of  moist  and  dry  rales  passing  rapidly  into  the  sub-mucous  and 
mucous  rhonchi,  all  over  the  chest  from  the  clavicles  to  the  diaphragm, 
posteriorly  and  anteriorly. 

The  accumulation  in  the  lungs  is  sometimes  so  rapid  that  the  air  ceils 
become  literally  overwhelmed  by  compression  and  oedematous  infiltration 
in  three  or  four  hours,  shutting  the  air  off  so  completely  that  the  patient 
dies  directly  from  suffocation.  One  case  of  this  kind  came  under  my  ob- 
servation many  years  ago,  that  terminated  fatally  in  about  eight  hours. 
More  recently,  in  consultation  with  another  physician,  I  saw  a  case  almost 
equally  rapid  in  its  progress,  but  which  was  arrested,  and  recovery  took 
place. 

In  the  fourth  or  choleraic  group  of  cases,  the  force  of  the  disease  seems 
to  fall  more  directly  upon  the  digestive  organs,  causing  in  addition  to  the 
general  depression  and  coldness,  great  epigastric  distress  and  restlessness, 
with  frequent  turns  of  vomiting  and  purging,  intense  thirst,  dryness  of  the 
mouth  and  fauces,  coldness  and  blueness  of  the  surface  and  extremities,  and 
weakness  of  voice,  constituting  a  group  of  symptoms  so  closely  resem- 
bling a  severe  attack  of  epidemic  cholera,  that  the  case  would  be  readily 
classed  as  such  if  the  latter  disease  should  happen  to  be  prevailing  in  the 
community  at  the  same  time.  Generally,  however,  there  are  less  muscular 
cramps,  and  the  discharg-es  less  like  rice  water  in  appearance  than  in  chol- 
era. In  some  of  this  group  of  cases,  especially  in  warm  climates,  and 
when  th^  pernicious  character  manifests  itself  after  one  or  more  paroxysms 
of  a  milder  grade,  more  or  less  haemorrhage  accompanies  the  stage  of  ex- 
haustion. 

I  recollect  an  instance  occurring  outside  of  the  city  limits,  twenty  years 
ago,  in  the  latter  part  of  the  summer,  where  a  man,  past  the  middle  period 
of  life,  had  a  periodical  fever  for  four  or  five  days,  accompanied  by  loose. 


SYMPTOMS.  199 

ness  of  the  bowels,  and  which  ended  in  a  paroxysm  of  extreme  depression, 
during  which  he  had  three  or  four  copious  discharges  of  dark  grumous 
blood,  and  in  less  than  five  hours  he  was  in  a  state  of  complete  collapse, 
and  soon  died,  apparently  from  the  direct  effects  of  the  haamorrhage. 

Haemorrhage  in  these  cases  may  take  place  from  the  gums,  from  the 
mouth,  and  from  the  nasal  passages,  the  renal  organs,  or  into  the 
subcutaneous  tissues,  just  as  we  see  sometimes  in  malignant  cases 
of  the  eruptive  fevers.  I  saw,  not  two  weeks  since,  a  case  of  measles 
where  the  disease  manifested  itself  in  this  malignant  form.  A  general 
hsemorrhagic  tendency  was  developed  so  early  that  on  the  second  day  of 
the  eruption  there  was  more  or  less  extravasation  into  the  tissues,  and  an 
oozing  of  blood  into  the  mouth,  and  the  patient  died  within  twenty-four 
hours  from  the  time  I  saw  her,  which  was  on  the  evening  of  the  third  day 
of  eruption.     It  was  a  young  woman  in  the  vigorous  period  of  adult  life. 

A  similar  pathological  condition  is  occasionally  seen  in  the  more  malig- 
nant cases  of  all  the  varieties  of  idiopathic  fever. 

I  have  now  described  briefly  the  comatose  and  the  spasmodic  cases 
which  involve  prominently  the  cerebro-spinal  nervous  centres,  the  pul- 
monary, or  such  as  endanger  life  from  suspension  of  the  respiratory  func- 
tion, and  the  choleraic,  involving  most  prominently  the  digestive  organs. 
The  last  cases  described,  accompanied  by  hgemorrhage,  are  by  most  writers, 
placed  in  a  separate  group  called  the  ha^morrhagic.  There  is  another 
variety  still,  that  is  known  as  pre-eminently  the  cold  or  algid  group.  Pri- 
marily all  are  more  or  less  cold,  but  there  is  a  class  of  cases  where  the 
patient  becomes  almost  at  once  cold  and  blue,  and  ultimately  his  organic 
functions  cease  without  any  specific  determination  to  one  important  organ 
more  than  another,  unless  it  be  to  the  cutaneous  surface  in  the  form  of 
copious  cold  sweating.  And  even  the  post-mortem  examination  in  these 
cases  reveals  nothing  more  than  a  paler  and  drier  state  of  the  tissues  than 
natural.  When  death  has  taken  place  in  the  comatose  groups  of  cases, 
the  post-mortem  examination  reveals  more  fullness  of  the  vessels  of  the 
brain,  with  more  or  less  oedematous  infiltration  into  the  cerebral  substance. 
In  the  spasmodic  or  convulsive  group  similar  appearances  are  found  in  the 
spinal  cord  or  medulla  oblongata,  or  both.  In  the  pulmonary  group  the 
predominant  post-mortem  appearances  are  passive  engorgement  of  the 
vessels  and  oedema  of  the  tissue  of  the  lungs.  True  hepatization  or  other 
inflatnmatory  changes  are  very  seldom  seen.  In  the  choleraic  groups  of 
cases  the  chief  post-mortem  changes  are  increased  fullness  of  the  vessels, 
with  softening  of  portions  of  the  mucous  membrane  of  the  alimentary 
canal,  with  a  similar  condition  of  the  spleen,  and,  less  notably,  of  the  liver. 

All  these  post-mortem  changes  point  directly  to  certain  pathological 
conditions,  such  as  general  impairment  of  tonicity  in  the  tissues,  including 
especially  the  coats  of  the  blood-vessels,  and  ready  passive  exudations 
wherever  local  determinations  take  place.  These  are  shown  by  the  copious 
sweating  from  the  skin,  the  still  more  copious  serous  and  hgemorrhagic  dis- 
charges from  the  internal  surfaces,  the  vascular  fullness  with  oedema  of 
the  brain  and  lungs,  and  the  actual  reduction  of  temperature.  In  regard 
to  the  latter.  Dr.  Hertz  mentions  a  case  in  which  the  clinical  thermometer 
gave  only  31°  C.  (88°  F.)  in  the  mouth,  .30°  C.  (86°  F.)  in  the  anus,  and 
28.8°  C.  (84°  F.)  in  the  axilla.  Such  reduction  of  temperature,  as  well  as 
the  whole  assemblage  of  changes  I  have  described,  clearly  indicate  a  great 
impairment  of  tonicity,  including  muscular  contractility,  and  of  molecular 
changes  and  innervation. 

If  these  views,  sustained  alike  by  clinical  observation  and  post-mortem 
examinations,  are  correct,  they  furnish  two  leading  and  important  indica- 


200  PEENICIOUS    FEVERS. 

tions  for  treatment.  First,  to  bring  about  general  and  uniform  reaction  by 
the  prompt  use  of  such  means  as  will  most  efficiently  increase  the  tonicity 
of  the  tissues,  the  molecular  changes,  and  the  vaso-motor  sensibility.  If 
we  succeed  in  this,  and  thereby  conduct  the  patient  safely  to  the  com- 
mencement of  a  period  of  remission  or  intermission,  the  second  indication 
is  to  bring  him,  as  speedily  as  possible,  so  fully  under  the  influence  of 
some  anti-periodic  as  to  prevent  the  supervention  of  another  paroxysm. 

In  endeavoring  to  fulfill  the  first  indication,  it  has  been,  from  the  earliest 
period  in  the  history  of  the  disease,  a  common  practice  to  endeavor  to 
establish  reaction  and  warmth  by  administering  large  doses  of  hot  stimu- 
lating remedies  internally,  and  applying  all  kinds  of  heating  and  irritant 
applications  externally.  Hot  whisky  or  brandy  punch,  with  or  without  the 
addition  of  pepper,  has  been  given  most  liberally,  with  external  frictions, 
sinapisms,  hot  bricks,  hot  corn,  bottles  of  hot  water,  and  hot  baths,  and 
yet  without  the  slightest  beneficial  effect  on  the  patient. 

Dr.  Daniel  Drake,  in  his  valuable  work  on  the  Topography  and  Diseases 
of  the  Interior  Valley  of  the  Continent,  states  that  he  has  seen  the  skin 
made  red  by  hot  frictions  without  the  slightest  effect  on  the  temperature. 
In  one  case  he  saw  the  patient  immersed  in  a  hot  bath  containing  a  liberal 
quantity  of  salt,  mustard  and  whisky  ;  and  in  another  the  patient  was  en- 
veloped in  cloths  or  sheets  wet  with  an  infusion  of  Peruvian  bark  as  hot 
as  could  be  borne,  and  covered  with  oiled  silk  to  prevent  evaporation,  but 
in  neither  was  there  any  improvement  in  the  circulation  or  the  tempera- 
ture. And  he  states  as  the  result  of  his  extensive  personal  investigations, 
that  both  external  heat  and  the  internal  use  of  what  are  called  alcoholic 
stimulants,  are  absolutely  useless  in  the  depression  of  a  true  pernicious 
paroxysm  of  malarial  fever.  From  what  we  now  know  of  the  effects  of 
alcohol  as  an  anaesthetic  to  nerve  sensibility,  and  direct  retarder  of  mole- 
cular changes  and  capillary  circulation,  we  should  not  only  expect  no 
benefit,  but  positive  harm  from  its  use  in  these  cases.  Under  the  theory 
of  internal  congestion,  especially  of  the  portal  system  of  vessels,  bleed- 
ing, large  doses  of  calomel,  and  various  kinds  of  emetics  have  been  tried, 
but  with  no  encouraging  results,  except  in  a  few  cases,  when  an  emetic  of 
salt  and  mustard  appeared  to  aid  in  establishing  reaction. 

Dr.  Milne  Edwards  many  years  ago  demonstrated  very  clearly,  by  an 
ample  series  of  experiments  upon  the  living  animal,  that  heat  diminishes 
the  general  tonicity  and  relaxes  the  contractile  tissues  of  the  body,  and 
that  cold  increases  both  by  bringing  the  atoms  closer  together  and  strength- 
ening the  play  of  vital  affinity. 

The  results  obtained  by  Dr.  Edwards  have  been  fully  confirmed  by  later 
observations;  and  whether  you  agree  with  me  that  malaria  acts  directly 
upon  the  elementary  properties  common  to  all  living  tissues,  or  indirectly 
through  a  primary  paralyzing  influence  on  the  vaso-motor  nervous  system, 
as  suggested  by  most  writers,  they  point  directly  to  the  sudden  and  tem- 
porary application  of  cold  as  the  most  rational  and  efficient  means  we  pos- 
sess for  arousing  nerve  sensibility,  capillary  circulation,  molecular  move- 
ments, and,  as  a  result,  an  increase  of  temperature.  I  have  repeatedly 
seen  this  power  efficiently  displayed  in  the  treatment  of  cases  of  opium 
poisoning.  In  the  case  of  a  little  child  to  whom  the  mother  had  given  an 
overdose  of  laudanum  by  mistake,  I  was  called  in  the  middle  of  the  night, 
and  as  I  entered  the  room  the  child  appeared  to  be  breathing  out  its  last 
gasp.  I  immediately  caught  a  cup  of  cold  water  and  suddenly  dashed  a 
part  of  it  on  the  child's  face  and  chest,  which  aroused  two  or  three  quick 
and  full  inspirations,  followed  by  shorter  and  shorter  ones,  until  another 
apparent   stop;    another  dash  of  cold  water  renewed  them,  and  for  more 


TREATMENT.  201 

than  three  hours  I  sat  by  the  child  repeating  the  dash  as  often  as  the  re- 
spiratory movements  failed,  during  which  the  poison  was  so  far  eliminated 
and  the  nervous  sensibility  restored  that  it  was  safe  to  leave  the  patient. 

]n  using  the  dash  of  cold  water  for  the  purpose  of  establishing  general 
reaction  from  the  cold  stage  of  pernicious  fever,  the  patient  should  be 
stripped,  and  several  gallons  of  cold  water  suddenly  dashed  over  the  head 
and  trunk  of  the  body,  then  c(uickly  rolled  up  in  warm  dry  flannel  blank- 
ets for  thirt}"  minutes.  If  there  is  not  a  decided  improvement  in  the  pulse 
and  temperature  at  the  end  of  that  time,  unwrap  him  and  repeat  the  dash, 
following  it  by  the  warm  blankets  as  before.  This  process  may  be  repeat- 
ed three  or  four  times,  if  necessary,  but  in  most  of  the  instances  in  which 
it  has  been  tried,  one  or  two  repetitions  have  been  sufficient.  I  do  not 
recommend  to  you  this  method  of  treating  the  pernicious  chill  on  mere 
theoretical  grounds,  for  it  has  had  the  sanction  of  direct  clinical  experi- 
ence. So  early  as  1830,  Dr.  Fearn,  of  Huntsville,  A'abama,  one  of  the 
most  eminent  and  successful  practitioners  in  the  Southern  States  at  that 
time,  adopted  the  practice  with  such  success  as  to  attract  much  attention 
and  to  win  many  followers  in  the  South.  He  was  residing  in  the  belt  of 
country  most  favorable  for  the  development  of  this  variety  of  malarial 
fever,  and  at  a  jaei'iod  of  time  when  it  was  much  more  prevalent  than  it 
has  been  in  later  years.  Only  two  cases  have  come  directly  under  my 
observation  in  which  the  practice  was  adopted,  and  in  both  the  result  was 
favorable.  One  of  these  occurred  more  than  twenty  years  since.  The 
patient  was  a  young  woman  in  a  family  of  hydropathic  faith,  and  when 
they  were  told  l)y  the  attending  physician,  and  myself  in  consultation,  that 
the  patient  might  not  live  until  morning,  they  took  the  case  into  their 
own  hands,  wrapped  her  in  cold  wet  sheets  for  a  pack  nearly  half  an  hour, 
then  changed  to  warm  dry  blankets,  from  which  time  she  began  to  im- 
prove, and  in  less  than  eight  hours  she  had  safely  entered  the  stage  of 
intermission. 

Very  recently,  Dr.  J.  P.  Davidson,  of  New  Orleans,  in  a  valuable  paper 
read  to  the  New  Orleans  Medical  and  Surgical  Association,  on  Pernicious 
Fever,  has  added  his  testimony  in  favor  of  the  cold  douche  in  the  most 
emphatic  manner.* 

While  I  have  no  doubt  but  that  the  sudden  and  alternate  application 
of  the  dash  of  cold  water  and  dry  warmth  constitutes  one  of  the  most  effi- 
cient methods  of  establishing  reaction,  there  are  other  remedies  of  real 
value,  especially  in  some  of  the  groups  of  cases  I  have  described,  and 
which  may  be  used  either  alone  or  in  conjunction  with  the  process  just 
indicated.  For  instance,  in  those  cases  of  the  comatose  variety  where  a 
partial  reaction  has  taken  place  and  the  face  is  deeply  flashed  and  the 
head  hot,  apply  an  ice  cap  to  the  head  and  back  of  the  neck.  In  other 
cases,  where  they  are  equally  comatose  but  pale  and  cool,  instead  of  the 
ice  cap  bring  the  patient's  head  over  a  tub,  and  with  a  pitcher  .filled  with 
tepid  water  pour  a  douche  of  two  or  three  quarts  of  water  over  the  occi- 
put, repeating  it  once  in  from  half  an  hour  to  an  hour,  and  it  will  consti- 
tute one  of  the  most  efficacious   means  of  relief.     The   same   means   are 

*See  Paper  on  Pernicious  Fever,  by  J.  P.  Davidson  M  D.,  in  the  New  Orleans  Medical  and  Sur- 
gical Journal  for  February,  ISbO.  On  pages  756  and  757,  Dr.  Davidson  uses  the  following  language: 
'■  In  cases  ot  the  algid  form  ol  the  disease,  in  which  the  symptoms  of  coilapse  manliest  tliems  ives 
early,  I  know  ol  no  plan  ot  ireatment  calculated  to  meet  the  exigencies  of  the  case  equal  to  tlie  cold 
douche.''  *  *  .-s  *  "No  time  is  to  be  lost  in  relieving  the  patient  of  the  lesion  of  innervMtion 
and  bringing  about  reaction.  Delay  in  experimenting  with  stimulants,  sinapisms,  frictions,  etc..  is 
time  thrown  away,  and  will  commonly  disappoint  the  expectations  of  the  physician.  While  the 
depressed  condition  of  the  hear.'s  aciion  coniinues,  with  the  serum  of  the  blood  exuding  through 
the  paralyzed  capillaries  of  the  whole  mucoias  lining  of  the  bowels,  and  the  copious  trimsudatioQ 
through  t-  c  skin,  exhausting  the  patient,  and  deepening  the  collapse,  calorification  is  difficult  to 
restore;  all  means.  Ihereioie,  of  arousing  the  energi.s  of  the  nervous  system  short  ot  the  shock 
produced  by  the  cold  douche,  properly  administeied,  will  avail  but  little." 


202  PEEIODICAL    FEVEES. 

applicable  to  the  neck  and  spiiie,  in  the  group  of  cases  described  as  spas- 
modic or  convulsive,  and  to  the  chest  in  those  cases  where  the  lungs  are 
involved.  In  the  choleraic  cases,  accompanied  by  great  restlessness^  fre- 
quent vomiting  and  purging,  with  cold  sweat,  much  collateral  advantage 
may  be  gained  by  the  judicious  use  of  morphia  and  atropia  hypodermical- 
ly.  If  the  heart's  action  is  very  feeble  the  injection  of  morphia  and  atro- 
pia may  be  alternated  with  suitable  doses  of  strychnia.  In  the  purely 
algid  cases,  as  I  have  described  them,  in  addition  to  the  efficient  applica- 
tion alteruatelv  of  cold  water  and  dry  warmth,  the  prompt  administration, 
either  by  the  stomach  or  hypodermically,  of  strychnia  and  atropia,  without 
morphine,  will  constitute  the  best  treatment  you  can  adopt. 

Atropia  is  one  of  the  most  reliable  remedies  we  have  for  checking  ex- 
cessive perspiration  and  increasing  the  blood  in  the  peripheral  capillaries, 
while  strychnia  is  equally  efficient  in  increasing  muscular  contractility, 
and  thus  strengthening  the  heart. 

If,  by  the  means  I  have  detailed,  or  any  other,  the  reaction  is  estab- 
lished, and  the  patient  approaches  the  period  of  intermission  or  remission, 
how  can  we  fulfill  the  second  indication  I  have  named,  and  most  certainly 
prevent  another  parox^-sm  ?  I  answer,  by  bringing  the  patient  as  rapidly 
as  possible  under  the  full  influence  of  sulphate  of  quinia,  which  is 
very  generally  conceded  to  be  more  reliable  for  this  purpose  than  any 
other  remedy  in  the  materia  medica.  For  accomplishing  this,  1.0  to  1.3 
grams  (gr.  xv  to  xx)  of  quinine  should  be  given  at  once  by  the  mouth, 
and  the  same  quantity  repeated  at  such  intervals  that  three  doses  will  be 
taken  before  the  time  for  commencing  another  paroxysm.  If  the  stomach 
rejects  the  remedy  by  vomiting,  2.0  grams  (gr.  xxx)  may  be  given  in  the 
form  of  enema,  and  repeated  at  the  same  intervals,  as  if  given  by  the 
mouth  ;  or  from  0.5  to  0.6  grams  (gr.  viii  to  x)  may  be  used  hypodermi- 
cally, and  repeated  as  by  the  other  methods.  Nearly  the  same  quantities 
should  be  administered  the  second  day,  and  one-half  as  much  the  third  ; 
after  w-hich  ordinary  doses  with  rest  and  proper  nourishment,  will 
complete  the  convalescence.  Many  have  recommended  much  larger 
doses  of  the  quinine  than  I  have  indicated,  some  giving  from  2.0 
to  4.0  grams  (gr.  xxx  to  Ix)  at  a  dose,  and  repeating  until  8.0 
grams  (3ii)  or  more,  have  been  taken  in  from  twelve  to  twenty- 
four  hours.  Such  doses,  however,  have  produced  complete  loss  of  both 
sight  and  hearing  in  some  cases,  and  in  others,  the  death  of  the  patient ; 
and  I  believe  them  to  be  wholly  unnecessary.  Ail  attacks  of  pernicious 
fever  leave  the  patient  much  debilitated,  and  hence  proper  caution  should 
be  exercised  in  regard  to  both  mental  and  physical  exercise  until  health 
and  strength  are  fully  restored. 

jSIo.lario.l  Ilcematxiria  or  Saemorrhagic  Malarial  Fever. — During 
the  last  twenty  years  a  form  of  malarial  fever  has  been  met  with,  more 
especially  in  the  States  bordering  on  the  Lower  Mississippi  and  the  Gulf 
of  Mexico,  characterized  by  a  chill,  unusually  severe  nausea  and  vomiting, 
very  rapid  development  of  a  deep  yellow  color,  hgemorrhage  from  the  kid- 
neys and  bladder,  with  dangerous  prostration.  Cases  of  the  same  form 
have,  doubtless,  been  met  with  in  former  times  and  in  other  countries,  but 
did  not  attract  special  attention  until  fully  described  by  Drs.  Michel, 
Osborn,  Ghent,  Barnes,  Davidson,  and  others  in  the  Southern  States,  and 
more  recent!}-  by  Dr.  Berenger-Feraud,  as  it  appeared  in  Senegambia  and 
Cochin  China.  In  the  Southern  States  it  has  prevailed  chiefly  in  the 
winter  or  cold  and  rainy  season  of  the  year.  It  generally  attacks  persons 
who  have  already  become  anemic  from  previous  malarial  attacks,  and  is 
often  immediately  preceded  by  three  or  four  paroxysms  of  ordinary  inter- 


TREATMENT.  203 

mlttent  fever.*  The  discharge  of  very  dark  bloody  urine  commences 
almost  immediately  after  the  initial  chill;  the  matters  vomited  and  purged 
are  copious  in  quantity,  almost  as  black  as  tar  from  the  intermixture  of 
bile,  and  often  change  to  a  deep  green  after  exposure  to  the  light  and  air. 
They  contain  no  blood.  The  tongue  is  generally  coated;  pulse  is  quick 
and  Veak;  temperature  varies  from  37°  to  40°  C.'(99°  to  104°  F.)  and  the 
discharge  of  blood  with  the  urine  continues  until,  in  many  of  the  cases, 
fatal  collapse  ensues.  The  duration  of  the  disease  may  vary  from  twelve 
hours  to  as  many  days. 

The  prognosis  is  very  unfavorable. 

Post-mortem  examinations  show  no  structural  changes  specially  charac- 
teristic of  this  variety  of  malarial  fever.  The  stomach  generally  contains 
a  dark  fluid  mixed  with  altered  bile  ;  its  mucous  membrane  is  injected 
with  blood  and  more  or  less  tumefied  ;  the  spleen  and  kidneys  much  en- 
larged from  vascular-congestion,  and  the  latter  from  hasmorrhagic  exuda- 
tion. 

Treatment. — The  chief  indications  for  treatment  in  these  cases  are, 
to  arrest  the  progress  of  the  general  fever;  stop  the  h^einaturia,  and 
restore  the  natuial  secretory  action  of  the  liver  and  kidneys.  For 
accomplishing  the  two  first  objects,  large  doses  of  quinine,  opium,  and 
ordinary  astringents,  have  been  frequently  used,  but  with  very  little 
success;  indeed,  the  opium  and  pure  astringents  are  more  likely  to  cause 
suppression  of  lu-ine  and  favor  uremic  poisoning  than  they  are  to  do  good. 

The  use  of  the  sulphite  or  hyposulphite  of  soda  in  full  doses,  is  very 
strongly  recommended  by  Dr.  F.  C.  Fahs,  of  Alabama,  and  Dr.  G.  B. 
Malone,  of  Arkansas.  The  latter  claims  to  have  treated  forty-four  cases 
without  a  single  death.  He  gives  2  grams  (gr.  xxx)  of  the  hyposulphite 
of  sodium,  and  4  cubic  centimeters  (fl.  3i.)  of  fluid  extract  of  buchu  dis- 
solved in  30  cubic  centimeters  (fl.  §1.)  of  water,  and  repeats  the  dose  every 
three  hours  until  the  disease  is  arrested.  While  the  hyposul]ihite  is 
being  administered  to  arrest  the  general  disease,  the  hasmorrhage  from  the 
congested  and  partially  paralyzed  renal  vessels  may  be  most  effectually 
checked  and  the  natural  secretion  promoted,  by  giving  between  the  doses 
of  the  hyposulphite,  4  cubic  centimeters  (fl.  3'-)  of  spirits  of  nitre  and 
0.33  cubic  centimeters  (rain,  v)  of  oil  of  turpentine  in  a  little  sweetened 
water.  In  the  beginning  of  the  treatment  if  the  vomiting  is  persistent, 
allowing  the  patient  to  drink  freely  of  cold  water  until  the  efforts  at  vom- 
iting cease,  has  been  found  beneficial.  The  use  of  small  and  frequently 
repeated  doses  of  iresh  buttermilk  or  milk  whey,  through  the  whole  course 
of  the  disease,  will  aid  in  improving  the  renal  secretion  and  nourishing  the 
patient.  After  the  paroxysms  of  fever  and  the  haematuria  have  heen. 
fairly  arrested,  and  the  hepatic,  renal,  and  intestinal  secretions  restored, 
the  pitient  may  be  put  upon  the  same  tonics  and  nutrients  as  I  have 
already  recommended  during  convalescence  from  other  varieties  of 
malarial  fever. 

Typho-Malarial  Fever. — As  I  explained  fully  when  discussing  the 
subject  of  typhoid  fever,  there  are  many  localities  in  which  the  causes  of 
both  continued  and  periodical  fevers  exist  at  the  same  time,  and  are  con- 
sequently exerting-  their  influence  up  n\  the  human  system  conjointly. 
The  result  is,  not  the  production  of  a  separate  and  distinct  form  of  fever, 
to  be  designated  typho-malarial;  but  simply  an  intermingling  of  the  symp- 
toms   and   pathological    changes    of    the   two  types  of  fever  in  the  same 

*  Dr.  Michel,  of  Alabama,  describe-  the  disease  as  "a  malignant  malarial  fever,  following  repeated 
attacks  of  intermittent,  characterized  bj' intense  nansea  and  voniiiing,  very  rapid  and  coniiilete 
.iaundiced  condition  of  the  snrlacj,  as  well  as  most  of  the  internal  organs  of  the  body,  an  impacted 
gull  bjadder  and  heemorrhage  Irom  the  kidneys." 


204  ERUPTIVE    FEVEES. 

patient.  The  symptoms  and  general  progress  of  such  cases  are  suffi- 
ciently considered  in  the  11th  lecture  of  the  present  course.*  The 
correct  xiew  is  to  regard  the  cases  of  fever  occurring  under  such 
influences  as  mixed  or  complicated  fevers.  If  the  malarial  element 
predominates,  the  case  will  be  one  of  periodical  fever,  complicated  bv 
typhoid  symptoms  and  tendencies.  If  the  causes  of  typhoid  predominate, 
the  cas  '  will  be  true  t^'phoid  fever,  complicated  with  symptoms  of 
inalarinl  influence.  It  is  of  much  practical  importance  that  the  physician 
should  recognize  the  true  character  of  all  such  cases,  and  use  conjointly 
the  proper  remedies  for  both,  instead  of  trying  to  relieve  one  class  of 
symptoms  before  prescribing  for  the  other.  Moderate  anti-periodic  doses 
of  quinine  should  be  promptly  given  and  repeated  until  the  symptoms 
produced  by  the  malarious  element  are  removed,  and  at  the  same  time  the 
jjathological  changes  of  the  t3'^phoid  class  may  be  checked  and  ultimately 
overcome  by  the  administration  of  0.8  cubic  centimeters  (min.  xii)  of  the 
aqueous  solution  of  iodine  every  four  or  six  hours. f  In  the  middle  and 
later  stages  of  each  case,  such  additional  remeiiies  should  be  given  as  the 
development  of  local  symptoms  may  indicate.  These  have  been  iuliy 
detailed  in  previous  lectures,  and  need  not  be  repeated  here. 


LECTURE  XXIII. 

Eruptive  Fevers— Their  Naraes,  History,  Causes,  Patholt'gy  and  Anatomical  Cliaracteristics. 

GENTLEMEN  : — I  come  now  to  the  consideration  of  the  third,  and 
last  group,  or  subdivision,  of  the  acute  general  diseases. 

This  group  is  called  erupiive  fevers,  for  the  reason  that  each  disease 
properly  included  in  the  group,  is  characterized  at  a  certain  stage  of  its 
progress  bv  the  appearance  upon  the  cutaneous  surface  of  an  eruption  of 
a  uniform  character,  and  bearing  a  certain  relation  to  the  progress  oi'  the 
general  disease.  The  diseases  included  under  this  head  are,  variola  with 
its  modifications,  varioloid  and  vaccina  ;  varicella  and  sudamina  ;  scar- 
latina ;  rubeola  ;  rotheln  ;  roseola  ;  and  miliaria.  To  these  I  shall  add 
parotitis  contagiosa  or  mumps,  and  pertussis  or  whooping-cough,  for 
though  neither  of  them  have  any  characteristic  eruption  upon  the  surface, 
both  present  so  many  circumstances  analagous  to  those  accompanying  the 
true  eruptive  fevers,  that  they  can  be  more  properly  considered  in  this 
connection  than  elsewhere. 

History. — All  these  diseases  have  been  known  and  described  from  the 
earliest  period  of  medical  history,  although  not  accurately  dilferentiated 
as  separate  diseases  until  the  latter  part  of  the  eighteenth  century.  They 
were  generally  classed  together  as  acute  exanthenis.  Variola  or  small- 
pox, was,  perhaps,  the  first  to  receive  a  separate  recognition,  having  been 
traced  in  China  and  India  to  a  very  early  period  of  time.  It  is  not  cer- 
tain that  it  was  known  among  the  ancient  Greeks  and  Romans,  but  was 
introduced  iiito  Euiope  through  the  Arabians  during  the  sixth  century  of 

*See  pp.  90-!>l  of  this  volume. 
tSee  formula  on  page  Ibl. 


CAUSES.  205 

the  Christian  era.  From  that  time  to  the  introduction  of  vaccination  in 
the  latter  part  of  the  eighteenth  century,  it  repeatedly  spread  over  the 
larger  part  of  Europe  in  severe  epidemic  form,  and  soon  became  one  of 
tlie  most  dreaded  of  ail  the  diseases  that  scourge  the  human  race.  During 
the  same  period  of  time  the  scnvlet  fever,  measles,  diphtheria,  and  rOtheln, 
■\v3re  included  together  under  the  names  of  cyiianche  or  angina,  and  in  the 
agg-regate  proved  but  little  less  destructive  to  lile  th;tn  the  variola.  Prior 
to  the  pracdce  of  vaccination  by  Dr.  Jenner,  the  l)cst  English  authorities 
estimate  tiiat  the  average  annual  mortality  from  vaviola  in  Europe  was  not 
less  than  210,000,  and  in  Great  Britain  and  Ireland,  at  least  45,000.  If 
you  add  to  these  figures  the  average  annual  mortality  from  the  scarlet 
fever  and  other  mom.jers  of  the  group,  youwid  have  abetter  idea,  both  of 
the  importance  of  tliese  several  diseases,  and  of  the  value  of  vaccination 
and  other  prophylactic  and  sanitary  measures,  adopted  for  their  prevention. 

Causes. — All  the  diseases  I  have  named  as  helonging  to  the  class  of 
eruptive  fevers,  except  roseola,  sudamina.  and  miliaria,  arise  directly  from 
specific  contagiums  or  viruses,  reproduced  in  the  bodi^^s  of  the  sick,  and 
communicable  from  one  individual  to  another,  either  by  inhalation  of  an 
infected  atmosphere  or  by  inoculation.  Other  influences  may  increase  the 
susceptibility  of  the  individual  to  the  action  of  the  specific  poison,  or  may 
impair  his  power  of  resistence  Avhen  attacked,  and  therel>y  act  the  part  of 
predisposing  agents.  The  protracted  influence  of  cold  and  dampness 
appears  to  favor  the  prevalence  of  these  aifections,  as  they  are  generally 
more  prevalent  during  the  cold  season,  including  the  spring  and  autumn, 
than  in  the  summer. 

Such  atmospheric  impurities  as  are  produced  by  neglect  of  ventilation 
and  cleanliness,  also  favor  their  spread,  and  increase  their  fatality.  But 
the  most  efficient  of  all  the  predisposing  influences  is  that  mysterious 
atmospheric  condition  called  the  "epidemic  constitution,"  which  occurs  at 
variable  periods  of  time,  and  during  which  they  exhibit  a  persistency  in 
the  disposition  to  spread,  and  to  search  out  the  unprotected  members  of 
the  community  far  more  actively  than  during  the  years  between  these 
special  epidemic  periods. 

Aside,  however,  from  all  predisposing  causes,  each  of  the  diseases  under 
consideration  has  its  own  specific  exciting  cause,  which  evidently  consists 
of  a  contagious  organic  substance  or  virus,  elaborated  in  the  bodies  of  tlie 
sick;  and  in  some  of  them,  as  the  variola,  vaccina,  and  varicella,  capable 
of  isolation  and  examination.  In  the  three  diseases  just  named,  the  virus 
collects  in  fluid  form,  during  the  active  progress  of  each  disease,  in  vesi- 
cles and  pustules  in  tlie  skin,  from  which  an  abundance  can  be  obtained 
for  examination  and  analysis,  both  chemically  and  microscopically.  In  the 
exanthematous  members  of  this  group,  namely,  the  scarlatina,  rubeola 
and  rotheln,  the  specific  contagium  also  produces  more  or  less  inflamma- 
tion in  the  skin,  but  does  not  collect  in  fluid  form  in  visible  vesicles  or 
pustules,  but  is  eliminated  with  the  exhalations  from  the  skin  and  mu- 
cous membrane  of  the  air  passages.  That  each  has  a  specific  virus,  and 
that  it  exists  in  the  blood  during  the  active  progress  of  the  symptoms,  is 
proved,  however,  not  only  by  the  contagiousness  of  the  emanations  just 
mentioned,  but  by  the  ability  to  reproduce  the  disease  by  inoculating  well 
persons  with  the  blood  of  those  who  are  sick. 

Microscopic  examinations  have  revealed  the  existence  of  minute  organic 
germs  in  the  blood  of  all  these  contagious  eruptive  diseases,  and  in  the 
virus  or  lymph  that  collects  in  the  vesicles  and  pustules  of  variola,  vari- 
cella, etc.;  but  the  germs  thus  discovered  do  not  differ  in  any  appreciable 
degree  from  the  bacteria  and   micrococci,  found  under  many  other  condi- 


206  ERUPTIVE   FEVERS. 

tions  having  no  connection  with  these  diseases.  Consequently  there  is  no 
evidence  that  these  organic  germs  constitute  the  active  contagiums  on 
which  these  several  diseases  depend  for  their  existence  and  propagation. 
On  the  contrary,  there  are  some  lacts  which  bear  strongly  against  such  an 
inference.  It  is  well  known  that  the  emanations  from  the  skin  and  lungs 
of  patients  aiFected  with  any  of  the  diseases  under  consideration,  are  suffi- 
ciently impregnated  with  the  specific  contagious  material  to  communicate 
the  disease  to  others  who  may  chance  to  breathe  the  air  of  a  room  contain- 
ing such  emanations.  Yet  no  one,  I  think,  has  been  able  to  detect  any 
germs  in  the  exhalations  from  the  skin  and  lungs  of  those  sick,  that  were 
not  found  equally  numerous  in  the  exhalations  from  the  same  sources  in 
persons  enjoyif'g  good  health.  In  the  latter  part  of  the  year  1870,  the 
late  Dr.  F.  H.  Davis,  of  this  city,  instituted  a  series  of  observations  on  the 
exhalatioiiD  of  patients  laboring  under  typhoid  fever,  diphtheria,  erysipe- 
las, scarlatina  and  rubeola.  The  organic  materials  in  the  atmosphere  of 
the  sick  room,  in  the  breath  exhaled,  etc.,  were  collected  on  clean  glass 
slides,  moistened  with  i^ure  glycerine,  and  submitted  to  thorough  micro- 
scopic examination.  The  results  were  given  in  his  inaugural  theses  in 
March,  1871.  He  found  an  abundance  of  dust  particles  and  a  variety  of 
organic  atoms,  but  nothing  whatever  that  he  did  not  find  equally  abund- 
ant on  the  slides  exposed  in  the  same  way  to  the  breath  and  the  air  of 
rooms  occupied  by  persons  in  good  health.*  It  is  highly  probable,  there- 
foe,  that  the  true  contagium  does  not  consist  of  bacteria  or  any  other  liv- 
ing germs,  but  of  a  subtle  fluid  impregnating  the  serum  of  the  blood, 
capable  of  collecting  with  such  serum  in  vesicles  and  pustules,  and  of 
being  exhaled  with  the  aqueous  vapor  from  the  skin  and  lungs,  and  pos- 
sibly with  all  the  excretions  from  the  bodies  of  the  sick.  But  whatever 
may  be  the  form  of  the  several  specific  contagiums  that  give  rise  to  the 
eruptive  fevers,  the  laws  that  govern  their  action  upon  the  human  system 
are  more  definitely  ascertained,  and  are  of  great  practical  importance. 
When  introduced  into  the  human  system,  whether  by  inoculation,  inhala- 
tion, or  any  other  method,  they  require  a  certain  period  of  time,  either  for 
self-multiplication  or  for  effecting  certain  changes  in  the  quality  of  the 
blood,  probably  for  both,  before  any  appreciable  effects  are  produced  upon 
the  functions  of  the  body.  The  time  thus  required  is  called  the  period  of 
incubation.  Its  length  is  not  the  same  in  all  of  these  affections,  but 
varies  from  an  average  of  five  days  in  scarlet  fever,  to  twelve  or  fourteen 
days  in  variola. 

The  period  of  incubation  having  passed,  they  all  present  evidence  of 
possessing  active  irritative  qualities  sufficient  to  induce  the  rapid  develop- 
ment of  a  high  grade  of  general  fever,  which  continues  from  two  to  four 
days  before  the  characteristic  eruptions  appear  upon  the  cutaneous  surface. 
This  is  called  the  period  of  primary  or  premonitory  fever.  The  eruption 
in  each  disease  presents  a  definite  stage  of  increase,  maturity,  and  decline, 
which  together  constitute  the  period  of  eruption.  At  the  end  of  the 
period  of  eruption,  convalescence  ensues,  unless  it  is  postponed  by  the 
severity  of  such  local  complications  as  are  liable  to  occur  in  nearly  all 
these  varieties  of  fever. 

You  perceive,  therefore,  that  the  events  following  the  introduction  of 
any  one  of  these  specific  poisons,  succeed  each  other  in  a  definite  order, 
each  event  occupying  a  definite  period  of  time,  accompanied  by  distinctive 
symptoms,  and  ending  spontaneously  in  convalescence. 

The  diseases  they  produce  are,  therefore,  strictly  self-limited  in  dura- 
tion, and  one  attack,  as  a  rule,  permanently  destroys  the  susceptibility  of 

*See  Chicago  Medical  Examinfir,  Vol.  xii,  pp.  197-8. 


PATHOLOGY.  207 

the  system  to  future  attacks  of  the  same  disease.  With  the  exception  of 
variohi,  all  the  diseases  under  consideration  occur  far  more  frequently  in 
childhood  and  youth,  than  at  any  later  period  of  life,  yet  no  age  is  en- 
tirely exempt  from  liability  to  an  attack.  Neither  sex  nor  nationality 
appear  to  exert  any  influence  over  the  susceptibility  to  this  class  of  diseases. 

Patholoc/y. — What  I  have  been  stating  to  you  concerning  the  efficient 
causes  of  eruptive  fevers,  leads  naturally  to  an  inquiry  into  their  general 
pathology,  or  the  nature  of  the  morbid  processes  that  take  place  during 
the  successive  stages  of  their  progress.  That  the  specific  contagium,  how- 
ever small  the  quantity  primarily  introduced,  enters  the  blood  and  there 
undergoes  aii  increase  more  or  less  rapid  during  the  period  of  incubation, 
is  undoubtedly  true.  That  it  circulates  with  the  blood  throughout  all  the 
living  structures,  and  when  sufficiently  developed,  produces  a  direct  irri- 
tative effect,  thereby  morbidly  exalt  ng  the  susceptibility  and  disturbing 
the  vital  affinity  in  such  a  way  as  to  pervert  the  molecular  changes  con- 
cerned in  nutrition,  disintegration  and  secretion,  coincidently  with  dis- 
turbance of  innervation  and  temperature,  is  clearly  evident  from  the 
uniform  establishment  of  general  irritative  fever  prior  to  the  appearance 
of  any  local  inflammations  in  the  skin  or  elsewhere. 

Yet  a  careful  clinical  study  of  the  symptoms  characterizing  the  further 
progress  of  each  case,  shows  that,  in  addition  to  this  general  irritative 
action,  the  exciting  cause  or  poison  possesses  a  special  affinity  for  the 
cutaneous  tissue  and  certain  parts  of  the  mucous  membrane  of  the  respira- 
tory passages,  causing  it  to  accumulate  therein  with  greater  or  less  rapidity, 
and  to  establish  at  each  point  of  accumulation  an  inflammation  of  a  grade 
peculiar  to  itself.  In  the  ordinary  cases  of  variola,  varioloid  and  varicella, 
the  accumulation  of  these  poisons  in  the  cutaneous  tissue,  is  so  rapid  that 
by  the  third  or  fourth  day,  the  blood  has  become  free  from  their  presence, 
and  consequently  the  general  fever  subsides  coincidently  with  the  appear- 
ance of  the  eruption,  or  points  of  local  inflammation  on  the  surface;  and 
if  any  renewal  of  fever  takes  place  during  the  subsequent  progress  of  the 
case,  it  results  from  the  extent  and  intensity  of  the  local  inflammations,  and 
not  fi'om  the  action  of  the  primary  poison  in  the  blood.  In  scarlatina, 
rubeola  and  rcjtheln,  the  exciting  cause  or  contagium  is  attracted  to  the 
cutaneous  tissue  less  rapidly,  and  the  blood  does  not  become  free  from  the 
poison  until  the  cutaneous  and  other  local  inflammations  have  reached 
their  climax,  which  is  from  three  to  five  days  after  they  first  become  visible. 
Consequently,  the  general  fever,  instead  of  ceasing  at  the  time  of  the  first 
appearance  of  the  points  of  inflammation  on  the  surface,  as  in  variola,  con- 
tinues unabated  until  such  local  inflammations  or  efflorescences  have 
reached  their  full  maturity,  and  then  both  decline  together,  accompanied 
by  a  more  or  less  complete  exfoliation  of  the  cuticle,  and  leaving  the  sys- 
tem free  from  the  specific  poison.  The  contagiums  of  variola  and  varicella 
manifest  very  little  affinity  for,  or  tendency  to  find  lodgments  in,  any 
other  than  the  cutaneous  structure.  A  few  points  of  lodgment  and  con- 
sequently of  pustular  or  vesicular  inflammation  are  seen  in  the  mucous 
membrane  lining  the  mouth  and  fauces  in  a  large  proportion  of  the  cases. 
They  appear  at  the  same  time  and  pass  through  the  same  stages  as  the 
eruption  on  the  surface.  But  the  contagiums  of  scar.atina  and  rOtheln 
manifest  quite  as  much  affinity  for  the  mucous  membrane  of  the  fauces, 
pharynx  and  nostrils,  with  the  contiguous  glands,  as  for  the  cutaneous 
tissue;  and  in  many  cases  establish  in  these  parts  a  dangerous  degree  of 
inflammation;  while  that  of  rubeola  selects  for  its  special  lodgment  and 
irritative  action,  the  mucous  membrane  of  the  nostrils,  trachea,  and  larger 
bronchial  tubes,  in  addition  to  the  skin. 


20S  ERUPTIVE    FEVEKS. 

In  a  large  maiority  of  the  cases  of  all  varieties  of  eruptive  fever,  the 
quantity  and  quality  of  the  contag'ium  developed  in  the  system  of  the 
patient  is  such  that  the  whole  of  it  finds  first  lodgment  in,  and  subse- 
quently complete  exit  tlirough,  the  surfaces  I  have  mentioned,  and  an 
early  convalescence  is  established.  In  a  smaller  number  the  quantity  or 
quality  of  the  poison  is  such  that  the  extent  and  intensity  of  the  inflam- 
mation in  the  skin,  fauces,  and  glands  of  the  neck,  may  be  sufficient  to 
endanger  the  life  of  the  patient,  as  in  confluent  variola  and  anginose  scar- 
latina. In  a  still  smaller  number  of  cases,  owing  either  to  the  quantity  and 
quality  of  the  poison,  or  to  some  prior  defect  in  the  properties  of  the  tis- 
sues, the  specific  poison  fails  to  impinge  or  find  complete  lodgment  in 
the  cutaneous  and  other  tissues  I  have  named,  consequently  a  large  part  of 
it  remains  in  the  blood,  not  only  perpetuating  the  general  fever,  but  caus- 
ing so  rapid  an  impairment  of  the  quality  of  the  blood  itself  as  to  speedily 
endanger  the  life  of  the  patient.  These  constitute  the  class  of  cases  usually 
called  malignant.  You  thus  see  that  we  may  have  three  groups  of  cases 
in  each  of  the  eruptive  fevers,  namely,  the  simple,  the  intensely  inflam- 
matory, and  the  malignant.  In  reference  to  variola,  authors  designate 
the  first  of  these  groups  as  distinct,  or  discrete  small-pox  ;  the  second  as 
confluent,  and  the  third  as  malignant.  In  reference  to  scarlatina,  the  cases 
in  the  first  group  are  called  scarlatina  simplex  ;  those  in  the  second,  scar- 
latina anginosa  ;  and  those  in  the  third  scarlatina  maligna.  The  cases  be- 
longing to  the  first  group  of  all  the  varieties  of  eruptive  fever,  uniformly 
tend  to  convalescence  and  early  recovery.  Those  classed  in  the  second  group 
tend  towards  recovery  or  death,  in  proportion  to  the  extent  and  intensity  of 
the  local  inflammations,  and  the  prior  constitutional  condition  of  the  pa- 
tient. In  variola,  for  instance,  the  number  of  points  of  local  inflammation  or 
pustules  on  the  surface,  may  be  so  great  that  in  the  progress  of  develop- 
ment they  touch  margins,  and  become  continuous,  one  with  another,  over 
a  very  large  part  of  the  cutaneous  surface,  causing  them  to  be  termed  con- 
fluent cases.  The  secondary  fever  and  copiousness  of  the  suppurative 
process  ate  sufficient,  in  many  of  these  cases,  to  produce  fatal  exhaustion 
before  the  suppurative  stage  is  completed.  Another  source  of  danger  in 
these  cases  is  the  absorption  of  septic  matter  from  the  suppurative  sur- 
faces, the  re-poisoning  of  the  blood,  and  the  consequent  rapid  and  fatal 
exhaustion  of  the  patient.  If,  however,  the  confluence  of  the  pustules  is 
not  general,  but  limited  mostly  to  the  face  and  hands,  and  the  constitu- 
tional condition  of  the  patient  is  good,  the  tendency  will  be  towards  re- 
covery. In  scarlatina  the  cases  included  in  the  second  group  will  be 
dangerous  to  life,  in  proportion  to  the  extent  and  intensity  of  the  inflam- 
mation of  the  fauces,  tonsils  and  glands  of  the  neck.  The  swelling  of 
these  parts  may  be  sufficient  to  so  obstruct  both  respiration  and  deglu- 
tition as  to  cause  a  fatal  result  during  the  first  three  or  four  days.  Or, 
with  less  tumefaction,  there  may  follow  such  a  degree  of  ulceration  and 
persistent  suppurative  action  in  the  fauces,  nostriis,  etc.,  as  to  cause  a 
slower  but  none  the  less  fatal  degree  of  exhaustion.  There  are  many 
cases,  however,  belonging  to  this  group,  in  which  the  local  inflammation  is 
less  severe,  the  ulcerations  limited,  and  sufficient  nourishment  can  be  taken 
to  sustain  the  strength  of  the  patient  until  convalescence  ensues.  The 
cases  included  in  the  malignant  group  of  eruptive  fevers,  are  those  in 
which  the  specific  cause  accumulates  in  the  blood  to  such  a  degree  that  the 
latter  is  incapable  of  maintaining  the  mutual  relations  between  it  and  the 
several  structures  of  the  body  ;  consequently  the  tonicity  of  the  latter 
becomes  rapidly  impaired,  molecular  changes  fail,  nervous  sensibility  is 
blunted,   and  all  the   phenomena   of  life  soon  cease.     In  many  of  these 


ANATOMICAL    CHAKACTEKISTICS.  209 

cases  petechial  or  hfemorrhagic  exudations  and  has morrh ages  precede  the 
fatal  result.  By  attcmptinir  to  classify  all  cases  of  eruptive  fever  into  the 
three  groups  I  have  named,  you  must  not  infer  that  there  is  any  well  de- 
fined or  broad  line  of  difference  separating  these  groups.  On  the  con- 
trary, at  the  bed-side,  you  will  find  the  severer  cases  of  the  first  group  so 
closely  approximating  the  milder  ones  of  the  second,  that  you  will  often 
be  in  doubt  as  to  whether  you  should  assign  a  given  case  to  one  or  the  other. 
The  same  is  true  if  you  compare  the  most  severe  cases  included  in  the  sec- 
ond group  with  the  least  malignant  of  those  in  the  third.  Having  ex- 
plained, as  fully  as  practicable,  the  views  I  entertain  concerning  the 
causes,  pathological  conditions,  and  tendencies  of  those  acute  general 
diseases  classed  as  eruptive  fevers,  I  will  next  direct  your  attention  to  the 
anatomical  characters  or  structural  changes  belonging  to  each. 

Anatomical  Characteristics. — The  most  constant  and  distinctive  ana- 
tomical or  structural  lesions  found  in  these  fevers,  are  developed  on  the 
cutaneous  surface  in  the  form  of  eruptions. 

These  eruptions  are  presented  in  three  distinct  primary  forms,  each 
form  having  its  own  structural  peculiarities,  and  its  own  modes  of  further 
development.  The  first  form  is  primarily  a  papule  or  small  hard  pimple 
between  the  cuticle  and  cutis  vera,  sufficiently  elevated  to  be  readily 
detected  by  the  touch,  and  on  the  apex  of  which  may  be  seen  a  minute 
vesicle  filled  with  transparent  serum  or  lymph.  These,  at  a  certain  stage 
of  their  progress,  become  inflamed  and  suppurate,  by  which  the  serum 
they  contain  is  changed  to  a  purulent  fluid,  the  hard  base  much  increased 
in  circumference,  the  vesicle  flattened  and  depressed  or  umbilicated  in 
the  center,  constituting  a  mature  pustule.  The  fevers  characterized  by 
this  form  of  eruption  are  the  variola,  varioloid,  and  vaccine. 

The  second  is  that  of  a  true  vesicle  produced  by  sufficient  inflammation 
at  a  given  point  in  the  cutis  vera  to  cause  an  exudation  of  serum  and 
elevation  of  the  cuticle  into  a  transparent  vesicle,  larger  in  circumference 
and  without  the  hard  base  that  belongs  to  the  pustule.  The  only  erup- 
tive fevers  charactered  by  this  vesicular  form  of  eruption  are  the  varicella 
and   sudamina. 

The  third  appears  in  the  form  of  small  red  points  or  spots,  without  the 
hard  elevation  belonging  to  the  first  variety,  or  the  vesicle  of  the  second. 
There  is  no  exudation  of  serum  sufficient  to  elevate  the  cuticle,  nor  sup- 
puration, in  any  part  of  their  progress.  Remaining  as  simple  red  points 
or  spots  throughout  their  course,  they  are  called  exanthems,  or  more  pop- 
ularly the  rash.  They  may  be  pretty  uniformly  diffused  over  the  surface 
and  so  numerous  as  to  cause  general  redness,  as  in  scarlatina;  or  they  may 
be  aggregated  in  clusters,  leaving  the  intervening  parts  of  the  skin  natu- 
ral as  in  rubeola.  The  fevers  characterized  by  this  form  of  eruption  are 
scarlatina,  rubeola,  rotheln,  roseola,  and  miliaria;  hence  they  are  prop- 
erly styled  acute  exanthematous  diseases,  as  distinguished  from  those  I 
have  named  as  vesicular  and  pustular. 

An  accurate  knowledge  of  the  special  characters  of  each  of  these  forms 
of  eruption  is  of  much  importance  as  an  aid  in  the  diagnosis  of  the  several 
diseases  in  which  they  occur. 

The  pustule  commences  by  simple  congestion  or  accumulation  of  blood 
in  the  capillaries  of  the  papillse  of  the  corion  in  a  very  small  spot  of  the 
skin.  This  is  quickly  followed  by  exudation  of  minute  specks  of  serum 
in  the  connective  tissue  and  swelling  of  the  epithelial  cells  of  the  rete 
Malpighii.  It  is  this  exudation  and  enlargement  of  cells  that  causes  the 
hard  elevation  or  distinct  papule;  and  it  is  simply  an  increase  of  the  serum 
or  lymph  that  elevates  the  cuticle  and  gives  the  appearance  of  a  minute 
14 


210  ERUPTIVE    FEVERS. 

vesicle  on  the  apex  of  the  papule.  The  two  essential  features  of  the  pus- 
tule, namely,  the  papular  or  hardened  base  and  the  superimposed  vesicle, 
having  so  far  developed  as  to  become  plainly  recognizable  by  the  eye  and 
the  touch,  both  continue  to  increase  in  size,  and  pass  through  the  stages 
of  suppuration  to  maturity,  and  desiccation  with  cicatrization  and  a  return 
to  health. 

The  vesicle  commences  like  the  pustule  with  a  simple  primary  conges- 
tion of  the  capillaries  of  the  papillae  at  a  point  in  the  skin,  but  without 
sufficient  swelling  of  the  epithelial  cells  to  cause  an  elevated  and  hard 
base,  while  the  serous  exudation  accumulates  more  rapidly,  and  separat- 
ing the  cuticle  from  the  cutis  vera,  presents  at  once  a  well  formed  vesicle 
filled  with  clear  lymph,  which  subsequently  becomes  turbid  but  not 
purulent.  The  exanthem  consists  of  the  same  primary  congestion  of  the 
capillaries  of  the  papillae  of  the  corion,  causing  small  red  points,  but  with- 
out the  enlargement  of  the  epithelial  cells  of  the  pustule,  and  without 
sufficient  exudation  of  serum  or  lymph  to  elevate  the  cuticle  into  a  vesicle; 
consequently  there  is  neither  lymph  nor  pus  visible  during  any  part  of 
their  progress.  Yet  there  is  sufficient  disturbance  of  the  connection 
between  the  cuticle  and  the  vascular  structure  beneath,  to  cause  a  general 
exfoliation  of  the  former  at  the  commencement  of  convalescence. 

Whatever  anatomical  or  structural  changes  may  be  found  in  the  internal 
organs  and  structures,  after  death  from  any  one  of  the  eruptive  fevers, 
will  be  the  result  of  local  inflammatory  complications,  and  not  in  any 
•degree  characteristic  of  the  general  disease.  Evidences  of  such  local 
.inliammatory  complications  are  most  frequently  found  in  the  mucous  mem- 
brane of  the  respiratory  passages,  fauces  and  glands  of  the  neck,  kidneys, 
■and  parenchyma  of  the  lungs.  In  the  malignant  cases,  the  blood  is  found 
in  a  condit'on  closely  resembling  the  state  of  that  fluid  in  the  more  severe 
•cases  of  typhoid  and  typhus  fevers. 

General  Princijyles  of  Treatment. — If  the  views  I  have  expressed  con- 
■cerning  the  etiology  and  general  pathology  of  this  group  of  diseases,  are 
correct,  they  point  to  certain  general  principles  of  therapeutic  manage- 
ment of  much  practical  importance.  1st.  The  existence,  in  all  these 
fevers,  of  an  incubative  stage,  during  which  the  minute  quantity  of  the 
contagiura  primarily  imbibed,  is  presumed  to  be  undergoing  development 
■or  multiplication,  suggests  the  question  whether  it  is  not  possible  to  intro- 
duce into  the  blood  enough  of  some  efficient  antiseptic  to  prevent  such 
multiplication,  on  the  S'lme  principle  of  action  that  the  presence  of  a  cer- 
tain quantity  of  the  sulphite  of  calcium  in  a  cask  of  sweet  cider  or  other 
fermentable  liquid,  prevents  the  fermenting  process  for  an  indefinite  period 
of  time.  The  antiseptics  most  likely  to  effect  this  object  are  the  sulphites 
or  hyposulphites  of  sodium,  calcium,  or  magnesium;  both  on  account 
of  their  known  efficacy  in  preventing  fermentation,  and  the  safety  of 
using  them  in  sufficient  doses  to  more  freely  impregnate  the  blood  than 
can  be  done  with  most  of  the  remedies  belonging  to  the  same  class.  The 
opportunities  for  testing  the  value  of  remedies  in  this  stage  are  not 
frequent,  as  the  physician  is  seldom  consulted  until  active  symptoms  of 
disease  have  appeared.  When  it  does  happen  that  an  individual  comes 
under  the  care  of  a  physician  soon  after  fair  exposure  to  one  of  these  con- 
tagiums,  the  antiseptic  is  given  freely  through  the  whole  incubative  stage 
and  no  active  symptoms  of  disease  follow,  there  are  left  two  points  of 
uncertainty.  First,  the  possibility  that  none  of  the  contagium  was 
imbibed  at  the  time  of  exposure;  and  second,  the  insusceptibility  of  the 
individual  to  its  action  from  other  causes.  Observation  has  long  since 
shown  that  many  children  do  not  take  the  eruptive  fevers  of  the  exanthe- 


PRINCIPLES    OF    TREATMENT.  211 

matous  variety  when  fully  exposed  to  contact  with  them,  while  the  very 
general  practice  of  vaccination  interferes  with  the  results  of  other  tests 
as  applied  Id  variola.  In  regard  to  the  latter  disease,  three  cases  have 
come  under  my  observation,  affording  apparently  fair  opportunities  for 
testing  the  efficacy  of  the  hyjjosulphite  of  sodium.  The  first  of  these 
occurred  as  early  as  1856,  and  the  last  one  was  only  one  year  since.  All 
the  three  cases  were  nursing  children,  belonging  to  mothers  who  had 
direct  care  of  unmodified  small-pox,  the  babies  remaining  in  the  room  and 
often  lying  on  the  bed  with  the  sick  through  the  whole  course  of  the 
disease!  Two  of  these  were  cases  in  which  the  father  was  attacked  with  the 
variola,  and  the  other  in  which  a  daughter,  eighteen  years  of  age,  had  the 
disease.  In  each  case,  the  mothers  having  nursing  babies  varying  from 
four  to  eight  months  old,  and  never  vaccinated,  insisted  on  taking  joer- 
sonal  care  of  the  sick  member  of  their  families.  As  the  little  nurslings 
had  been  fully  exposed  before  I  saw  them,  I  thought  it  better  to  comply 
with  the  wishes  of  their  mothers.  I  immediately  vaccinated  each  one  as 
it  came  under  my  notice,  and  at  the  same  time  commenced  giving  it  a 
solution  of  the  hyposulphite  of  sodium  in  mint  water,  four  times  a  day.  The 
first  vaccination  did  not  take  and  it  was  repeated  a  second  and  a  third 
time,  but  with  no  effect  whatever.  In  the  last  ca,se,  one  of  the  vaccina- 
tions was  done  by  a  medical  officer  sent  from  the  city  health  office.  The 
internal  use  of  the  hyposulphite  of  sodium  was  continued  in  each  of  these 
cases,  not  only  during  the  ordinary  period  of  incubation,  but  during  the 
whole  time  they  remained  exposed  to  the  respective  cases  of  variola. 
Neither  of  these  nursing  children  showed  any  signs  of  being  affected  by 
ei::her  the  vaccine  or  the  variola. 

Of  course  these  three  cases  are  not  enough  to  justify  me  in  stating  any- 
thing more  than  the  simple  facts. 

After  the  incubative  stnge  is  passed  and  the  virus  or  contagium  is  fully 
developed,  as  shown  by  the  supervention  of  active  febrile  symptoms,  there 
remains  the  same  indication  for  the  administration  of  such  remedies  as 
might  be  capable  of  neutralizing  or  destroying  the  noxious  agent  in  the 
blood,  and  thereby  rendering  the  further  progress  of  the  disease  abortive. 
There  is  an  important  difference,  however,  between  the  prevention  of  the 
multiplication  of  an  organic  poison  by  the  presence  and  catalytic  action  of 
some  antiseptic  remedy  during  the  period  of  incbation,  and  the  destruc- 
tion or  neutralization  of  such  poison  after  the  quantity  has  already  become 
sufficient  to  induce  active  morbid  phenomena.  To  accomplish  the  lat- 
ter would  require  a  much  stronger  impregnation  of  the  blood  with  the 
antiseptic  than  is  found  practicable  or  compatible  with  the  safety  of  the 
patient.  It  does  not  follow  as  a  necessary  inference,  that,  because  safe 
doses  of  efficient  antiseptics  will  not  whollv  neutralize  the  poison  and 
render  the  disease  abortive,  they  are  of  no  value  in  the  treatment  of  this 
class  of  contagious  diseases.  On  the  contrary,  my  own  clinical  experience 
has  led  me  to  think  that  when  the  administration  of  some  of  this  class  of 
remedies  is  commenced  with  the  beginning  of  active  symptoms,  they 
may  destroy  so  much  of  the  poison  as  to  materially  lessen  the  severity  of 
the  case,  as  I  shall  state  more  fully  when  I  come  to  speak  of  the  treatment 
of  each  disease  separately. 

2nd.  Admitting  that  we  have  no  reliable  remedies  for  fulfilling  the  object 
just  stated,  the  next  rational  indication  is,  to  adopt  such  measures  and 
give  such  remedies  as  will  lessen  the  irritative  action  of  those  contagiums 
on  the  living  structures  and  aid  in  effecting  their  elimination.  When,  at 
the  commencement  of  active  symptoms,  the  temperature  rises  rapidly  with 
corresponding  increase  in  the  activity  of  respiration   and  circulation,   fre- 


212  ERUPTIVE    TEVEES. 

quent  sponging  of  the  surface  with  milk-warm  water,  and  the  internal  use 
of  such  doses  of  veratrum  viride  or  aconite  in  connection  with  spirits  of  ni- 
trous ether  or  liquor  ammonii  acetatis,  as  will  moderate  the  force  and  fre- 
quency of  the  action  of  the  heart  and  favor  increased  eliminations  from  the 
skin  and  kidneys,  will  lessen  much  the  suffering  and  restlessness  of  the  pa- 
tient, and  favorably  modif}^  the  progress  of  the  disease.  You  must  keep  con- 
stantly in  mind  the  fact  that  these  specific  poisons  have  a  natural  tendency 
to  accumulation  in  the  cutaneous  textures,  and  that  their  final  elimination 
is  chiefly  through  this  surface,  aided,  perhaps,  by  the  kidneys  and  the 
mucous  membrane  lining  the  first  part  of  the  respiratory  passages.  Con- 
sequently, all  cathartics  or  other  actively  evacuant  measures  calculated  to 
divert  the  circulation  from  the  surface  should  be  avoided  during  the  pre- 
monitory fever,  and  only  the  milder  laxatives  used  even  after  the  eruptions 
are  well  established  on  the  surface. 

3d,  A  third  indication  to  be  fulfilled  in  many  of  the  cases,  more  espe- 
cially of  variola  and  scarlatina,  is  to  lessen  the  severity  and  mitigate  the 
effects  of  the  local  inflammations  which  accompany  them.  As  I  have 
already  explained  to  you,  a  large  proportion  of  the  deaths  from  variola 
result  from  the  exhausting  influence  of  the  suppurative  stage  in  the  con- 
fluent cases;  while  a  still  larger  proportion  of  the  deaths  from  scarlatina  are 
the  result  of  the  local  inflammations  and  obstructions  in  the  fauces,  nostrils 
and  glands  of  the  neck.  Two  influences  are  needed  in  the  management 
of  these  local  affections;  one  calculated  to  lessen  the  amount  of  the  local 
morbid  actions  while  they  are  developing;  the  other  to  sustain  the 
important  functions,  especially  those  of  nutrition  and  repair,  until  con- 
valescence is  established. 

If,  as  I  have  already  suggested,  the  extent  and  severity  of  the  local 
developments  of  disease  in  all  the  eruptive  fevers  depend  on  the  quantity 
and  activity  of  the  specific  contagiura  developed  during  the  periods  of  incu- 
bation and  primary  fever;  then  so  far  as  we  can  succeed  in  fulfilling  the  first 
and  second  indications  I  have  pointed  out,  just  so  far  will  we  be  lessening 
the  catxse  of  the  local  affections,  and  thereby  accomplishing  the  first  part 
of  this  third  indication.  The  second  part  is  to  be  accomplished  by  secur- 
ing for  the  patient  as  good  pure  air  as  possible,  the  faithful  use  of  such 
nourishment  as  is  most  easily  converted  into  the  nutrient  elements  of  the 
blood,  and  the  administration  of  such  tonics  as  are  best  adapted  to  each 
case. 

4th.  The  last  indication  which  should  claim  your  attention  is  to  guard 
your  patients  against  the  development  of  those  important  sequelae  that  are 
so  well  known  as  liable  to  occur  during  the  convalescence  from  some  of 
these  fevers.  If  you  study  carefully  the  immediate  causes  of  these  several 
sequelae  in  connection  with  the  hereditary  and  constitutional  tendencies 
of  each  patient,  you  will  often  find  it  far  easier,  by  timely  attention  and 
advice,  to  prevent  their  development,  than  to  cure  them  after  they  are 
established. 

Having  now  considered  the  causes  and  general  pathology  of  this  third 
group  of  acute  general  diseases,  together  with  the  general  indications  and 
principles  that  should  occupy  our  attention  and  guide  us  in  their  manage- 
ment, we  are  better  prepared  to  enter  directly  upon  the  consideration  of 
the  symptoms  or  clinical  history,  diagnosis  and  special  treatment  of  each 
member  of  the  group. 


VAKIOLA.  213 


LECTURE  XXIV. 

Variola,  Varioloid,  and  Vaccine— Their  Symptoms,  Diagnosis,  Prognosis,  Special  Treatment, 
and  Prophylaxis. 

GENTLEMEN:  Although  variola,  or  small-pox,  has  been  deprived  of 
much  of  that  power  to  destroy  human  life,  which  it  so  frequently 
manifested  before  the  discovery  and  practice  of  vaccination,  yet  it  perpet- 
uates its  existence,  and  is  still  a  terror  to  all  classes  of  the  people.  Its 
history,  causes,  pathology,  and  anatomical  characteristics  were  sufficiently 
explained  in  the  preceding  lecture,  consequently  I  shall  proceed  directly  to 
a  description  of  its  symptoms  and  progress  as  presented  at  the  bed-side 
in  the  different  stages  of  the  disease. 

Symptoms. — After  a  period  of  incubation  varying  from  nine  to  fourteen 
days,  the  active  symptoms  of  variola  usually  commence  abruptly  by  a 
chill  of  varying  degrees  of  severity,  from  mere  chilliness  to  a  severe  chili 
of  half  an  hour  or  more  in  duration;  accompanied  by  severe  pain  in  the 
loins;  small,  variable  pulse;  paleness  of  features;  oppression  or  distress 
in  the  epigastrium,  and  sometimes  vomiting.  The  cold  stage  soon  gives 
place  to  increased  heat;  flushed  face;  a  full  and  frequent  pulse;  acceler- 
ated respiration;  heat  and  dryness  of  the  skin;  a  white  fur  on  the  tongue; 
scanty  and  high-colored  urine;  very  severe  pain  in  the  lumbar  portion  of 
the  back;  general  aching  of  the  head,  back,  and  limbs,  with  more  distress 
in  the  epigastrium  and  frequent  efforts  at  vomiting.  There  is  also  much 
thirst  and  general  restlessness,  with  more  or  less  delirium  in  the  severer 
class  of   cases. 

The  symptoms  of  the  initial  stage,  you  perceive,  are  nearly  the  same 
as  those  which  characterize  the  first  stage  of  all  active  fevers.  The  tem- 
perature of  the  body  increases  rapidly,  in  many  cases  reaching  from  40° 
to  41°  C.  (104°  to  106°  F.)  during  the  second  and  third  days"  There  is 
usually  but  little  variation  or  abatement  of  the  febrile  phenomena  until  a 
few  hours  before  the  commencement  of  visible  eruptions  upon  the  sur- 
face. There  may  be  a  slight  remission  or  decrease  of  temperature  each 
morning  compared  with  the  evening,  and  temporary  appearances  of  moist- 
ure on  the  skin  at  irregular  intervals.  The  first  appearance  of  eruption  is 
usually  on  the  evening  of  the  third  or  the  morning  of  the  fourth  day  after 
the  initial  chilliness,  and  consists,  at  first,  of  small  red  spots  or  points  a 
little  elevated  and  distinctly  hard  to  the  touch.  In  a  few  hours  the  little 
hard  papule  becomes  more  elevated  and  pointed,  and  a  minute  vesicle 
containing  transparent  lymph,  or  serum,-  may  be  seen  at  its  apex.  A  few 
hours  before  the  eruption  becomes  visible  the  patient  begins  to  be  less 
restless,  and  often  falls  asleep.  The  temperature,  which  had  reached  its 
climax  about  the  middle  of  the  third  day,  declines  so  rapidly  as  to  reach 
the  natural  standard  in  all  cases  of  moderate  severity  at  the  end  of  the 
fourth  day,  with  a  corresponding  subsidence  of  all  the  other  febrile  symp- 
toms. In  all  such  cases  the  patient  remains  quite  free  from  active  symp- 
toms for  three  days,  or  until  the  morning  of  the  seventh  day  from  the  initial 
symptoms,  when  active  inflammation  in  the  pustules  becomes  apparent, 
and  the  temperature  again  rises  to  38°  or  39°  C.  (101°  or  102.5°  F.)  with 
moderate  restlessness,  some  thirst,  and  increase  of  frequency  in  the  pulse, 


214  VARIOLA. 

but  without  the  pains  in  the  back  and  head  that  marked  the  first  stage. 
This  renewal  of  fever,  caused  by  the  inflHmmation  attending  the  progress 
of  the  eruption,  continues  until  the  suppurative  process  is  completed, 
which  is  from  the  tenth  to  the  twelfth  day  after  the  commencement  of 
active  symptoms,  wrhen  the  temperature  again  falls  rapidly  to  near  the 
natural  standard,  and  remains  there  until  the  process  of  desiccation  is  com- 
pleted and  convalesence  established.  In  the  more  severely  confluent 
cases,  during  the  primary  fever  there  is  a  greater  degree  of  distress  in  the 
epigastrium,  with  more  persistent  and  severe  vomiting;  more  frequent  and 
smaller  pulse,  and  n'lore  decided  delirium;  and  when  the  eruption  appears 
the  temperature  and  other  active  symptoms  subside  more  slowly,  not 
reaching  the  natural  standard  of  temperature  until  the  end  of  the  fifth  day. 
In  such  severe  cases  the  secondary  fever  is  also  renewed  with  greater  in- 
tensity from  the  seventh  to  the  eighth  day,  and  usually  continues  until  the 
eleventh  or  twelfth,  when  the  siippurative  stage  is  completed,  and  if  the 
patient  survives,  the  process  of  desiccation  commences,  attended  by  a  rapid 
decline  of  all  the  febrile  phenomena.  In  many  of  the  more  severely  con- 
fluent cases,  however,  soon  after  tlve  commencement  of  the  secondary 
fever  and  while  the  suppurative  process  in  the  pustules  of  the  eruption 
is  progressing  actively,  the  febrile  symptoms  present  more  of  a  typhoid 
character;  the  pulse  becomes  more  frequent  and  feeble,  varying  from  120 
to  140  per  minute;  respiration  unsteady,  and  sometimes  sighing;  lips  and 
finger-nails  leaden  in  hue;  miud  wandering,  with  suhsultus  and  picking  of 
bed-clothes;  and  finally  involuntary  discharges  from  the  bowels,  suppression 
or  retention  of  urine;  complete  collapse,  and  death,  most  frequently  be- 
tween the  ninth  and  fourteenth  days  from  the  initial  symptoms  of  the  dis- 
ease. In  some  of  these  cases  the  fatal  result  is  preceded  by  the  appear- 
ance of  petechial,  or  hgemorrhagic  spots  in  the  skin,  or  by  sudden  and  co- 
pious haemorrhage  from  the  bowels,  or  by  both.  The  petechial  spots  are 
most  apt  to  occur  on  the  upper  part  of  the  chest,  sides  of  the  neck,  inside 
of  the  thighs,  and  on  the  legs. 

In  the  truly  malignant  grade  of  variola  the  commencement  of  the  pri- 
mary fever  is  marked  by  a  severe  chill,  followed  by  intense  pyrexia,  the 
temperature  rising  during  the  first  forty-eight  hours  to  42°  or  43°  C.  (108° 
or  110°  F.);  respirations  hurried,  irregular,  and  sighing;  pulse  very  fre- 
quent, small,  and  feeble;  face,  neck,  and  upper  part  of  the  chest  deeply 
suffused  With  a  purplish  redness;  extreme  sense  of  oppression  across  the 
chest,  and  distress  in  the  epigastrium,  with  severe  vomiting;  more  or  less 
delirium;  urinary  secretion  very  scanty,  and  sometimes  suppressed;  and 
the  bowels  quiet,  though  sometimes  loose.  The  eruption  in  some  of  these 
cases  is  preceded  by  the  appearance  on  the  evening  of  the  second  or 
morning  of  the  third  day  of  deep  red  spots  upon  the  surface,  sometimes  in 
the  form  of  an  exanthematous  rash,  and  in  other  cases  more  resembling 
large  spots  of  roseola.  These  appearances  usually  disappear  within  twenty- 
four  hours,  and  are  replaced  by  the  eruption  specially  characteristic  of 
variola.  The  appearance  of  the  latter  is  not  accompanied  by  any  decided 
diminution  of  the  febrile  symptoms,  as  in  the  non-malignant  cases.  On 
the  contrary,  all  the  symptoms  I  have  just  mentioned  continue,  with  the 
addition  of  ])etechial  spots  on  the  surface,  and  haemorrhages  from  the  nose, 
mouth,  stomach,  intestines,  and  in  some  cases  from  the  kidneys,  followed 
by  low  muttering  delirium,  involuntary  discharges,  and  death  between 
the  fifth  and  seventh  days.  Having  indicated  the  more  prominent  and 
essential  symptoms  accompanying  the  different  grades  and  stages  of  va- 
riola, I  must  direct  your  attention  to  the  successive  changes  that  occur  in 
the  pustules,  from  tiieir  appearance  on   the   third   or  fourth   day  to   their 


SYMPTOMS.  215 

complete  cicatrization  between  the  fifteenth  and  twenty-first.  As  I  have 
already  stated,  the  pustule  appears  first  as  an  elevated,  hard,  and  slightly 
reddened  spot,  or  papule,  easily  recognized  both  by  the  eye  and  the  touch. 
In  from  six  to  twelve  hours  later  a  minute  vesicle  is  readily  seen  on  the 
summit  of  the  papule,  or  hard  base.  From  this  time  (evening  of  the 
fourth  day)  to  the  seventh  day  of  the  disease,  or  fourth  day  of  the  erup- 
tion, both  the  hard  base  and  the  vesicle  are  steadily  increasing  in  circum- 
ference, the  latter  umbilicated,  or  indented  in  the  centre,  and  filled  with 
a  constantly  increasing  quantity  of  transparent  serum,  or  lymph.  During 
this  time  there  is  no  discoloration  of  the  skin  between  the  pustules,  and 
no  general  swelling;  but  at  the  beginning  of  the  fourth  day,  after  the  first 
appearance  of  the  eruption,  an  active  inflammation  attacks  each  pustule, 
causing  an  areola,  or  circle  of  redness  around  the  base  of  each,  with  con- 
siderable tumefaction  of  the  part,  and  a  slightly  turbid  appearance  of  the 
serum  in  the  vesicle.  The  inflammation  and  swelling  increase  for  three 
or  four  days,  during  which  time  the  vesicle  becomes  more  distended,  and 
finally,  in  most  cases,  loses  its  umbilicated  appearance,  while  the  fluid 
within  has  become  fully  transformed  into  pus.  The  stage  of  inflammation 
and  suppuration  having  reached  its  climax  on  the  tenth  or  eleventh  day 
of  the  disease,  or  the  seventh  of  the  eruption,  in  one  or  two  days  more  a 
dry,  brownish  spot  appears  at  the  point  of  previous  umbilication  in  each 
pustule,  which  daily  increases  in  size  and  becomes  darker  in  color  until  it 
constitutes  a  dark-brown  or  black  scab  the  full  size  of  the  pustule  and 
closely  imbedded  in  the  surface.  As  this  drying  up  or  desiccating  process 
goes  on  the  febrile  symptoms  abate,  the  tumefaction  gradually  disappears, 
and  cicatrization  is  rapidly  progressing  under  the  scabs.  The  latter  proc- 
ess is  usually  completed  in  from  five  to  seven  days  after  the  completion 
of  the  suppurative  stage,  when  the  scabs  become  rapidly  detached,  leav- 
ing the  patient  quite  free  and  ready  to  be  washed  and  clothed  in  about 
three  weeks  from  the  commencement  of  the  disease.  The  degree  of  tume- 
faction of  the  surface  during  the  stage  of  inflammation  and  suppuration 
will  depend  almost  entirely  on  the  number  of  the  pustules. 

In  the  distinct,  or  discrete  variety,  the  swelling  of  the  face  is  rarely 
sufficient  to  close  the  eyelids,  and  the  secondary  fever  is  mild  and  of  short 
duration.  When  the  number  of  the  pustules  is  sufficient  to  cause  them 
to  coalesce,  or  become  confluent,  however,  the  tumefaction  is  so  great  that 
the  eyelids  are  completely  closed,  the  natural  lines  and  expression  of  the 
face  obliterated,  with  considerable  swelling  of  the  whole  surface.  In  the 
more  severe  cases  of  this  variety,  as  the  patient  approaches  the  comple- 
tion of  the  suppurative  stage,  there  is  much  oedematous  infiltration  into 
the  subcutaneous  areolar  tissue  indicated  by  pitting  wherever  pressure  is 
made,  and  sometimes  cellular  abscesses  form  in  several  places  and  add  to 
the  discomfort  of  the  patient. 

I  have  said  nothing  thus  far  concerning  the  pustules  that  come  in  the 
fauces  and  pharynx.  They  appear  at  the  same  time  and  pass  through  the 
same  stages  as  those  on  the  surface;  but  their  presence  causes,  at  first, 
simply  a  feeling  of  soreness,  with  an  increased  secretion  of  viscid  saliva, 
or  mucus,  and  when  the  inflammatory  stage  comes,  the  increased  heat, 
soreness  and  swelling  around  them,  with  a  more  abundant  secretion  of 
mucus,  is  often  sufficient  to  cause  much  pain  and  difficulty  of  swallowing 
and  much  annoyance  from  the  necessity  of  frequent  spitting  or  efi'orts  to 
clear  the  throat.  In  confluent  cases,  accompanied  by  numerous  pustules 
in  the  pharynx,  it  has  sometimes  happened  that  during  the  suppixrative 
stage  the  tumefaction  around  the  inflamed  pustules  has  been  increased  by 
more  or  less  oedema  of  the  submucous  tissue  extending  to  the  base  of  the 


216  VARIOLA. 

epii^lottis,  and  sometimes  so  obstructing  the  breathing  as  to  cause  death 
from  suffocation.  One  such  case  came  under  my  own  observation  a  few 
years  since.  In  some  of  these  cases  the  inflammation  has  extended  tot  he 
tongue,  causing  it  to  become  so  swollen  as  to  protrude  between  the  teeth  and 
add  much  to  the  difficulty  of  deglutition.  In  rare  instances  one  or  more 
pustules  appear  on  the  conjunctiva  of  the  eye,  causing  great  irritation  and 
sometimes  sufficient  ulceration  to  result  in  permanent  impairment  or  loss 
of  vision.  From  the  commencement  of  the  suppurative  stage  to  the  es- 
tablishment of  convalescence  there  is  a  peculiar  and  unpleasant  odor 
emanating  from  the  body  of  the  sick,  which  in  the  more  severely  confluent 
and  malignant  cases  is  so  strong  as  to  impregnate  the  whole  atmosphere 
of  the  room  and  require  constant  attention  to  disinfection  and  ventilation. 

Diagnosis. — During  the  stage  of  primary  fever,  before  any  appearance 
of  an  eruption,  there  are  no  symptoms  so  peculiar  or  distinctive,  as  to  en- 
able the  physician  to  make  a  positive  diagnosis  between  small-pox  and  at- 
tacks of  other  active  grades  of  fever. 

The  abruptness  of  the  attack  from  a  previous  state  of  good  health,  the 
rapid  rise  of  temperature,  the  general  redness  of  the  surface,  and  espe- 
cially the  severe  pains  in  the  loins,  should  be  sufficient  to  excite  the  sus- 
picions of  the  practitioner.  And  if  these  symptoms  have  supervened  in 
from  nine  to  fourteen  days  after  a  known  exposure  to  the  contagion  of  va- 
riola, it  would  change  the  suspicion  into  an  approach  to  certainty. 

It  is  not,  however,  until  the  appearance  of  the  eruption  that  the  diag- 
nosis can  be  made  positive.  The  appearance  on  the  evening  of  the  third 
or  morning  of  the  fourth  day,  upon  the  face,  neck  and  upper  part  of  the 
chest,  of  a  greater  or  less  number  of  hard  elevated  points,  with  minute 
vesicles  forming  on  the  apex  of  each,  and  generally  accompanied  by  a 
marked  subsidence  of  the  febrile  symptoms,  is  so  distinctive  as  to  leave 
no  room  for  further  uncertainty.  The  elevation  and  hardness  of  the  pimples 
at  once  distinguishes  them  from  all  the  exanthematous  varieties  of  fever. 
The  sraallness  of  the  vesicle  on  its  first  appearance,  and  its  position  on  a  hard 
and  elevated  base,  equally  distinguishes  it  from  the  much  larger  vesicle, 
without  any  hard  base,  that  characterizes  varicella.  Each  subsequent 
day  after  the  first,  only  serves  to  make  the  distinctive  features  more  plain 
by  the  enlargement,  flattening  and  umbilication  of  the  vesicles. 

Prognosis. — In  all  cases  of  distinct  or  discrete  variola,  the  prognosis  is 
favoralDle.  In  all  cases  presenting  only  a  moderate  degree  of  confluence 
of  the  eruption,  such  as  confluent  patches  of  limited  extent  on  the  face 
and  back  of  the  hands,  the  tendency  is  to  recovery.  But  in  the  more  ex- 
tensively confluent  cases,  and  those  presenting  special  symptoms  of  ma- 
lignancy, there  is  a  strong  tendency  to  fatal  results  ;  and  no  method  of 
treatment  has  been  devised  capable  of  preventing  a  high  ratio  of  mortal- 
ity. The  general  ratio  of  deaths  to  the  whole  number  of  cases  of  unmod- 
ified small-pox,  varies  from  one  in  three  to  one  in  ten.  It  is  more  fatal  in 
early  childhood  and  in  old  age,  than  in  the  middle  period  of  life.  A  large 
percentage  of  the  deaths  are  caused  by  such  complications  as  pneumonia, 
oedema  of  the  glottis,  endocarditis  and  uremia  from  active  renal  con- 
gestion. 

Special  Treatment. — In  speaking  of  the  general  principles  which 
should  guide  us,  and  the  objects  to  be  accomplished  in  the  treatment  of 
the  whole  class  of  eruptive  fevers  yesterday,  I  stated  that  it  was  desirable, 
in  the  early  stage,  to  cause  the  destruction  or  elimination  of  as  much  of 
the  specific  cause  as  possible  ;  to  palliate  its  direct  irritative  action  on 
the  structures  of  the  body  ;  and  in  the  middle  and  later  stages,  to  sus- 
tain the  nutrition    and   strength  of  the  patient.     Among  the   antiseptics 


TREATMENT.  217 

supposed  to  be  capable  of  neutralizing  or  destroying  animal  poisons  or 
specific  contagiums,  I  have  found  none  capable  of  being  used  safely  in 
sufficient  quantity  to  make  an  impression,  except  the  hyposulphites  of 
sodium  and  calcium.  During  the  last  twenty  years  I  have  given  nearly  all 
the  cases  of  uimiodified  variola,  coming  under  my  care  in  the  early  stage, 
from  0.66  to  1.00  gram.  (gr.  x  to  xv)  of  the  hyposulphite  of  sodium,  dis-. 
solved  in  mint  water,  every  four  hours  ;  and  throug-h  the  stage  of  erup- 
tion in  the  confluent  cases,  it  has  been  continued  from  three  to  four  times  a 
day.  In  the  discrete  variety  of  cases,  its  continuance  after  the  establish- 
ment of  the  eruption  on  the  surface,  is  not  necessary.  Neither  is  it  nec- 
essary to  give  patients  laboring  under  this  mild  variety  of  the  disease  any 
active  remedies  after  the  primary  fever  has  disappeared.  To  keep  their 
rooms  well  ventilated,  cleanly,  and  at  a  comfortable  temperature  ;  to  give 
them  light,  plain  food;  an  occasional  laxative  or  enema  if  the  bowels  do  not 
move  without,  and  a  moderate  dose  of  the  compound  powder  of  opium 
and  ipecacuanha  at  night  during  the  suppurative  stage,  constitutes  all  the 
treatment  necessary,  unless  some  important  local  complication  occurs.  In 
cases  of  greater  severity,  however,  accompanied,  during  the  primary  fe- 
ver by  great  epigastric  distress  and  frequent  vomiting,  I  give  six  centi- 
grams (gr.  i)  of  calomel  with  three  decigrams  (gr.  v)  of  white  sugar, 
every  two  or  three  hours,  and  half  way  between  the  powders,  four  cubic 
centimeters  (£1,  3i  )  or  a  teaspoon  ful  of  the  carbolic  acid  mixture  (see  for- 
mula on  page  138)  until  the  vomiting  ceases  and  the  eruption  begins  to 
appear  upon  the  surface.  During  the  same  time  I  apply  sinapisms  to  the 
epigastrium  and  along  the  lower  dorsal  and  lumbar  portions  of  the  spine  ; 
and  while  the  skin  is  hot  and  dry  have  it  frequently  sponged  over  with 
milk- warm  water,  and  if  there  is  delirium  I  keep  the  head  covered  with  cloths 
wet  in  water  of  the  same  temperature.  In  these  more  severe  cases,  if 
the  hyposulphite  of  sodium  is  rejected  by  the  stomach,  it  can  be  given 
by  enema.  When  the  eruption  has  appeared,  accompanied  by  the  usual 
abatement  of  fever,  if  the  bowels  have  not  moved  during  the  two  preced- 
ing days,  I  give  a  saline  laxative  sufficient  to  evacuate  the  bowels  mildly, 
and  discontinue  all  the  preceding  remedies,  except  the  solution  of  the  hypo- 
sulphite, which  I  continue  at  intervals  of  once  in  six  hours,  and  secure  rest 
at  night  by  a  single  dose  of  0.4  or  0.5  grams  (gr.  vi  or  viii)  of  the  com- 
T>ound  powder  of  opium  and  ipecacuanha  given  at  bed-time.  If  pustules 
appear  in  the  fauces  and  pharynx,  mucilaginous  and  slightly  astringent 
gargles  are  used  frequently  to  allay  the  heat  and  help  to  dislodge  the  ex- 
cess of  mucus.  Milk  and  meat  broths  are  given  in  quantities  sufficient  to 
sustain  a  good  degree  of  nutritioti.  "When  the  stage  of  inflammation  and 
suppviration  commences  in  the  eruption,  and  secondary  fever  with  more 
weakness  supervenes,  I  discontinue  the  hyposulphite,  and  give  in  its  place 
moderate  doses  of  the  tincture  of  the  chloride  of  iron  and  sulphate  of 
quinia  every  four  hours  ;  and  as  this  stage  progresses  toward  comple- 
tion, if  the  pulse  becomes  decidedly  soft  and  weak,  respiration  occasion- 
ally sighing,  and  the  mind  either  dull  or  wandering,  I  give  four  cubic 
centimeters,  or  a  teaspoonful  of  the  follovang  mixture,  between  the  doses 
of  the  quinine  and  iron: — 

^     Ammonii  Carbonatis 
Aquoe  Camphorje 
Syrupus  Simplicis 

Mix.     Put  each  dose  with  an  additional  tablespoonful  of  water  when  it 
is  given  to  the  patient. 


10  grams 

3iiss 

110  c.  c. 

§iiis3 

15  c.  c. 

3ss 

218  VAEIOLA. 

Close  attention  should  also  be  g-iven  at  the  same  time  to  the  faithful  ad- 
ministration of  such  nourishment  as  milk,  milk  and  flour  gruel,  and  meat 
broths,  with  small  and  frequent  doses  of  pretty  strong  tea  or  coffee,  to 
maintain  nerve  sensibility.  If,  as  sometimes  happens,  the  bowels  at  this 
stage  become  loose,  giving  rise  to  thin  discharges,  the  emulsion  of  tur- 
pentine and  tincture  of  opium  should  be  promptly  given  in  such  doses 
and  at  such  intervals  as  is  necessary  to  hold  them  in  check.*  If  petechial  or 
hfemorrhagic  spots  appear  on  the  surface,  or  the  intestinal  discharges  be- 
come bloody,  suitable  doses  of  strychnine  and  nitric  acid  may  be  given  in- 
stead of  the  quinine,  between  the  doses  of  the  emulsion.  If  free  intestinal 
haemorrhage  occurs,  it  is  proper  to  use  astringent  enemas,  and  for  imme- 
diate effect  in  controlling  the  flow  of  blood,  from  sixty  to  one  hundred 
and  twenty  milligrams  (gr.  i  to  ii)  of  persulphate  of  iron  in  solution 
with  water,  may  be  given  every  hour  until  the  hgemorrhage  is  checked, 
when  the  emulsion  and  other  remedies  should  be  resumed,  as  I  have  just 
stated. 

Malignant  Cases. — The  genuinely  malignant  cases  of  this  disease  have 
generally  progressed  to  a  fatal  result,  regardless  of  the  influence  of  an}^ 
remedies  hitnerto  proposed.  Yet  it  is  the  duty  of  the  physician  to  make 
an  effort  to  relieve  his  patient,  however  small  may  be  the  chance  of  suc- 
cess ;  and  the  effort  should  be  founded  on  some  rational  indications  af- 
forded by  the  pathological  conditions  of  the  patient.  If  it  be  true  that 
the  special  symptoms  indicating  malignancy  depend  upon  the  continued 
action  of  the  poison  on  the  blood,  either  through  excess  of  its  quantity  or  its 
failure  to  be  fully  lodged  in  the  cutaneous  tissue  at  the  commencement  of 
the  eruptive  stage,  then  the  first  and  most  important  indication  is,  to  neu- 
tralize or  in  some  way  destroy  this  excess  of  virus  and  thereby  render  the 
blood  again  capable  of  making  its  natural  impression  on  the  properties 
of  the  tissues  and  the  sensibility  of  the  vaso-motor  nervous  system.  I 
know  of  no  agents  better  calculated  to  fulfill  this  indication,  than  a  com- 
bination of  the  hyposulphite  of  sodium  and  carbolic  acid,  given  in  such 
doses  and  at  such  intervals  as  will  most  rapidly  impregnate  the  blood  as  fully 
as  is  compatible  with  the  safety  of  the  patient.  In  two  cases  of  a  decidedly 
malignant  type  occurring  in  the  practice  of  the  late  Dr.  F.  H.  Uavis,  the 
following  foriuula  was  given  with  decided  benefit,  apparently  modifying 
the  condition  of  the  patients  to  such  a  degree  that  both  finally  recovered. 
In  another  case  to  which  I  was  called  during  the  past  year,  presenting  ex- 
tensive petechial  and  hasmorrhagic  symptoms,  the  patient  died  within  for- 
ty-eight hours  after  my  first  visit,  without  showing  any  apparent  effect  of 
remedies.     The  formula  I  have  used  is  as  follows: 

]^      Sodii  Hyposulphitis 
Acidi  Carbolici 
Aquae  Menthae, 

Mix.  Shake  the  vial  and  give  four  cubic  centimeters,  or  one  tea- 
spoonful,  in  a  tablespoouful  of  additional  water  every  one  or  two  hours 
until  some  effect  is  obtained,  and  then  lengthen  the  interval  between 
the  doses.  During  the  same  time  the  patient  may  be  supported  by  the 
taking  of  carbonate  of  ammonia  and  camphor,  and  the  use  of  nutritive 
enemas.  In  all  other  respects  these  cases  inay  be  treated  in  the  same 
manner  as  the    more  severe  variety  of  the    confluent  form. 

*  See  formula  on  page  116. 


25.0  grams 

3vj 

0.6       " 

grs. 

130.0  c.    c. 

!j^ 

SYMPTOMS.  219 


VARIOLOID. 


Soon  after  .the  introduction  of  .vaccination  as  a  preventive  of  variola, 
it  was  ascertained  tliat  a  small  proportion  of  those  who  had  taken  the  vac- 
cine, at  some  subsequent  period  when  exposed  to  the  contagion  of  vari- 
ola, took  the  disease,  but  always  had  it  in  a  modified  form,  being  shorter  in 
duration  and  in  all  respects  less  severe.  To  distinguish  these  cases  from 
those  of  unmodified  variola,  they  were  called  varioloid. 

You  will  understand,  therefore,  that  cases  of  varioloid  are  simply  cases 
of  small-pox,  rendered  milder  and  less  dangerous  to  the  patient  on  ac- 
count of  the  partial  protection  alforded  by  a  previous  vaccination.  All 
these  cases  are  caused  by  the  true  variolous  poison  or  virus;  and  no  matter 
how  mild  they  may  have  been  rendered  by  the  influence  of  the  previous 
vaccination,  they  are  all  capable  of  communicating  the  true  unmodified 
small-pox  to  any  unprotected  persons  with  whom  they  may  come  in  contact. 

Symptoms. — The  period  of  incubation  is  the  same  as  in  ordinary  vari- 
ola; and  all  the  symptoms  accompanying  the  onset  of  active  phenomena 
and  the  three  or  four  days  of  primary  fever,  are  the  same  as  in  the  corre- 
sponding stage  of  mild  or  discrete  small-pox.  The  eruption  also  appears 
during  the  night  of  the  third  or  morning  of  the  fourth  day,  and  presents 
the  same  hard,  papular  elevations,  with  minute  vesicles  at  the  apex,  and  is 
accomjjanied  by  an  entire  subsidence  of  the  general  febrile  symptoms. 
The  amount  of  the  eruption  varies  very  much  m  different  cases,  from  no 
more  than  five  or  six  pustules  in  some,  to  a  number  fully  equal  to  those  ac- 
companying the  iinmodified  discrete  variety  of  the  variola.  The  pustules, 
whether  many  or  few,  increase  in  size,  and  the  vesicles  become  first  flat- 
tened, slightly  urabilicated,  and  filled  with  clear  lymph;  then  are  attacked 
with  inflammation  and  suppuration,  but  less  severely,  and  accompanied  by 
less  tumefaction  and  less  secondary  fever  than  in  the  mildest  cases  of  the 
unmodified  disease.  Consequently  the  suppurative  stage  is  shorter,  many 
of  the  vesicles  failing  to  fill  up  with  matter,  and  the  whole  drying  up 
and  commencing  to  desquamate  in  from  seven  to  nine  days  after  the:r  ap- 
pearance on  the  surface.  From  the  mildness  of  many  of  these  cases,  and 
the  sparseness  of  the  eruption,  some  of  the  patients,  not  suspecting  the 
nature  of  their  sickness,  get  up  as  soon  as  the  primary  fever  is  passed, 
and  go  out  to  their  usual  places  of  business,  and  thereby  do  more  to  spread 
the  disease  than  any  other  class  of  subjects. 

I  have  known  several  cases,  in  which  individuals  after  suffering  severe 
pains  in  the  loins  and  back  with  some  general  fever  for  three  or  four  days, 
were  altogether  relieved  on  the  appearance  of  a  few  pimples  on  the  face  and 
neck,  but  not  liking  the  appearance  of  the  pimples,  have  gone  directly  to 
some  one  of  the  public  dispensaries,  and  in  two  instances  to  a  physician's 
office,  and  sat  in  the  midst  of  other  patients  in  the  waiting-room,  until 
their  time  came  for  examination.  It  is  by  such  means  that  many  individ- 
uals not  fully  protected,  come  in  contact  with  the  contagium  of  the  disease, 
and  take  it  without  the  slightest  knowledge,  on  their  part,  of  the  time  or 
place  of  their  exposure.  It  is  therefore  of  great  importance  that  all  cases 
of  varioloid,  however  slight,  should  be  recognized  early  and  subjected  to 
the  same  complete  isolation,  as  in  the  more  severe  cases  of  small-pox. 

Diagnosis. — The  sudden  development  of  unusual  pains  in  the  back  and 
loins  with  some  general  fever,  continuing  three  or  four  days,  and  disap- 
pearing on  the  appearance  of  distinct  hard  papules  with  minute  vesicles 
on  their  apex,  on  any  part  of  the  cutaneous  surface,  but  more  especially 
on  some  parts  of  the  face,  neck,  and  upper  part  of  the  chest,  constitute 
a  group  of  symptoms  following  each  other  in  such  order  as  to  make  them 


220  VACCINIA. 

reliably  diagnostic  of  variola  or  varioloid,  even  though  the  pustules  did 
not  exceed,  half  a  dozen    n  number. 

Prognosis. — The  prognosis  in  varioloid  is  favorable,  cases  very  rarely 
terminating  fatally,  unless  from  some  important  complication,  as  pneumo- 
nia, dysentery,  etc.  Indeed,  the  essential  idea  indicated  by  the  word  va- 
rioloid, is  a  modified  or  less  severe  form  of  variola.  And  a  case  which  is  so 
little  influenced  by  the  previous  vaccination  that  it  proceeds  to  a  fatal  result, 
from  its  own  gravity  would  certainly  be  more  properly  designated  as  va- 
riola than  as  varioloid. 

Treatment. — The  treatment  of  cases  of  varioloid  does  not  differ  in  any 
respect  from  that  required  by  mild  cases  of  variola.  The  same  care 
should  be  exercised  to  isolate  the  patient  ;  to  preserve  strict  cleanliness 
and  good  ventilation  of  the  sick  room  ;  to  adhere  to  a  plain,  simple  diet  ; 
and  use  only  such  medicines  as  may  be  required  to  regulate  the  bowels 
and  more  important  secretions,  and  to  remove  any  important  complica- 
tions that  may  arise. 

Prophylaxis. — Aside  from  strict  isolation  of  the  sick  and  the  preserva- 
tion of  good  sanitary  regulations,  the  principal  measure  relied  upon  for 
preventing  the  occurrence  of  both  variola  and  varioloid,  or  limiting  their 
spread  in  any  community,   is  vaccination. 

VACCINIA. 

By  vaccination  is  meant  the  introduction  through  the  skin,  of  a 
virus  originally  obtained  from  a  peculiar  sore  or  pustule  that  is  oc- 
casionally found  on  the  bidder  of  cows  ;  and  which  not  only  makes  a 
specific  local  pustule  at  the  point  of  introduction,  but  so  changes  the  con- 
dition of  the  whole  system  as  to  render  it  thereafter  incapable  of  being 
influenced  by  the  contagium  of  variola.  From  what  source  the  cow  be- 
came affected  with  the  vaccine  disease  is  not  known.  Some  writers  have 
claimed  that  it  was  from  the  disease  called  Grease  on  the  ankles  of 
horses,  and  that  it  was  communicated  to  the  udder  of  the  cow  by  the  hands 
of  milkmen  who  were  at  the  same  time  handling  the  horses  affected  with 
that  disease.  Others  have  claimed  that  the  pustules  on  the  cow  were 
simply  the  result  of  the  contagium  of  variola,  and  consequently  that  the 
virus  of  variola  and  vaccine  are  identical,  the  latter  having  been  ren- 
dered milder  in  its  properties  and  effects  by  its  passage  through  the  sys- 
tem of  the  cow.  Though  much  has  been  written  on  this  subject,  and 
manv  experiments  performed  to  prove  or  disprove  this  and  that  theory, 
the  real  origin  of  the  vaccine  disease  in  the  cow  has  not  been  ascertained 
with  any  reasonable  degree  of  certainty.  The  discovery  of  the  true  cow- 
pox  and  the  application  of  the  virus  found  in  the  pustules  on  the  udder 
of  the  cow  to  the  vaccination  of  man  for  destroying  his  susceptibility  to 
small-pox,  was  made  by  Dr.  Edward  Jenner,  a  surgeon  who  commenced 
practice  in  Berkeley,  Gloucestershire,  England,  in  1772.  His  attention  was 
arrested  by  the  remark  of  a  milk-maid,  to  the  effect  that  she  could  not 
take  the  small-pox  because  she  had  previously  had  a  sore  on  her  hand 
contracted  from  a  sore  on  the  udder  of  a  cow  while  milking.  This  led 
him  to  a  thorough  investigation  of  the  subject,  by  which  he  identified 
the  true  cow-pox  pustule  and  such  proofs  of  its  power  to  protect  those  in- 
dividuals from  small-pox  who  had  been  accidentally  inoculated  with  the 
virus  from  it,  that  he  felt  justified  in  trying  it,  first,  on  a  member  of  his 
own  family,  and  subsequently  on  others.  He  early  communicated  freely 
with  the  celebrated  John  Hunter  of  London  who  encouraged  him  to  con- 
tinue his    experiments.      This  he    did,  and    published    the    full  results  in 


HISTORY.  221 

1738.  The  same  year  Mr.  Cline  commenced  vaccinating  in  London  with 
the  matter  obtained  from  Dr.  Jeniier.  And  though  the  new  practice  ex- 
cited much  appreliension  and  some  intemperate  opposition  both  in  and 
out  of  the  profession,  yet  so  rapidly  were  its  benefits  demonstrated  by  act- 
ual experience,  that  in  two  short  years,  it  received  the  unequivocal  en- 
dorsement of  the  best  part  of  the  profession  in  London  and  other  parts 
of  England. 

The  next  year  after  Mr.  Cline  commenced  vaccinating  in  London,  the 
practice  was  initiated  in  Boston  by  Dr.  Benjamin  Waterhouse,  the  first 
professor  of  practical  medicine  in  the  medical  school  of  Harvard  Univer- 
sity. The  new  practice  met  here  the  same  opposition  and  prejudices  as  in 
London,  but  both  were  soon  overwhelmed  by  the  rapidly  accumulated 
proofs  of  its  safety  and  efficacy  as  a  preventive  of  variola.  Such  was  the 
origin  of  vaccination,  which  in  less  than  one  century  has  bestowed  upon 
our  race  an  amount  of  benefit  that  cannot  be  properly  expressed  in  either 
words  or  figures.  I  will  not  trespass  upon  your  time,  however,  to  enter 
upon  any  consideration  of  the  history  of  vaccination  since  the  days  of 
Dr.  Jenner,  but  assuming  that  it  affords  a  safe  and  reliable  mode  of  pre- 
venting one  of  the  most  destructive  and  loathsome  diseases  in  the  list 
of  acute  afi"ections,  I  will  call  your  attention  atoncetothe  following  ques- 
tions of  great  practical  importance  :  First,  what  are  the  characteristics 
of  the  genuine  vaccine  disease  as  developed  in  the  human  subject  by  vac- 
cination? Second,  what  is  the  best  method  of  procuring  and  preserving 
reliable  vaccine  virus  for  use  inordinary  practice?  Third,  in  what  man- 
ner and  at  what  times  should  vaccination  be  practiced  in  order  to  insure 
the  most  reliable  protection  from  variola? 

In  answer  to  the  first  question,  I  will  say  that  when  the  vaccine  matter 
is  introduced  into,  or  placed  in  contact  with  the  cutis  vera,  at  some  point 
on  the  cutaneous  surface,  there  is  no  appearance  of  active  influence  until 
some  time  between  the  beginning  of  the  fourth  and  sixth  days  ;  when 
there  appears  at  the  point  of  insertion  a  slightly  red  and  hard  elevation, 
which  in  twenty-four  hours  more  has  increased  in  circumference  and  de- 
veloped a  slightly  flattened  vesicle  on  its  surface.  Both  the  hard  base 
and  the  vesicle  continue  to  increase  in  size  (the  latter  becoming  indented 
or  umbilicated  in  the  centre),  for  about  four  days  after  their  first  appear- 
ance, during  which  time  the  vesicle  is  filled  with  transparent  lymph 
contained  in  several  distinct  compartments,  as  in  the  vesicles  of  variola. 
At  the  end  of  the  fourth  day  of  progress,  or  the  eighth  after  vaccina- 
tion, a  red  areola  appears  around  the  base  of  the  sore,  accompanied  by 
some  swelling,  heat  and  slight  pains,  with  a  slightly  turbid  appearance  of 
the  lymph. 

The  redness  and  tumefaction  increase  for  three  days  more,  accompa- 
nied byslight  general  fever;  sometimes  pains  in  the  head,  back  and  limbs  ; 
occasionally  swelling  of  the  glands  in  the  axilla  ;  and  always  a  more 
complete  conversion  of  the  contents  of  the  vesicle  into  a  thick  straw-col- 
ored pus.  At  the  end  of  this  time,  about  the  eleventh  day  after  the  vac- 
cination, the  pustule  or  pock  has  reached  its  full  maturity;  a  dark-brown 
spot  now  appears  in  the  center  of  the  sore  at  the  point  of  umbilication  ; 
the  redness  and  swelling  begin  to  abate  ;  the  general  feverishness  disap- 
pears ;  and  by  the  fifteenth  day,  a  dark-brown  thick  scab  has  taken  the 
place  of  the  vesicle.  Cicatrization  goes  on  under  this  scab,  and  somewhere 
between  the  twenty-first  and  the  twenty-fifth  days  it  is  completed  and 
the  dry  scab  falls  ofi",  leaving  a  concave  cicatrix  with  from  one  to  four  or 
five  distinct  depressions,  or  pits  as  they  are  generally  called.  The  pres- 
ence of  these  pits  or  indentations  in  the  cicatrix  is  permanent,  and  ever 


222  VACCINIA. 

afterwards  affords  proof  that  the  vaccine  sore  was  genuine.  The  forma 
tion  of  these  indentations  in  the  scar  resulting  from  a  true  vaccine  sore, 
maybe  prevented,  however,  by  unusually  deep  or  extensive  ulceration 
during  the  suppurative  stage  of  the  sore.  Consequently  their  absence 
from  the  scar  cannot  be  regarded  as  conclusive  evidence  that  the  vaccina- 
tion'was  spurious.  You  will  see  by  the  description  I  have  given,  that  a 
true  vaccine  sore  or  pustule  develops  in  the  same  manner  and  passes 
through  the  same  stages  as  the  pustule  of  variola,  differing  chiefly  in  the 
attainment  of  a  much  larger  size  than  any  single    pustule  of  the    latter. 

On  the  contrary,  the  sores  produced  by  the  use  of  spurious  vaccine  matter, 
commence  sooner  after  its  introduction,  run  their  course  more  rapidly  to 
the  suppurative  stage,  seldom  present  any  distinct  umbilication,  and 
either  dry  up  early  and  leave  a  smooth  cicatrix,  or  extend  the  suppurative 
stage  into  a  large  spreading  ulcer  with  an  abundant  formation  of  thin 
pus,  and  no  disposition  to  cicatrize.  Sometimes,  though  rarely,  the  prog- 
ress of  true  vaccination  is  accompanied  by  a  scattering  eruption  of  small 
vaccine  pustules  on  different  parts  of  the  surface.  These  pass  through 
the  same  stages  and  disappear  with  the  parent  sore. 

Methods  of  procuring  and  preserving  the  vaccine  matter  for  use  are 
numerous,  and  each  has  its  advocates.  Until  a  recent  date  the  disease 
was  propagated  exclusively  by  taking  the  matter  from  the  vaccine  pustule 
on  the  arm  of  one  individual  to  vaccinate  others,  thereby  extending  it 
from  individual  to  individual  by  what  is  now  called  humanized  virus. 

Many  preferred  to  use  the  transparent  lymph  obt lined  from  the  vac- 
cine vesicle  just  before  the  commencement  of  the  suppurative  stage. 
By  pricking  the  vesicle  at  this  stage  the  drops  of  lymph  that  ooze  out 
may  be  received  on  quill  or  ivory  points,  allowed  to  dry  on,  the  same  en- 
veloped in  a  little  cotton,  and  kept  in  a  dry,  well-stopped  vial  until  needed 
for  use.  The  leading  objection  to  this  method  is,  that  the  virus  is  so  much 
exposed  to  the  air  that  it  will  retain  its  activity  but  a  brief  period  of  time. 
Another  method  consists  in  receiving  the  lymph,  at  the  same  stage  of  the 
vaccine  vesicle,  into  capillary  glass  tubes,  hermetically  sealing  them,  until 
needed  for  use.  By  this  method  the  virus  may  be  preserved  active  for 
a  long  period  of  time,  provided  the  tubes  remain  unbroken,  and  are  not 
exposed  to  too  great  extremes  of  temperature.  In  this  country  perhaps  the 
larger  number  of  practitioners  have  preferred  to  let  a  genuine  vaccine 
pustule  complete  its  course  unbroken,  until  cicatrization  is  complete  and 
the  dry  scab  is  loosened  and  ready  to  fall  off.  The  dry  scab  is  then  taken, 
allowed  a  few  hours  for  f\irther  drying,  and  preserved  for  use  in  one  of  the 
following  modes:  First,  the  dry  scab  maybe  immediately  wrapped  in 
tin  foil  and  inclosed  in  the  center  of  a  ball  of  white  wax.  This  excludes 
nearly  all  the  air  and  is  capable  of  preserving  the  active  properties  of  the 
scab  several  weeks.  Second,  the  dry  scab  is  comminuted  or  broken  up 
and  mixed  with  pure  glycerine,  which  is  capable  of  dissolving  the  active 
principle  of  the  scab,  and  if  the  vial  is  kept  well  stopped,  and  secluded 
from  the  light,  preserving  it  active  for  an  indefinite  length  of  time.  One 
fresh  ordinary  sized  scab  is  capable  of  impregnating  from  one  to  two 
drams  of  glycerine.  Third,  a  fully  matured  and  dry  scab  may  be  cut  in- 
to four  pieces,  each  piece  closely  enveloped  in  foil,  and  one  of  them 
placed  in  the  center  of  a  ball  of  white  wax  for  immediate  use,  while  each 
of  the  other  three  should  be  placed  in  glass  tubes  hermetically  sealed  at 
one  end,  the  air  mostly  expelled  by  a  moderate  heat  and  the  other  end 
sealed  quickly,  and  kept  secluded  from  light  or  high  heat  until  needed 
for  use.  When  needed,  the  tube  is  broken  and  the  inclosed  piece  of  scab 
transferred  to  the  ball  of  wax  as  already  mentioned.     This  can    be  open- 


BOVINE  VIRUS.  223 

pd,  a  part  of  the  seal.)  shaved  off  on  a  clean  piece  of  glass,  and  the  rest 
returned  to  the  wax  enclosure,  as  often  as  a  person  is  presented  for  vacci- 
nation, until  i.t  is  all  used,  or  by  time  and  repeated  exposure  to  the  air, 
its  active  properties  have  been  lost.  If  the  general  practitioner  will  see 
that  every  baby  born  within  the  circle  of  his  practice,  is  properly  vacci- 
nated between  the  ages  of  four  and  eighteen  months,  he  can  easily  select 
scabs  enough  from  the  arms  of  strictly  healthy  children,  to  keep  his  sup- 
ply good,  if  prepared  in  the  manner  last  indicated.  It  is  the  method  that 
1  have  practiced  for  more  than  thirty  yeais  with  almost  uniform  success, 
and  without  any  bad  results.  The  scab  should  be  allowed  to  fully  mature 
on  the  arm,  and  should  be  selected  only  from  strictly  healthy  children 
undergoing  a  primary  vaccination.  Until  1866,  the  humanized  virus,  ob- 
tained and  preserved  in  some  one  of  the  ways  just  mentioned,  was  solely 
relied  on  by  the  profession  for  vaccination.  At  that  date  a  case  of  spon- 
taneous vaccinia  or  cow-pox,  was  discovered  at  Beaugency,  in  France, 
and  the  virus  obtained  from  that  case  was  carefully  multiplied  and  prop- 
agated by  successive  vaccinations  from  one  heifer  to  another,  under  the 
direction  of  M.  Depaul,of  the  French  Academy  of  Medicine.  The  work 
was  sanctioned  by  the  Academy  and  aided  by  the  French  government. 

The  fresh  virus  thus  obtained  was  used  for  human  vaccinations,  under 
the  name  of  bovine  or  non-humanized  virus. 

In  1870,  virus  from  this  stock  was  obtained  by  Dr.  Henry  A.  Martin, 
of  Boston,  who  immediately  commenced,  and  still  continues,  its  careful 
propagation  from  heifer  to  heifer,  and  from  whose  establishment  near 
Boston,  large  quantities  of  the  virus  have  been  furnished  to  the  profession 
in  all  parts  of  the  country,  and  extensively  used  as  a  substitute  for  the 
humanized  virus  previously  so  universally  depended  iipon. 

The  demand  for  the  bovine  virus  increased  so  rapidly  that  several  other 
establishments  for  its  propagation  have  been  started  in  different  parts  of 
the  country,  the  virus  from  which  appears  at  present,  to  be  wholly  super- 
seding that  obtained  from  the  human  subject.  The  impression  has  be- 
come quite  general,  that  the  protective  influence  of  the  bovine  is  superior 
to  that  of  the  humanized  virus.  I  am  constrained  to  say,  however,  that 
I  deem  the  evidence  on  this  point  by  no  means  conclusive.  That  the 
fresh  bovine  virus  furnished  from  the  propagating  establishments  gener- 
ally produces  a  larger  vaccine  sore,  more  intense  local  inflammation,  and 
more  specimens  of  large,  open  ulcers,  slow  to  heal,  I  think  is  fully  proved 
by  the  experience  of  the  profession  in  this  city.  I  have  certainly  seen  a 
larger  number  of  such  results  in  the  last  two  years,  during  which  the  bo- 
vine virus  has  been  so  extensively  used  in  this  city,  than  during  all  the 
years  of  my  professional  life  previously.  This,  however,  is  no  proof  that 
the  protective  influence  is  greater,  or  more  permanent. 

Indeed,  if  you  remember  that  it  is  only  eleven  years  since  Dr.  Martin 
introduced  and  commenced  the  propagation  of  the  Beaugency  stock  of 
virus  in  this  country,  you  will  readily  perceive  that  the  time  since  the  first 
vaccinations  with  it,  has  not  been  sufficient  to  afford  an  opportunity  to 
make  any  deductions  concerning  the  comparative  durability  of  its  effects. 
I  can  find  nothing  in  the  known  laws  governing  the  development  of  or- 
ganic matter,  which  would  explain  why  a  particular  specific  virus  should 
deteriorate  anymore  by  transmission  from  one  child  to  another,  than  from 
one  heifer  to  another.  And  as  a  matter  of  clinical  experience,  I  must 
say  that  I  have  discovered  no  difference  whatever  between  the  degree  of 
protection  afforded  by  a  genuine  vaccination  with  humanized  virus  now, 
and  fifty  years  ago.  During  that  whole  period  I  have  not  known  a  single 
instance  where  a  successful  vaccination  with  matter  taken  from  a  genuine 


224  VACCINIA. 

vaccine  pustule  resulting  from  a  primary  vaccination,  has  not  afforded  full 
protection  for  at  least  a  term  of  ten  or  fifteen  years.  I  say  matter  from 
a  pustule  resulting  from  a  primary  vaccination,  because  I  am  well  satis- 
fied that  all  the  deterioration  which  has  taken  place  in  the  humanized 
virus  since  the  days  of  Jenner,  has  resulted  from  the  use  of  lymph  or 
scabs  taken  from  secondary  vaccinations,  or  imperfect  vaccine  sores,  and 
which  may  be  regarded  as  bearing  the  same  relation  to  the  primary  vac- 
cination that  varioloid  does  to  variola. 

From  a  full  consideration  of  this  important  subject,  I  am  satisfied  that 
the  safest  and  best  course  for  every  practitioner  to  pursue  is,  to  procure  a 
supply  of  fresh  bovine  virus,  select  a  healthy  child  between  two  and  five 
years  of  age,  never  before  vaccinated,  introduce  the  fresh  virus  at  the 
proper  place  on  the  arm,  and  if  a  good  characteristic  vaccine  sore  is  pro- 
duced, let  it  run  its  complete  course  undisturbed,  and  when  the  dry  scab 
begins  to  loosen,  take  it  off,  leave  it  exposed  to  the  air  a  few  hours  until 
more  perfectly  dry;  then  take  one-quarter  of  it  for  immediate  use,  en- 
closed in  foil  and  wax,  as  already  described,  and  put  each  of  the  other 
quarters  into  as  many  glass  tubes,  hermetically  sealed  for  longer  preserva- 
tion as  reserve  stock. 

Let  him  make  it  a  rule  of  professional  life  to  see  that  every  child  born 
within  the  circle  of  his  practice,  is  vaccinated  with  the  matter  he  has  in 
store,  and  as  often  as  he  finds  a  healthy  child  from  healthy  parents,  save 
the  vaccine  scab  and  treat  it  as  just  described,  and  he  will  not  only  be 
able  to  keep  his  stock  good  for  five  or  ten  years  at  a  time,  but  he  will 
have  the  satisfaction  of  affording  the  highest  degree  of  protection  to  those 
who  depend  upon  him  as  a  medical  adviser,  with  the  smallest  number  of 
casualties  or  bad  results.  If  by  some  chance  his  stock  fails,  immediately 
procure  a  fresh  supply  and  commence  the  work  of  independent  propaga- 
tion anew.  While  I  have  no  hesitation  in  recommending  this  as  the  safest 
and  most  reliable  course  for  every  general  practitioner  to  pursue,  the 
demands  of  public  institutions  and  municipal  health  boards,  will  make 
the  continuance  of  a  few  well-conducted  establishments  for  propagating 
the  bovine  virus  not  only  a  convenience,  but  a  public  necessity,  even  if 
they  should  require  governmental  aid  and  regulation.  And  this  brings 
me  to  the  third  and  last  question,  namely,  in  what  manner  and  at  what 
times  should  vaccination  be  practiced?  I  know  of  no  simpler  or  better 
mode  of  practicing  vaccination  than  to  very  lightly  scarify  one  or  more 
places  on  the  arm  near  the  insertion  of  the  deltoid  muscle,  on  which  the 
vaccine  matter  should  be  placed  in  a  liquid  or  moist  condition.  The  best 
instrument  for  the  purpose  is  a  sharp  pointed  knife  or  lancet,  and  the 
scarifications  should  be  so  directed  as  to  scrape  off*  the  cuticle,  carrying 
the  incisions  just  deep  enough  to  make  the  blood  visible  without  causing 
it  to  start  out  in  drops. 

If  you  have  the  virus  on  quill  or  ivory  points,  these  should  be 
moistened  with  clean  water  when  you  commence  to  scarify,  and  then 
rubbed  freely  into  the  scarified  place.  If  you  use  the  dry  scab,  a  small 
part  of  this  should  be  shaved  off"  on  a  clean  piece  of  glass  or  earthen,  and 
rubbed  up  with  just  water  enough  to  moisten  and  dissolve  it,  then  taken 
up  on  the  point  of  the  knife  and  placed  on  the  scarified  spot,  and  rubbed 
or  pricked  into  it  with  due  care.  After  the  matter  is  introduced,  it  should 
be  left  uncovered  until  entirely  dry,  and  then  covered  only  by  the  ordin- 
ary clothing. 

Some  statistics  have  been  published  which  seem  to  indicate  that  the  de- 
gree and  duj-ability  of  the  protection  from  vaccination  depends  in  some 
measure  on  the  number  of  vaccine  sores  made  on  the  arm.     Consequently 


VAKICELLA.  225 

it  has  become  a  common  practice  to  scarify  two,  three  and  sometimes  four 
places  on  the  arm,  thereby  produsing  a  correspondino-  number  of  sores. 

So  far  as  these  statistics  have  come  under  my  observation,  they  are  too 
meagre  in  amount,  and  unaccompanied  by  certain  collateral  observations 
which  are  essential  to  give  them  value.  For  instance,  each  case  should 
be  accompanied  by  the  age  at  which  the  vaccination  took  place,  and  the 
number  of  years  intervening  between  the  latter  and  the  time  of  taking  the 
variola.  In  vaccinating  infants  under  one  year,  I  would  make  but  one 
sore.  In  older  children  and  adults,  it  may  be  well  to  make  two  points  of 
insertion.  In  regard  to  the  times  at  which  vaccination  should  be  practiced, 
all  agree  that  every  child  living,  and  in  ordinary  health,  should  be  vac- 
cinated, if  possible,  between  the  ages  of  six  and  eighteen  mouths.  The 
operation  should  be  considered  of  sufficient  importance  to  receive  the  care- 
ful attention  of  the  physician,  and  it  would  be  better  if  its  efficiency  should 
be  tested  by  a  second  vaccination,  one  or  two  months  after  the  first. 

Having  thus  secured  a  genuine  and  efficient  vaccination  in  infancy, 
there  is  no  need  of  repeating  it  until  the  child  has  arrived  at  maturity  of 
growth,  between  eighteen  and  twenty-five  years  of  age.  Then  the  vac- 
cination should  be  repeated,  and  tested  with  the  same  care  as  at  the  first.  I 
think  thorough  vaccinations  with  virus  of  known  active  qualities,  at  the 
two  periods  named,  is  sufficient  for  the  whole  life-time,  except  in  those  in- 
dividuals, who,  after  the  second  vaccination,  have  suifered  some  attack  of 
disease,  v^^hereby  their  tissues  become  so  wasted,  that  the  repair  is  almost 
equal  to  a  new  growth,  or  have  made  a  radical  and  permanent  change  of 
climate. 

Such  exceptional  cases  should  be  vaccinated  a  third  time,  after  the 
changes  mentioned  have  taken  place.  While  these  are  all  the  vaccinations 
I  deem  necessary  for  the  safety  of  the  individuals  and  of  the  commu- 
nities, provided  they  are  done  with  proper  care,  and  with  virus  known  to  be 
genuine  and  active,  yet  every  physician  is  justified  in  vaccinating  his  pa- 
trons as  much  oftener  as  they  desire,  provided  their  fears  can  not  be  allayed 
without  so  doing. 


LECTURE  XXV. 

Varicella— Its  Symptoms.  Diagnosis  and  Treatment.    Su.lamina— Scarlatina— Its  Historv,  Symp- 
toms aai  diagnosis. 

GENTLEMEN:  I  shall  first  occupy  your  attention  with  the  consideration 
of  varicella  or  chicken-pox.  The  name,  varicella,  literally  means  little 
small-pox^  and  was  adopted  in  the  early  period  of  medical  history,  when 
the  disease  was  very  generally  regarded  as  a  modified  form  of  the  variola. 
That  it  is  entirely  distinct  and  unconnected  with  small-pox,  however, 
is  proved  by  the  following  facts  :  The  period  of  incubation  is  longer  ;  the 
primary  fever  before  the  eruption  is  shorter  ;  the  eruption  is  purely  vesic- 
ular, instead  of  pustular,  and  completes  its  course  in  much  less  time,  and 
one  attack  of  varicella  affords  no  protection  against  subsequent  attacks  of 
variola,  neither  does  one  attack  of  variola  or  of  vaccinia,  afford  any  protec- 
tion against  varicella. 

is 


226  VAEICELLA. 

It  prevails  chiefly  in  epidemic  form,  and  almost  exclusively  amono^  chil- 
dren and  youth,  though  it  sometimes  occurs  during  adult  life. 

It  is  contagious  or  communicable  from  one  child  to  another,  and  rarely 
attacks  the  same  patient  more  than  once.  Most  of  the  attempts  to  prop- 
agate the  disease  by  inoculation  have  failed.  Its  period  of  incubation  is 
stated  variously  by  different  writers.  By  some  it  is  placed  from  twelve  to 
seventeen  days  (Flint);  by  others  as  short  as  from  four  to  five  days 
(Hartshorne).  The  primary  or  premonitory  fever  is  only  one  day,  and  is 
so  slight  as  not  to  attract  any  attention  in  many  cases  until  the  eruption 
begins  to  appear.  In  other  cases  it  is  sufficient  to  cause  two  or  three  de- 
grees elevation  of  temperature;  slight  increase  in  the  frequency  of  the 
pulse,  with  aching  pains  in  the  head,  back  and  limbs,  and  some  restless- 
ness. The  eruption  begins  on  the  second  day,  and  is  often  the  first  thing 
to  attract  the  attention  of  the  patient  or  of  those  about  him.  It  generally 
appears  first  on  the  body,  and  quickly  extends  to  the  neck  and  scalp,  the 
vesicles  being  scattered  or  widely  separated  from  each  other,  and  new 
ones  continue  to  appear  for  two  or  three  days,  during  which  time  the  gen- 
eral febrile  symptoms  disappear.  The  vesicles  constituting  the  erup- 
tion vary  in  size  from  that  of  a  pin's  head  to  the  circumference  of  a  large 
pea.  They  are  preceded  for  a  few  hours  by  a  simple  red  or  rose-colored 
spot  on  the  surface,  without  hardness  or  elevation,  and  soon  give  place  to 
the  vesicle,  which  attains  its  full  size  in  a  single  day,  is  filled  with  trans- 
parent lymph,  and  by  the  third  day  has  commenced  to  shrivel  or  dry  up, 
without  any  decided  areola  of  redness  around  it,  and  without  suppuration 
-or  tumefaction  of  the  surface.  The  scab  formed  is  th-n,  light-colored, 
:and  falls  off,  leaving  no  permanent  cicatrix  or  indentation.  The  whole 
•course  of  the  disease  is  usually  completed  in  from  seven  to  nine  days. 
The  disease  is  so  brief  and  mild  in  its  character  as  to  require  little  or 
.no  professional  attention. 

J) ia gnosis. — The  chief  interest  attached  to  it  relates  to  a  proper  diag- 
nosis between  it  and  the  other  eruptive  fevers.  The  only  one  of  these 
with  which  it  could  be  confounded  without  great  carelessness,  is  varioloid. 
,But  if  you  remember  that  the  primary  fever  in  both  variola  and  varioloid 
is  three  days,  and  is  of  considerable  severity,  and  that  the  eruption  is  in 
both  always  papular  and  elevated,,  with  only  a  minute  vesicle  on  the  point 
of  the  papule,  while  in  varicella  the  primary  fever  is  so  slight  as  to  at- 
tract but  little  attention;  and  that  the  eruption  appears  on  the  first  or  sec- 
ond day,  and  is  a  simple,  plain  vesicle  filled  with  transparent  lymph,  with- 
out any  hard  base,  without  umbilication  or  indentation  in  the  center;  and 
that  it  beoiiis  to  shrivel  or  dry  up  without  inflammation  in  three  days; 
you  can  hardly  fail  to  distinguish  the  varicella  from  the  varioloid  and  vari- 
ola. Still  greater  is  the  contrast  between  the  fair-sized,  prominent  ves- 
icle of  varicella,  and  the  small  red  points  constituting  the  eruptions  of 
scarlatina  and  measles. 

Treatment. — A  very  large  majority  of  the  cases  of  varicella  need  only 
hygienic  management;  rest,  a  mild,  simple  diet,  and  the  m^iintenance  of 
a  comfortable  temperature,  with  proper  ventilation,  and  cleanliness,  are 
all  that  is  necessary.  In  a  very  few  of  the  more  severe  cases,  it  may  be 
better  to  act  gently  on  the  secretions  and  promote  regular  intestinal  evac- 
uations, by  giving  the  patients  moderate  doses  of  the  bi-tartrate  of  potas- 
sium dissolved  in  cold  water,  with  a  little  sugar.  If  four  grams  (3i)  of 
the  bi-tartrate  are  dissolved  in  an  ordinary  sized  tumbler,  full  of  cold 
water,  and  a  little  sui^ar  added  to  render  it  palatable,  from  four  to  sixteen 
cubic  centimeters  may  be  taken  every  three  hours  during  the  day,  the 
■dose   being  varied  in   accordance   with  the  age  of  the  patient.     If  at  any 


SUDAMIXA  AND  SCAKLATIXA.  227 

time  tlie  bowels  become  too  loose,  a  moderate  dose  of  the  compound 
powder  of  opium  and  ipecacuanha,  may  be  g^iven  at  nig'ht,  and  it  will  both 
correct  the  Looseness  and  promote  sleejo.  No  important  sequelae  follow 
attacks  of  varicella. 

SUDAMINA. 

There  is  no  distinct  form  of  febrile  disease  called  sudamina;  but  the 
name  is  applied  to  an  eruption  of  very  small,  white,  or  silver-colored  ves- 
icles that  sometimes  appear  on  the  skin  during  the  progress  of  many 
febrile  diseases;  more  especially  those  cases  which  are  characterized  by 
copious  and  protracted  sweating.  Their  appearance  is  generally  limited 
to  the  trunk  of  the  body  and  lower  part  of  the  neck.  The  vesicles  are 
usually  not  more  than  one  line  in  diameter,  filled  with  perfectly  transpar- 
ent fluid,  and  pretty  closely  aggregated,  but  they  are  so  small  and  color- 
less that  their  presence  is  easily  overlooked.  The  contents  of  the  vesicles 
give  an  acid  reaction,  and  contain  chlorides.  They  give  no  uneasiness  to 
the  patient,  and  usually  shrivel  up  and  disappear  in  from  three  to  five 
days,  M'ith  roughness  from  desquamation  of  the  cuticle.  They  are  most 
freciuently  seen  in  those  cases  of  acute  rheumatic  fever,  accompanied  by 
continuous  sweating,  and  in  such  cases  of  typhoid  and  typhus  as  present 
the  same  symptom  for  one  or  more  days  at  a  time.  Indeed,  the  eruption 
appears  to  be  caused  by  excessive  perspiration,  especially  of  an  acrid  or 
sour  reaction,  and  the  fluid  in  the  vesicles  appears  like  retained  perspira- 
tion.    No  treatment  is  needed  for  this  form  of  eruption. 

SCARLATINA. 

I  come  now  to  consider  the  exanthematous  group  of  eruptive  fevers. 
The  most  important  of  these  is  scarlatina,  or  scarlet  fever,  as  it  is  famil- 
iarly termed. 

History. — A  careful  reading  of  the  histories  of  epidemics,  in  wbicb  cu- 
taneous eruptions  and  inflammations  of  the  throat  and  glands  of  the  neck 
were  prominent  symptoms,  of  which  there  were  many  in  different  parts 
of  Europe  during  the  first  five  or  six  centuries  of  the  Christian  Era,  leaves 
no  doubt  but  that  scarlet  fever  constituted  a  part  of  several  of  these  epi- 
demics. It  was  not  differentiated  from  measles,  roseola,  and  some  forms 
of  angina  until  the  middle  of  the  sixteenth  century.  In  1556  Ph.  In- 
gracsias  published  an  account  of  an  epidemic  in  Italy,  under  the  name  of 
roseola^  which  was  plainly  identical  with  the  scarlatina  of  our  time.  The 
disease  prevailed  with  considerable  severity  in  London,  from  ]661  to  1675, 
and  was  very  accurately  described  by  Sydenham,  under  the  name  of 
"  Febris  Scarlatina,"  in  a  paper  published  in  1676.  Since  that  time  it  has 
prevailed  to  some  extent  in  all  the  countries  of  Europe,  and  has  extended 
to  some  parts  of  Asia,  Africa  and  America.  Its  periods  of  epidemic  prev- 
alence usually  continue  from  one  to  three  years,  especially  in  large  cities, 
with  intervals  of  from  three  to  five  years  of  comparative  exemption. 
Throughout  the  temperate  zone  its  greatest  prevalence  is  generally  in  the 
transition  seasons,  spring  and  autumn,  though  no  part  of  the  year  is 
exempt  from  a  liability  to  its  prevalence.  It  often  prevails  coincidently 
with  diphtheria  in  the  same  communities  ;  and  sometimes,  though  rarely, 
some  of  the  more  prominent  symptoms  of  both  diseases  are  found  existing 
in  the  same  patient.  For  instance,  the  inflamed  surface  of  the  fauces  and 
tonsils  may  present  a  well  marked  diphtheritic  coating,  while  the  cuta- 
neous surface  is  covered  with  an  exanthematous  eruption  identical  with 
scarlet  fever.     A  large  majority  of  the  cases  of  scarlatina  occur  between 


22S  SCAKLATINA. 

the  ages  of  two  and  six  years.  After  six  or  seven  years  of  age  the 
susceptibility  to  the  disease  diminishes  as  the  ao;e  increases.  Yet  rare 
cases  have  occurred  in  a  few  weeks  afterbirth  and  in  old  age.  One  attack 
of  the  disease  so  far  removes  the  susceptibility  to  future  attacks,  that  very 
few  children  have  the  disease  a  second  time. 

Si/mjytojyis. — After  a  period  of  incubation,  averaging  from  five  to  seven 
days,  the  active  symptoms  of  scarlet  fever  usually  commence  abruptly, 
without  having  been  preceded  by  any  prodromic  or  forming  stage.  The 
child  is  first  seen  to  turn  pale,  and  seek  its  mother's  lap  or  lie  down  on 
the  floor,  or  on  whatever  is  most  convenient,  and  soon  vomits  sufficiently 
to  reject  whatever  was  contained  in  the  stomach  at  the  time.  Sometimes 
the  vomiting  is  accompanied  by  slight  rigors,  which  last  for  a  few  minutes 
only  and  give  place  to  a  rapid  access  of  general  fever.  The  face  becomes 
flushed,  the  skin  hot  and  dry,  the  pulse  and  respiration  accelerated  in 
frequency,  the  urine  scanty  and  high  colored,  the  bowels  natural,  with  a 
blush  of  deep  redness  in  the  membrane  covering  the  fauces  and  tonsils, 
and  a  sense  of  stiffness  or  soreness  behind  the  angles  of  the  jaw,  causing 
some  pain  in  deglutition,  and  frequent  turns  of  restlessness.  These 
symptoms  usually  continue  about  thirty-six  hours  before  the  eruption  or 
rash  appears  on  the  skin,  constituting  the  stage  of  primary  or  premonitory 
fever.  In  mild  cases  the  symptoms  just  enumerated  are  moderate,  and 
the  temperature  does  not  rise  above  39°  C.  (103°  F.),  and  are  not 
accompanied  by  any  notable  swelling  of  the  glands  of  the  neck. 

During  the  latter  part  of  the  second  day,  a  fine  red  efiiorescence  or  rash 
begins  to  show  itself;  first  on  the  face,  neck  and  upper  part  of  the  chest, 
which  extends  downward  over  the  trunk  of  the  body  and  extremities  in 
about  twenty- four  hours,  so  that  by  the  end  of  the  third  day  the  whole  sur- 
face is  covered  with  a  tine  red  rash,  pretty  evenly  diffused,  and  consisting  of 
small  red  points,  neither  hard  nor  elevated  so  as  to  be  perceptible  to  the 
touch,  and  without  the  slightest  appearance  of  vesicles.  The  rash  rather 
increases  in  redness  for  three  days,  or  until  the  fifth  day  from  the  com- 
mencement of  sickness,  when  the  whole  cutaneous  surface  presents  a  bright 
red  and  finely  dotted  appearance,  and  the  general  febrile  symptoms  have 
reached  their  maximum  of  intensity.  From  this  time  the  rash  begins  to 
fade  and  the  general  febrile  symptoms  to  abate,  and  in  from  two  to  three 
days  more  both  have  disappeared,  leaving  the  patient  convalescent  in  from 
seven  to  nine  days  from  the  commencement  of  the  disease.  During  the 
decline  of  the  rash,  there  is  much  prickling  and  itching  in  the  surface, 
which  becomes  rough  I'rora  the  gradual  exfoliation  of  the  cuticle.  When 
the  disease  runs  the  simple  course  I  have  now  indicated,  it  is  called  by 
most  writers  scarlatina  simplex.  In  a  more  severe  form  of  the  disease, 
the  mode  of  access  is  the  same,  but  all  the  symptoms  accompanying  the 
primary  fever  are  more  intense,  the  temperature  often  rising  to  40°  or  41° 
C.  (104°  to  10G°  F.),  the  pulse  ranging  from  110  to  130  per  minute,  with 
a  proportionate  increase  in  the  frequency  of  respiration,  and,  in  addition, 
the  fauces  and  tonsils  become  more  red  and  swollen,  with  rapid  swelling 
and  tenderness  of  the  glands  behind  and  below  the  angle  of  the  jaw, 
causing  difficulty  and  pain  in  swallowing,  and  adding  much  to  the  restless- 
ness of  the  patient. 

The  characteristic  eruption  or  rash  appears  first  on  the  face  and  neck, 
about  the  end  of  the  second  day,  and  increases,  as  already  described,  pari 
passu,  with  a  continued  increase  in  the  inflammation  and  tumefaction  in  the 
fauces  and  glands  of  the  neck,  and  the  maintenance  of  the  general  febrile 
phenomena  until  the  beginning  of  the  fifth  day.  From  this  time  the  rash 
begins  to  fade  and  disappears,  leaving  the  skin   rough  from  exfoliation  of 


SYMPTOMS.  229 

the  cuticle  between  the  seventh  and  ninth  days,  as  in  the  scarlatina  sim- 
plex. But  on  the  fifth  day,  when  the  rash  begins  to  fade,  the  inflauimation 
in  the  fauces  and  glands  of  the  neck  has  only  reached  its  climax.  The  se- 
cretion from  the  inflamed  mucous  membrane,  which  up  to  this  time  had  been 
transparent  and  tenacious,  adding  much  to  the  embarrassment  of  breath- 
ing, and  causing  occasional  paroxysms  of  coughing,  now  becomes  more 
opaque  and  abundant,  and  the  membrane  itself,  especially  over  the  tonsils 
and  folds  of  the  palate  becomes  ulcerated,  and  the  glands  and  tissues  be- 
hind the  angles  of  the  jaw  remain  swollen  and  hard,  making  it  difficult  to 
open  the  mouth  wide  enough  to  permit  an  examination  of  the  throat,  and 
equally  difficult  to  administer  medicine  or  nourishment.  The  local  inflam- 
mations cause  the  pulse  to  remain  frequent,  but  soft,  and  the  temperature 
above  the  natural  standard,  and  add  much  to  the  exhaustion  of  the  patient. 
But  in  a  considerable  proportion  of  these  cases,  after  the  end  of  the  first 
week,  the  swelling  of  the  glands  slowly  diminishes,  the  ulcerations  in  the 
fauces  and  throat  cease  to  spread  and  gradually  take  on  a  reparative  ac- 
tion, and  by  the  end  of  the  second  week,  convalescence  is  fairly  establish- 
ed. In  cases  a  little  more  severe,  the  inflammation,  about  the  fifth  or  sixth 
day,  extends  from  the  fauces  into  the  posterior  nares,  and  soon  involves  the 
whole  Schneiderian  membrane,  obstructing  the  nostrils  and  causing  a  mu- 
co-purulent  discharge,  sometimes  offensive,  and  adding  much  to  the  dis- 
comfort of  the  patient.  During  the  same  time,  in  a  smaller  number  of 
cases,  the  inflammation  extends  through  the  eustachian  tube  to  the  middle 
ear,  causing  pain,  suppuration,  perforation  of  the  tympanum  and  purulent 
discharge  from  the  external  meatus. 

In  a  large  proportion  of  these  cases,  if  recovery  from  the  acute  general 
disease  takes  place,  there  remains  a  chronic  otitis  vpith  permanent  im- 
pairment of  hearing.  In  many  of  the  cases  presenting  severe  inflammation 
in  the  throat,  glands  of  the  neck,  nostrils  and  ears,  the  respiration  and 
deglutition  become  so  much  obstructed  that,  somewhere  between  the  fifth 
and  ninth  days,  the  pulse  becomes  very  small,  frequent  and  feeble  ;  res- 
piration irregular  and  frequent  ;  the  temperature  high  ;  urine  very  scanty 
and  often  albuminous  ;  the  mind  dull  and  inclined  to  sleep,  but  often 
roused  to  paroxysms  of  great  restlessness  by  the  obstruction  in  the  throat; 
soon  the  hands  and  feet  begin  to  feel  cold  and  look  leaden  color  or  purple; 
and  the  patient  dies  apparently  from  exhaustion.  In  some  of  this  class 
of  cases,  gangrene  attacks  the  tonsils  and  other  more  intensely  inflamed 
parts  of  the  fauces,  causing  the  breath  to  be  very  offensive,  and  adding  to 
the  rapidity  of  the  exhaustion.  All  the  cases  accompanied  by  the 
different  degrees  of  inflammation  and  tumefaction  of  the  glands  of  the 
neck,  as  I  have  just  described,  are  included  by  writers  under  the  head  of 
scarlatina  anginosa.  In  nearly  all  of  the  more  severe  epidemics  of 
scarlatina,  cases  are  met  with  in  which,  from  the  very  beginning  of  active 
symptoms,  the  pulse  becomes  extremely  frequent  and  feeble;  the  temper- 
ature from  41°  to  43°  C.  (106°  to  110°  F.)  ;  respiration,  irregular  and 
panting,  like  one  tired;  the  surface  more  or  less  congested  and  sometimes 
mottled  with  purplish  spots  ;  the  extremities  cool  and  blue  or  leaden  color; 
the  mind  dull  and  sometimes  incoherent,  w^ith  paroxysms  of  great  restless- 
ness; and,  in  some,  there  is  swelling  of  the  glands  of  the  neck,  and  in  others 
none.  In  most  of  these  cases  the  characteristic  exanthem  or  rash  makes 
its  appearance  on  the  evening  of  the  second  day,  and  is  often  accom- 
panied by  petechial  spots,  increasing  exhaustion  and  death  between  the 
third  and  fifth  days.  I  have  seen  a  few  cases  in  which  death  took 
place  in  from  twenty-four  to  thirty-six  hours  after  the  initial  symptoms. 
The  cases  presenting  the  symptoms  just  detailed  present  all  the  character- 


230  SCAPvLATINA. 

istics  of  malignancy,  and   constitute  a  group  descril^ed   by  authors  under 
the  name  of  scarlatina  maligna. 

You  "svill  notice,  from  the  detail  of  symptoms  I  have  given,  that  scarlatina 
varies  very  much  in  the  degree  of  its  severity  in  different  cases — from  a 
very  mild,  simple,  irritative  fever,  of  short  duration,  and  uniformly  tending 
to  recovery,  to  one  of  the  most  malignant  and  rapidly  fatal  that  the  phy- 
sician has  to  encounter.  And  cases  are  met  with  presenting  every  grada- 
tion between  these  extremes,  leaving  no  well-defined  line  of  separa- 
tion between  those  designated  as  scarlatina  simplex^  scarlatina  anginosa., 
and  scarlatina  maligna.  Consequently  you  must  understand  these 
terms  as  indicating  simply  different  degrees  of  severity,  both  in  general 
phenonema  and  in  local  complications.  There  are  not  only  great  differ- 
ences in  the  severity  of  different  cases  in  the  same  season,  but  equal 
diversities  in  the  character  of  different  epidemics.  I  have  known  several 
epidemics,  in  which  large  numbers  were  attacked,  and  nearly  all  the  cases 
were  of  the  simple,  or  moderately  anginose  variety.  I  have  witnessed 
other  epidemics  in  which  a  large  proportion  of  all  the  attacks  were  severely 
anginose  or  malignant. 

Diagnosis. — Scarlatina,  in  all  grades  of  its  severity,  is  distinguished 
from  variola  and  varioloid  by  the  shorter  duration  of  the  primary  fever 
before  the  eruption,  the  greater  frequency  of  pulse  and  respiration,  the 
bright  redness  in  the  fauces  with  tumefaction  of  the  tonsils,  and,  in  many 
cases,  swelling  of  the  lymphatic  glands  in  the  parotid  and  sub-maxillary 
regions,  and  still  more  by  the  character  of  the  eruption  when  it  appears; 
the  latter  consisting  of  very  small  red  points  with  general  redness  of  the 
surface,  but  neither  elevated  nor  hard  to  the  touch,  while  that  of  variola 
and  varioloid  is  both,  with  a  small  vesicle  on  the  top;  and  that  of  varicella 
is  equally  prominent  and  more  largely  vesicular  from  the  beginning. 
From  rubeola,  or  measles,  it  is  distinguished  by  the  absence  of  the  coryza, 
cough  and  other  catarrhal  symptoms  that  accompany  the  latter;  by  the 
greater  intensity  of  the  fever;  the  earlier  appearance  of  the  eruption; 
and  the  smaller  and  more  evenly  diffused  red  points  that  constitute  the 
rash  or  exanthem.  The  same  characteristics  also  distinguish  it  from 
rotheln  and  roseo'a. 

JPrognosis. — The  prognosis  in  cases  of  scarlatina  simplex  is  always 
favorable,  so  far  as  the  direct  results  of  the  fever  are  concerned.  But  ex- 
perience has  shown  that  even  the  mildest  cases  are  liable  to  be  followed, 
during  convalescence,  by  that  form  of  acute  renal  congestion  which  speed- 
ily develops  general  dropsical  swelling,  insufficient  excretion  of  urea  and 
other  elements  of  urine,  and  consequent  dangerous  poisoning  of  the  nerv- 
ous centers.  The  anginose  variety  of  scarlatina  is  dangerous  in  proportion 
to  the  extent  and  intensity  of  the  inflammation  in  the  fauces  and  adja- 
cent lymphatic  glands.  During  the  active  progress  of  cases  belonging  to 
this  grade  of  the  disease,  the  urine  sometimes  becomes  scanty  and  con- 
tains both  albumen  and  tubular  casts,  indicating  a  dangerous  degree  of 
renal  congestion.  In  a  small  proportion  of  cases,  convulsioris  occur, 
either  at  the  beginning  or  during  the  progress  of  the  primary  fever,  and 
add  much  to  the  gravity  of  the  disease.  Cases  complicated  by  the  ap- 
pearance of  diphtheritic  exudations  on  the  membrane  lining  the  fauces, 
posterior  nares,  or  larynx,  are  very  liable  to  terminate  fatally.  The  prog- 
nosis, in  cases  of  a  true  malignant  character,  is  extremely  unfavorable, 
recoveries  being  exceptions  to  the  general  rule.  Adults,  when  attacked 
by  scarlatina  in  any  of  its  grades,  are  even  more  liable  to  a  fatal  result 
than  children.  When  it  attacks  a  pregnant  woman  it  creates  a  strong 
tendency  to  a  miscarriage  or  a  premature  labor,  and  is  very  apt  to  terminate 
fatally,  although  some  cases  of  this  kind  have  recovered. 


PATHOLOGICAL  CHANGES.  231 

Pathological  Changes. — The  morbid  chang-es  which  take  place  dur- 
inor  the  progress  of  scarlet  lever,  are  chiefly  such  as  result  I'rom  the 
iuflammations  in  the  skin,  mucous  membrane  ol  the  fauces,  glands  of 
the  neck  and  kidneys.  Each  exaiithem  or  red  point  on  the  cutaneous  surface 
is  caused  by  an  inflammatory  congestion  of  the  vessels  of  the  corium,  or  layer 
immediately  beneath  the  epidermis,  with  a  slight  accumulation  of  lymphoid 
cells.  In  all  ordinary  cases  there  is  not  sufficient  exudation  to  cause  any 
elevation  or  hardness,  and  even  the  redness  mostly  disappears  after  death. 
In  some  instances  in  which  the  rash  was  strongly  developed,  slight  exti-a- 
vasations  of  serum  and  blood  corpuscles  have  been  discovered  in  the  rete 
malpighii  and  in  the  lumen  of  the  sweat-glands.  The  congestion  of  the 
vessels  is  sufficient  to  interrupt  the  natm-al  relations  between  the  cutis 
vera  and  the  epidermis,  so  far  as  to  cause  a  very  general  exfoliation  of  the 
latter  on  the  subsidence  of  the  cutaneous  inflammation.  The  exfoli- 
ation over  the  surface  generally  is  in  the  form  of  thin  lamina,  but  in  the 
palms  of  the  hands  and  soles  of  the  feet  it  sometimes  separates  in  large 
thick  layers.  In  all  the  anginose  cases  the  mucous  membrane  covering  the 
fauces,  tonsils  and  pharynx  is  found  intensely  red  from  congestion  of 
blood  in  the  vessels,  more  or  less  swollen,  and  often  ulcerated  or,  in 
patches,  destroyed  by  gangrene.  In  many  cases  the  mucous  membrane  lin- 
ing the  posterior  and  middle  part  of  the  nostrils  is  in  the  same  condition. 
In  the  same  class  of  cases  the  tonsils  and  many  of  the  adjacent  lymphatic 
glands  are  much  tumefied  fiom  congestion  of  vessels,  exudation  of  white 
corpuscles  and  plastic  material  and  sometimes  the  formation  of  abscesses 
from  a  true  phlegmonous  inflammation.  The  inflammation  and  suppura- 
tion often  extend  into  the  connective  tissue  behind  and  beneath  the  angle 
of  the  jaw  ;  and,  in  some  cases,  burrow  in  behind  the  pharynx,  and 
not  only  render  breathing  and  deglutition  difficult,  but  sometimes  break 
and  discharge  the  matter  into  the  pharvnx  so  fast  as  to  be  drawn  into  the 
larynx  and  cause  sulfocation. 

A  case  terminated  fatally  from  this  cause,  under  my  own  care,  nearly 
forty  years  since.  The  patient  was  a  female  child  about  two  years  of  age, 
who  had  passed  through  the  active  stage  of  severe  scarlatina  anginosa, 
during  which  the  elands  and  connective  tissue  near  the  angle  of  the  jaw 
became  very  much  swollen  and  hard.  Suppuration  took  place  deep  be- 
neath the  facice  of  the  neck,  and  extended  inward  and  downward  behind 
the  lower  part  of  the  pharynx,  and  before  distinctly  pointing  externally, 
broke  almost  opposite  the  epiglottis,  and  filled  the  throat  so  rapidly  as  to 
cause  immediate  suffocation.  Post-mortem  examinations  also  show,  in 
some  cases,  severe  inflammation  and  suppuration  in  the  middle  ear,  with 
perforation  of  the  tympanum,  and  sometimes  necrosis  of  the  small  bones. 
In  some  epidemics  of  scarlatina,  the  mucous  membrane  covering  the  tonsils 
and  other  parts  of  the  fauces,  has  been  found  covered  with  a  layer  of 
fibrinous  exudation,  closely  resembling,  if  not  identical  with,  the  mem- 
branous exudation  in  diphtheria. 

Heubner  has  attempted  to  show  that  the  membrane  thus  seen  in  some 
cases  of  scarlatina  is  not  identical  with  that  of  true  diphtheria,  but  is 
thinner,  and  disintegrates  without  ever  being  detached  or  expectorated  in 
shreds  or  patches.  He  also  claims  that  scarlatinal  fibrinous  material  is 
exuded  beneath  the  epithelial  cells  and  into  the  connective  tiisae  of  the 
submucosa.  All  parties  admit,  however,  that  the  micrococci  found  present 
in  the  exudation  are  the  same  in  both  diseases.  Having,  in  my  own  ex- 
perience, never  seen  fibrinous  exudations  on  the  tonsils  and  fauces  of 
scarlatina  patients,  except  when  diphtheria  was  more  or  less  prevalent  in 
the  community  at  the  same  time,  I  have  regarded  its  presence  as  evidence 


232  SCARLATINA. 

that  the  causes  of  both  diseases  were  influencing  the  patient  coincidently, 
similar  to  the  coincident  action  of  the  causes  of  typhoid  and  periodical 
fevers,  in  producing  what  has  been  called  typho-malarial  fevers. 

The  frequent  occurrence  of  albumen  in  the  urine,  during  the  progress 
of  scarlet  fever,  and  of  the  marked  evidences  of  inflammatory  congestion 
of  the  secreting  structure  of  the  kidneys  after  death,  renders  it  probable 
that  the  scarlatina  poison,  or  contagium  has  much  the  same  affinity  for  the 
renal  tubules,  that  it  has  for  the  skin.  In  many  post-mortem  examina- 
tions the  kidneys  were  found  enlarged  and  pale  externally,  with  marked  con- 
gestion of  the  vessels  connected  with  the  tubules  and  glomeruli,  and  de- 
tached epithelial  cells  filling  and  obstructing  the  former.  It  is  this  action 
of  the  scarlatina  poison  on  the  renal  organs,  that  determines  the  frequent 
occurrence  of  acute  and  chronic  renal  afi'ections,  accompanied  by  dropsical 
symptoms  as  sequelae  of  the  general  disease. 

C otnplications  and  Sequelm. — The  most  important  complications  occa- 
sionally met  with  during  the  progress  of  scarlatina,  are  lobular  pneumonia, 
nephritis,  pericarditis,  convulsions,  and  sub-acute  articular  rheumatism; 
while  chronic  otitis,  with  purulent  discharges,  acute  and  chronic  renal 
congestions  and  degenerations,  with  dropsical  accumulations,  rheumatism, 
chorea,  and  general  anemia,  constitute  the  most  frequent  and  important 
sequelse.  The  complications  mentioned  may  occur  at  any  time  during  the 
active  progress  of  the  general  disease;  but  they  are  most  apt  to  be  devel- 
oped between  the  fifth  and  ninth  days  after  the  commencement  of  the  fe- 
ver, that  is,  during  the  decline  of  the  eruptive  stage.  The  various  seque- 
lae may  begin  at  any  time  during  the  convalescence,  or  within  from  one  to 
six  weeks  after  the  beginning  of  the  desquamation  of  the  cuticle. 

Treatment. — The  objects  to  be  accomplished  in  the  treatment  of  scar- 
let fever,  may  be  stated  as  follows: 

First,  to  remove  the  further  action  of  any  predisposing  causes  that  may 
exist,  and  to  neutralize  or  destroy  the  specific  contagium  in  the  system. 
Second,  to  lessen  the  direct  irritative  and  disturbing  action  of  the  specific 
cause  on  the  properties  of  and  molecular  changes  in  the  blood  and  organized 
structures  of  the  body,  by  such  remedies  as  allay  morbid  excitability, 
lessen  temperature,  and  promote  natural  secretory  action.  Third,  to  les- 
sen the  severity  of  the  local  inflammations,  especially  in  the  throat,  glands 
of  the  neck  and  kidneys.  Fourth,  to  sustain  the  nutrition  and  strength 
of  the  patient,  and  promote  the  repair  of  such  structures  as  may  have 
sufi'ered  injury  during  the  active  progress  of  the  disease. 

As  the  predisposing  causes  of  scarlatina  are  chiefly  impure  air  from 
imperfect  ventilation,  uncleanliness  and  bad  sewerage,  so,  when  cases  of 
the  disease  actually  exist,  the  attending  physician  can  not  be  too  careful 
to  have  his  patient  freed  from  the  furthur  influence  of  all  such  unsanitary 
conditions.  It  is  very  important  that  the  room  of  the  scarlet-fever 
patient  should  be  well  ventilated,  cleanly,  and  kept  at  a  temperature 
no  higher  than  is  pleasant  for  a  person  in  good  health.  Neither  should 
the  child  be  wrapped  in  any  unusual  amount  of  clothing.  You  will 
find  many  families  manifesting  a  persistent  determination  to  violate  these 
rules.  As  soon  as  they  are  aware  that  a  child  has  this  variety  of  fever, 
they  will  have  it  closely  bundled  from  head  to  foot  with  all  the  shawls 
and  blankets  they  can  get  around  it,  have  all  the  doors  and  windows 
closely  shut,   and   heat  the  room  to  an  uncomfortable  degree. 

They  could  hardly  do  anything  that  would  have  a  more  debilitating  in- 
fluence, or  render  the  patient  more  susceptible  to  cold,  or  more  disposed 
to  suffer  from  renal  congestion  and  dropsical  effusions  during  the  conva- 
lescence.    In  regard  to  remedies  for  destroying  or  neutralizing  the  speci- 


TREATMENT.  233 

fic  contagium  in  the  system,  and  thereby  arresting  its  further  disturbing 
influence,  we  have  none  that  have  proved  efficient  or  entirely  successful 
when  subjected  to  the  test  of  direct  clinical  experience.  Many  have  been 
tried,  and  received  more  or  less  commendation;  the  more  important  of 
which  are  iodine,  chlorine  in  solution  with  chlorate  of  potassium,  perman- 
ganate of  potassium,  the  hyposulphite  of  sodium  or  calcium,  sulpho-carbolate 
of  sodium,  benzoic  acid,  and  the  benzoate  of  sodium.  I  have  used  all  these 
remedies,  more  or  less,  in  the  treatment  of  the  early  stage  of  scarlatina. 
In  some  instances  they  appeared  to  lessen  the  severity  of  the  symptoms 
and  favorably  modify  the  progress  of  the  disease,  but  in  no  instance  have 
I  seen  the  disease  arrested  or  rendered  abortive,  as  though  its  essential 
cause  had  been  destroyed.  For  fulfilling  the  second  indication  speci- 
fied, the  most  safe  and  efficient  remedy  is  the  frequent  sponging  of  the  whole 
surface  with  cold  water,  and,  in  bad  cases,  the  application  of  the  wet 
sheet  with  the  sprinkling,  in  the  same  manner  as  I  have  detailed  when 
speaking  of  the  treatment  of  typhoid  fever.  Judiciously  used,  it  will  do 
more  to  allay  the  extreme  excitability,  lessen  the  temperature,  and  favor 
natural  molecular  changes  during  the  first  four  or  five  days,  than  can  be 
done  by  all  other  remedies.  It  was  chiefly  in  the  treatment  of  scarlet  fever 
that  Dr.  Currie,  of  London,  demonstrated  the  value  of  free  applications 
of  cold  water  to  the  surface  as  an  antipyretic,  more  than  a  century  since. 
The  common  fear  that  frequent  sponging  of  the  cutaneous  surface  with  wa- 
ter will  prevent  or  repel  the  eruption  is  entirely  without  foundation.  I 
think  it  was  Dr.  xVnderson,  of  Alabama,  who,  in  describing  one  of  the  most 
malignant  epidemics  of  scarlet  fever  that  ever  occurred  in  that  State, 
spoke  of  the  thorough  application  of  cold  water  to  the  surface  as  one  of 
the  most  efficient  means  adopted  for  the  relief  of  the  more  severe  cases. 

The  epidemic  to  which  I  allude  prevailed  prior  to  1850,  and  the  paper 
of  Dr.  i\.nderson  was  published  in  one  of  the  volumes  of  Fenner's  Southern 
Medical  Reports,  which  I  have  not  now  at  hand  for  accurate  reference. 
In  a  report  made  to  the  Scott  County  Medical  Society,  in  1850,  Dr.  W.  L. 
Sutton,  of  Georgetown,  Ky.,  says,  in  commenting  on  the  treatment  of 
scarlatina,  as  it  prevailed  in  that  State,  "the  external  application  of  water, 
cold  or  warm,  is  inferior  to  no  other  remedy."*  Dr.  R.  K.  Smith, of  Dela- 
ware county,  Penn.,  in  speaking  of  the  treatment  of  an  epidemic  of  this  fever, 
prevalent  in  that  county  in  1851,  says  the  treatment  most  successful  in  his 
hands  was  "  cold  ablutions,  followed  by  cold  inunction  with  lard  and  neutral 
mixture,  and  aperient  medicines  internally."  Dr.  Hiram  Corson,  of  Mont- 
gomery County,  Pa.,  alluding  to  the  prevalence  of  the  fever  in  that  county, 
the  same  year,  expresses  "  great  confidence  in  the  efficacy  of  cold  afi"usions." 
Similar  testimony  is  borne  by  Drs.  J.  P.  Heister,  of  Reading,  and  N.  Hayes 
Clark,  of  Newark,  the  same  year.f  I  give  you  these  references  for  two  pur- 
poses, namely  :  to  show  that  the  free  application  of  water  to  the  surface  in 
the  treatment  of  scarlet  fever  has  been  practised  by  many  American  physi- 
cians for  half  a  century;  and  that  the  effect  in  reducing  temperature,  less- 
ening excitability  and  restlessness,  and  promoting  normal  actions  in  the 
system,  is  as  prompt  and  beneficial  as  when  ajoplied  to  cases  of  typhoid, 
typhus,  or  any  of  the  other  acute  general  diseases. 

For  further  correcting  the  general  derangements  of  secretory  and  molec- 
ular action  in  the  severe  anginose  cases,  three  or  four  alterative  doses  of 
calomel,  given  during  the  first  twenty-four  hours,  and  the  subsequent  use 
of  the  aqueous  solution  of  iodine,  in  doses  suited  to  the  age  of  the  patient, 
constitute  as  efficient  measures  as  we  can  adopt.     I  deem  it   important  to 

*  See  Transactions  of  the  Amer.  Med.  AssociaMon.  Vol.  IV.  p.  120.  1851. 

t  See  Transactions  of  the  Amer.  Med.  Association,  Vol.  V,  pp.  121,  2,  5,  and  41,  lS-52. 


234  SCARLATINA. 

avoid  all  active  evacuants,  as  emetics  and  cathartics  during  the  first  two 
days,  as  liable  to  divert  the  specific  cause  or  contagium  from  its  natural 
tendency  to  lodgment  in  the  cutaneous  surface  and  favor  its  retention  in 
the  blood-  Such  movements  of  the  bowels  as  may  be  necessary,  cau  usually 
be  obtained  by  warm  water  enemas.  To  les,-en  the  severity  of  the  local  in- 
flammations in  the  fauces  and  glands  of  the  neck,  besides  the  general 
remedies  already  mentioned,  keeping  the  swollen  parts  covered  exter- 
nalh^  by  the  continuous  application  of  pounded  ice  inclosed  in  bladders,  or 
light,  soft  rubber  bags,  during  the  first  three  or  four  days,  will  be  found 
highly  beneficial  in  the  more  active  anginose  cases.  But  if  the  ice  is  not  at 
hand,  or  if  the  parents  are  too  strongly  prejudiced  against  cold  applica- 
tions, you  can  cover  the  swollen  parts  with  cloths  kept  wet  with  an  infusion 
of  aconite  leaves  and  muriate  of  ammonium.  The  infusion  may  be  made  by 
putting  one  litre  (two  pints)  of  water  boiling  hot  on  thirty-two  grains 
(p)  of  aconite  leaves,  and  sixteen  grams  (^ss)  of  ammonii  murias,  in  any 
convenient  vessel,  stirring  them  several  tunes  while  cooling,  and  use  it 
only  milk  warm.  It  really  constitutes  a  cooling,  narcotic,  and  discutient 
application,  that  T  have  used  as  an  external  application  during  the  first 
three  or  four  days,  both  in  scarlet  fever  and  diphtheria  for  many  years, 
and  with  much  apparent  benefit. 

For  the  inflamed  parts  in  the  fauces  and  throat,  during  the  same  stage 
of  the  disease,  I  know  of  no  better  application  than  a  dilute  solution  of 
chloi'ate  of  potassium,  containing  a  small  proportion  of  hydrochloric  acid 
and  tincture  of  belladonna,  used  in  the  same  manner  as  I  directed  when 
speaking  of  the  treatment  of  diphtheria.*  When  the  first  stage  is  passed, 
and  the  fever  and  rash  begin  to  decline,  if  the  swollen  glands  remain  hard 
and  but  little  disposed  to  undergo  resolution,  the  application,  three  times  a 
day,  of  a  liniment  composed  of  three  parts  of  camphorated  soap 
liniment  and  one  part  of  tincture  of  iodine,  may  be  used  instead  of  the 
infusion  or  ice.  At  the  same  stage,  the  internal  use  of  the  chlorate  of 
potassium  and  belladonna  solution  should  be  exchanged  for  suitable 
doses  of  the  tincture  of  the  chloride  of  iron  and  quinine,  both  for  their 
local  effect  on  the  throat,  and  tonic  and  antiseptic  eifect  upon  the  system 
at  large.  In  cases  presenting  unusual  weakness  and  frequency  of 
pulse,  the  administration  of  suitable  doses  of  a  solution  containing  liquor 
ammonias  acetatis,  tincture  of  digitalis  and  carbonate  of  ammonium, 
between  the  doses  of  the  tincture  of  iron  and  quinine,  may  be  given 
with  great  benefit.  In  the  fulfillment  of  the  fourth  indication  I  have 
named,  careful  attention  should  be  given  throughout  the  whole  course  of 
the  disease,  and  especially  during  its  middle  and  later  stage?,  to  the 
administration  of  nourishments,  of  which  good  milk,  thin  wheat  flour  and 
milk  gruel,  and  beef  tea,  are  the  best.  They  should  be  given  in  small 
quantities  at  a  time,  but  repeated  sufficiently  often  to  supply  a  fair  degree 
of  nutrition.  When  the  swelling  or  ulcerations  in  the  throat  are  such  as 
to  render  the  swallowing  of  nourishment  very  difficult,  a  nutritive  enema, 
consisting  of  milk  or  good  beef  tea  should  be  given  per  rectum  morning 
and  evening.  Such  cases  can  be  further  sustained  by  applying,  two  or 
three  times  a  day,  over  a  large  part  of  the  cutaneous  surface,  cod-liver  oil, 
holding  in  suspension  a  small  quantity  of  sulphate  of  quinia.  In  the  more 
malignant  cases  of  scarlatina  anginosa,  in  which  incipient  appearances  of 
gangrene  are  presented  in  the  fauces  or  tonsils,  between  the  third  and 
fifth  days,  I  have  been  in  the  habit  of  ordering  an  infusion  of  lour  grams 
(3i)  of  cayenne  pepper  in  130  cubic  centimeters  (fl.  riv)  of  boiling  milk,  and 
when  cool,  giving  to  a  child  five  years  of  age,  one  teaspoonful  every  one 

*  See  formula  and  directions  on  page  174. 


PROPHYLAXIS.  235 

or  two  hours,  vintil  the  critical  stage  is  passed  and  the  sloughs  separated, 
leaving-  clean,  ulcerated  surfaces,  when  the  pepper  is  omitted,  and  only 
slightly  astringent  and  soothing  gargles  used  locally,  with  quinine,  iron 
and  nourishment  internally. 

In  some  cases  of  the  more  malignant  grade  of  scarlet  fever,  accompa- 
nied by  a  high  temperature,  very  frequent  pulse,  hurried  breathing  and 
dullness  or  drowsiness  between  the  paroxysms  of  restless  tossing,  I  have 
caused  the  whole  surface  to  be  thoroughly  sponged  with  cool  water  every 
three  or  four  hours  and  this  to  be  followed  by  an  application  of  cod- 
liver  oil  containing  a  small  proportion  of  iodine;  and  apparently  with  de- 
cided benefit.  It  is  not  long  since  that  I  was  called  to  a  family  on  Fif- 
teenth street,  west  of  State  street,  where  three  children  had  been  attacked 
with  the  fever  in  a  very  malignant  form.  One  was  already  dead,  having 
been  sick  only  three  days;  another  was  dying;  and  the  third,  a  little  boy, 
who  had  sickened  two  days  later  than  the  other  two,  was  rapidly  develop- 
ing the  same  symptoms,  and  the  characteristic  eruption  had  appeared 
thickly  over  the  surface.  He  was  put  upon  the  use  of  such  internal 
remedies  as  I  have  already  indicated,  and  faithfully  sponged  with  the  cool 
water  followed  by  the  application  of  the  iodized  oil  as  just  described.  The 
spongings  were  followed  by  such  marked  improvement  in  the  pulse,  temper- 
ature, and  nervous  sensibility,  as  to  leave  no  doubt  of  their  beneficial  effect. 
The  case  ran  a  severe  course,  but  recovered  without  any  bad  sequelee. 
Having  indicated  as  clearly  as  possible  the  several  objects  to  be  ac- 
complished in  the  treatment  of  the  different  grades  and  stages  of  scarlet 
fever,  and  the  means  I  have  found  best  adapted  to  the  accomplishment  of 
these  objects,  I  will  only  remark  further  that  the  milder  cases  of  scarla- 
tina simplex  need  but  little  medicine  of  any  kind.  A  moderate  dose  of 
the  solution  of  chlorate  of  potassium,  hydrochloric  acid  and  belladonna* 
three  or  four  times  a  day  with  the  proper  hygienic  regulations,  is  all  that 
is  required  in  such  cases. 

Prophylaxis. — Isolation  of  the  sick  as  far  as  practicable,  and  faithful 
attention  to  cleanliness,  ventilation,  and  proper  disinfection,  constitute  the 
best  means  for  limiting  the  spread  of  the  disease.  Much  has  been  writ- 
ten in  relation  to  the  efficacy  of  belladonna  and  other  remedies  to  be  given 
internally  as  preventives  of  scarlet  fever.  The  fact  that  the  period  of 
ncubation  of  this  disease  is  not  well-defined,  coupled  with  the  further 
important  fact  that  many  children  who  are  fully  exposed  to  contact  with 
it,  do  not  take  the  disease  when  no  preventive  means  have  been  used, 
renders  it  very  difficult  to  determine  the  actual  value  of  any  given  drug 
when  administered  for  this  purpose.  In  cases  where  the  date  of  exposure 
to  the  contagium  is  knovvn,  and  the  patient  can  commence  immediately,  or 
at  least  as  early  as  the  second  day,  the  taking  of  fair  doses  of  a  solution  of 
the  hyposulphite  of  sodium  with  tincture  of  belladonna,  three  or  four 
times  a  day  until  the  time  for  active  symptoms  of  the  fever  to  begin  had 
passed,  I  feel  confident  that  the  development  of  the  disease  would  be 
either  entirely  prevented,  or  its  attack  rendered  very  mild.  For  a  child 
five  years'  of  age,  the  dose  of  the  hyposulphite  should  be  from  three  to 
five  decigrams  (gr.  v  to  viii)  with  tincture  of  belladonna  0.13  cubic 
centimeter  (min.  ii),  dissolved  in  mint  water. 

Sequelce. — Scarlet  fever,  more  than  any  other  one  of  the  acute  general 
diseases,  is  liable  to  be  followed  by  troublesome  and  important  sequelae. 
Inflammation  and  suppuration  in  the  middle  ear,  followed  by  perforation 
of  the  tympanum  and  a  protracted  purulent  discharge  from  the  exter- 
nal meatus,  with  more  or  less  impairment  of  hearing,  are  of  frequent 
occurrence  both  during  the  advanced  stage  of  severe  angi nose -cases,  and 

*See  page  174. 


236  SCARLATINA. 

during  any  part  of  the  period  of  convalescence,  from  attacks  even  of  the 
mildest  character.  The  commencement  of  the  inflammation  is  indicated 
hy  the  occurrence  of  sharp,  lancinating,  or  throbbing  pains  in  the  ear;  an 
increase  of  fever  and  restlessness  ;  and  sometimes  delirium. 

These  svmptoms  generally  continue  with  increasing  severity  from  two 
to  four  days,  when  a  discharge  commences  from  the  external  ear,  followed 
by  a  rapid  subsidence  of  the  pain  and  fever.  In  many  cases  the  discharge 
is  at  first  a  thin  serous  fluid,  quite  abundant  in  quantity,  which  subse- 
quently diminishes  and  becomes  more  purulent;  while  in  other  cases  it  is 
a  thick  white  pus  from  the  beginning.  In  a  large  proportion  of  the  cases, 
the  discharge  and  the  other  local  symptoms,  cease  altogether  in  from  one 
to  two  weeks,  leaving  the  hearing  unimpaired  ;  while  in  others  it  contin- 
ues indefinitely  and  is  accompanied  by  partial  or  complete  destruction  of 
the  tympanum,  and  sometimes  loss  of  one  or  more  of  the  small  bones  of 
the  ear,  with  partial  or  complete  deafness.  For  the  treatment  of  these 
cases  I  refer  you  to  the  lecture  on  otitis,  in  its  various  forms  and  stages. 
Another  painful  and  sometimes  protracted  sequel  is  sub-acute  rheumatism. 
It  generally  commences  in  the  early  part  of  convalescence,  and  is  most 
apt  to  attack  the  wrists,  ankles,  and  smaller  joints  of  the  hands  and  feet, 
but  sometimes  extends  over  nearly  all  the  articulations  of  the  extremities 
and  trunk  of  the  body,  and  even  to  the  structures  of  the  heart.  It  is 
best  relieved  by  the  same  remedies  that  have  been  found  efi'ectual  in 
similar  grades  of  rheumatic  inflammation,  occurring  unconnected  with 
scarlet  fever,  and  which  are  fully  considered  in  the  lectures  on  acute  and 
chronic  rheumatism. 

But  perhaps  the  most  important  and  dangerous,  if  not  the  most  frequent 
sequel  of  scarlatina,  is  some  degree  of  nephritis  or  renal  congestion,  ac- 
companied by  more  or  less  anasarca  or  general  dropsy.  During  the  active 
stage  of  the  general  fever,  the  urine  is  often  found  containing  albumen  and 
other  evidences  of  renal  congestion  and  irritation,  which  should  never  be 
overlooked  or  neglected  by  the  attending  physician.  All  the  facts  appear 
to  show  that  there  is  some  quality  of  the  essential  cause  of  the  fever,  which 
so  influences  the  renal  structures  as  to  leave  them  during  the  convales- 
cence, peculiarly  susceptible  or  predisposed  to  inflammatory  congestions 
of  all  degrees  of  severity.  The  common  impression  is,  that  the  renal 
dropsies  following  scarlatina  are  caused  by  undue  exposures  to  cold  or  go- 
ing out  too  soon;  but  my  ovvn  experience  does  not  sustain  that  impression. 
On  the  contrary,  a  large  majority  of  the  cases  which  have  come  under  my 
observation,  have  been  in  children  who  had  been  kept  in  rooms  too  warm 
and  too  little  ventilated,  and  have  used  more  or  less  of  alcoholic  remedies  as 
a  part  of  their  treatment.  The  renal  afi^'ections  following  scarlatina  may 
commence  at  any  time  during  the  four  weeks  following  the  subsidence  of 
the  general  fever  ;  but  much  the  larger  number  of  cases  are  noticed  be- 
tween the  third  and  tenth  days  after  the  beginning  of  convalescence.  They 
vary  much  in  severity,  and  mode  of  development,  from  a  very  acute  and 
dangerous  nephritis  to  a  simple  passive  congestion  sufficient  to  cause  the 
exudation  of  albumen  in  the  urine.  But,  as  all  these  affections  are  fully 
considered  in  the  lectures  on  acute  and  chronic  nephritis,  including  the 
various  pathological  conditions  causing  albumen  to  be  eliminated  in  the 
urine,  it  would  involve  unnecessary  repetition  to  enter  further  into  their 
discussion  at  this  time.  I  will  only  add,  therefore,  that  you  should  not 
only  pay  special  attention  to  the  renal  secretion  during  the  active  progress 
of  all  cases  of  scarlatina,  applying  proper  tests  for  albumen  as  often  as  ev- 
ery second  day,  but  you  should  always  instruct  the  patient  or  the  nurse  to 
keep  close  watch  of  the  quantity   and  ajapearance  of  the  urine  until  the 


EUBEOLA.  237 

period  of  convalescence  is  passed.  It  is  a  good  rule,  in  cases  presentino: 
albuminous  urine  during  the  active  stage  of  the  fever,  to  give  all  through 
the  stage  of  convalescence,  moderate  doses  of  spirits  of  nitrous  ether 
vs^ith  tincture  of  chloride  of  iron,  three  times  a  day,  well  diluted  with 
water. 


LECTUEE    XXVI. 

Rubeola— ROtheln— Roseola— Pertussis  and  Mumps— Their  History,  Causes,  Symptoms,  Diagnosis 
and  Treatment. 

GENTLEMEN:  In  this  country  the  word  rubeola  has  been  pretty  uni- 
formly used  to  designate  the  disease  called  morbilli  or  measles.  But  in 
recent  times  many  English  and  Continental  writers  (Aitken,  Reynolds, 
Trousseau,  Thomas  in  Ziemssen,  etc.)  have  applied  it  to  a  hybrid  disease 
known  in  this  country  as  rotheln,  or  "  Grerraan  measles."  By  others  the 
latter  has  also  been  called,  roseola;  thereby  producing  much  confusion  in 
the  application  of  names,  and  no  little  embarrassment  to  the  student  in 
his  efforts  to  preserve  a  clear,  differential  diagnosis  between  these  several 
milder  exanthematovis  diseases.  I  shall  adhere  to  the  American  custom 
of  regarding  rubeola,  morbilli  and  measles,  as  synonyms,  applicable  to 
true  measles  only.  The  hybrid  disease  intermediate  between  scarlet 
fever  and  true  measles  I  shall  call  rStheln;  while  roseola  will  be  used  to 
designate  a  very  mild  febrile  affection,  non-contagious,  and  characterized 
by  the  appearance  upon  the  skin  of  red  spots  instead  of  exanthematous 
points. 

Rubeola,  or  measles,  is  a  contagious  eruptive  fever  of  much  milder 
character  than  variola  or  scarlatina,  and  though  not  accurately  differen- 
tiated from  the  latter,  the  description  of  it  is  easily  recognized  in  the 
history  of  some  of  the  epidemics  that  occurred  in  the  early  part  of  the 
Christian  era.  Like  scarlet  fever,  it  attacks  mostly  children  and  youth, 
though  it  may  attack  persons  at  any  period  of  life;  and  suffering  from  it 
once  usually  destroys  the  susceptibility  to  the  action  of  the  specific  cause 
through  the  remainder  of  life.  Yet  there  are  many  who  have  had  the 
disease  twice  or  even  thrice.  Throughout  the  temperate  zone,  it  is  most 
apt  to  prevail  in  the  transition  seasons,  spring  and  autumn,  though  no  part 
of  the  year  is  exempt.  While  in  enlightened  countries  where  the  nature 
of  the  disease  is  well  understood,  and  reasonable  attention  is  given  to 
hygienic  and  sanitary  measures,  it  is  regarded  as  of  but  little  importance; 
its  introduction  into  some  countries  of  less  enlightened  people,  has  been 
followed  by  a  serious  degree  of  fatality.  For  instance,  an  extensive  prev- 
laence  of  the  disease  in  Japan,  in  1861,  according  to  the  statements  of 
Dr.  D.  B.  Simmers,  destroyed  75,000  lives;  and  in  the  Fiji  Islands,  in 
1875,  it  is  said  to  have  destroyed  the  lives  of  one-fifth  of  the  entire  popu- 
lation. The  measles  that  prevailed  quite  extensively  in  some  of  the 
military  camps  for  the  rendezvous  and  training  of  recruits,  during  the 
late  war  in  this  country,  was  accompanied  by  a  considerable  ratio  of 
mortality,  owing  chiefly,  however,  to  pneumonic  and  typhoid  complica- 
tions. 

Causes. — The  predisposing  causes  that  favor  the  development  and  spread 


238  RUBEOLA. 

of  rubeola,  are  youth,  overcrowding  and  bad  ventilation,  uncleanliness,  and 
damp,  cold  air.  The  essential  cause  is  a  specific  contagium  formed  in  the 
bodies  of  the  sick,  and  eliminated  chiefly  through  the  skin  and  lungs,  con- 
taminating the  air  immediately  around  the  patient,  and  capable  of  com- 
municating the  disease  to  other  persons  who  breathe  it,  and  capable  also 
of  becoming  attached  to  clothing,  and  being  transferred  to  other  places. 
Like  all  the  other  contagiums  and  miasms,  this  has  been  regarded  by 
modern  investigators  as  composed  of  organic  germs.  Dr.  J.H.  Salisbury, 
of  Clevelaijd,  Ohio,  claimed  to  have  discovered  the  specific  cause  to  be  a 
species  of  fungus  developed  on  damp  straw,  and  thus  attempted  to  explain 
tlie  prevalence  of  the  disease  in  some  of  the  military  camps  connected 
with  our  army.  His  observations,  however,  were  not  confirmed  by  those  of 
Drs.  Hammond,  Woodward,  and  others,  who  gave  special  attention  to  the 
subject ;  and  it  is  highly  probable  that  the  irritation  of  the  air  passages 
and  slight  fever,  sometimes  produced  by  the  fungus  developed  on  damp 
straw,  is  entirely  distinct  from  true  measles.  That  the  specific  cause  or 
contagium  is  developed  in  the  blood  of  patients  laboring  under  the 
disease,  is  proved  by  the  results  of  inoculations,  by  which  the  disease  is 
readily  communicated. 

Symptoms. — After  an  incubative  stage  varying  from  nine  to  fourteen 
days,  the  active  symptoms  commence  with  slight  alternations  of  heat  and 
cold  accompanied  by  some  headache,  a  general  sense  of  weariness,  moder- 
ate heat  of  skin,  slight  acceleration  of  pulse,  a  marked  sense  of  tightness 
or  oppression  in  the  chest  with  dry  harsh  cough,  fullness  and  dryness  of 
the  nostrils,  red  and  watery  appearance  of  the  eyes,  and  flushing  of  the 
face.  In  other  words,  all  the  usual  symtoms  of  an  attack  of  influenza,  or 
a  severe  "  common  cold."  All  these  symptoms  gradually  increase  in 
severity  until  the  evening  of  the  fourth  day,  when  generally  there  is  much 
redness  of  the  face  and  eyes,  sensitiveness  to  light,  a  severe  hoarse  rough 
cough  sending  a  sore  pain  through  the  anterior  part  of  the  head  and 
temples,  with  very  decided  soreness  and  sense  of  oppression  in  the  chest  ; 
moderate  fullness  and  acceleration  of  pulse  ;  temperature  from  39*^  to 
40°  C.  (102°  to  104°  F.)  ;  and  scattered  over  the  face  and  upper  part  of 
the  chest  an  eruption  of  small  red  points,  a  little  larger  than  the  points  or 
exanthems  of  scarlatina,  and  more  irregular  in  distribution  ;  there  being 
in  some  places  two  or  more  points  clustered  together,  and  in  others 
but  one,  leaving  the  skin  of  natural  color  between  them.  There  are  no 
hard  elevated  papules  either  with  or  without  vesicles,  but  simple  red 
points  hardly  perceptible   to   the  touch  as  the  finger  is  passed  over  them. 

The  eruption  thus  commenced  on  the  face,  neck  and  chest,  rapidly  extends 
over  the  whole  cutaneous  surface,  reaching  the  extremities  abont  the  end  of 
the  fifth  day,  or  twenty-four  hours  later  than  its  appearance  on  the  face. 
All  the  local  catarrhal  and  general  febrile  symptoms  continue  unabated 
until  the  third  day  of  the  eruption,  or  the  seventh  from  the  commence- 
ment of  active  symptoms,  when  the  disease  has  reached  its  climax,  and 
the  next  day  both  the  fever  and  rash  have  notably  diminished.  All  the 
symptoms  now  decline  steadily,  until  convalescence  is  fully  established, 
generally  between  the  tenth  and  twelfth  days  from  the  commencement  of 
catarrhal  sj^nptoms.  The  disappearance  of  the  rash  is  followed  by  slight 
desquamation  or  roughness,  but  not  so  much  as  after  scarlatina;  and  a 
moderate  bronchial  cough  often  lingers  through  the  convalescence.  The 
general  character  of  the  symptoms,  and  the  order  of  their  occurrence  in 
measles,  are  more  uniform  than  in  any  of  the  other  eruptive  fevers.  You 
will  meet  with  some  cases,  however,  in  which  the  febrile  symptoms  and 
the  amount  of  the  eruption  will  be  less  than  I  have  described,  and  others 


DIAGNOSIS    AND    PROGNOSIS.  239 

in  which  they  are  mora  severe.  In  some  of  the  latter  class,  at  the  time 
of  the  appearance  of  the  eruption,  the  temperature  may  rise  to  40.5"  or 
41°  C.  (105°  or  106°  F.);  the  eruption  over  the  face  and  neck  so  thick  as  to 
make  the  wHole  surface  red,  and  the  eyes  so  irritable  that  the  patient  will 
no":  open  them  to  the  light.  The  soreness  in  the  chest,  and  cough,  are 
very  severe,  with  tenacious  mucous  expectoration,  and  such  a  degree  of 
nervous  disturl)ance  as  to  cause  some  delirium,  especially  in  the  night.  A 
very  small  proportion  of  these  unusually  severe  cases  present  a  decidedly 
malignant  aspect.  Such  cases,  in  addition  to  the  high  temperature,  and 
other  severe  symptoms  just  named,  present  a  frequent  and  feeble  pulse  ; 
irregular  and  oppressed  breathing  ;  and  generally  more  or  less  of  petech- 
ial or  hetnorrhagic  spots  in  connection  with  the  eruption.  The  extrava- 
sated  blood  is  dark,  purplish  color,  and  gives  to  the  cutaneous  surface  a 
peculiarly  dark  and  spotted  appearance,  which  has  given  origin  to  the 
name  of  '•  hlack  measles?''  The  petechial  spots  more  frequently  appear 
over  the  abdomen,  inside  of  the  thighs  and  legs,  but  may  extend  to  the 
face,  and  other  parts  of  the  surface,  and  are  sometimes  accompanied  by 
hemorrhage  from  the  mouth,  gums,  nostrils,  or  from  the  mucous  membrane 
lining  the  stomach  and  lower  bowels.  It  is  only  a  few  months  since  I  saw 
a  case  of  this  kind,  in  the  person  of  a  young  woman,  which  terminated 
fatally  on  the  third  day  after  the  appearance  of  the  eruption. 

Diagnosis. — Rubeola  is  distinguished  from  all  the  other  eruptive  fevers 
by  the  presence  of  the  severe  catarrhal  symptoms  from  the  beginning.  From 
variola,  varioloid,  and  varicella,  it  is  further  distinguished  by  the  absence 
of  all  elevated  and  hard  pimples  and  vesicles,  and  instead,  the  presence  of 
small  red  points  or  exanthems,  which  differ  from  those  of  scarlet  fever  in 
being  irregularly  distributed  in  clusters  instead  of  uniformly  diffused 
over  the  cutaneous  surface. 

Prognosis. — Except  the  very  few  cases  of  a  special  malignant  character 
uncomplicated  cases  of  measles  uniformly  tend  to  recovery;  consequently 
the  ratio  of  mortality  resulting  from  its  prevalence  is  very  small.  Yet 
you  will  find  in  the  annual  statistics  of  mortality,  quite  a  number  of  deaths 
attributed  to  measles.  Judging  from  my  own  observations,  I  should  say  that 
three  out  of  every  four  of  these  deaths  were  caused  by  the  supervention  of 
broncho-pneumonia  during  the  eruptive  stage  of  the  general  fever.  This 
complication  is  most  apt  to  occur  in  young  children,  and  in  such  adults  as 
are  living  in  overcrowded  or  badly  ventilated  places.  In  the  latter  class  of 
cases  dysentery  is  also  liable  to  occur,  especially  in  the  advanced  stage  of  the 
fever,  and  sometimes  is  sufficiently  severe  to  cause  the  death  of  the  patient. 
It  was  the  supervention  of  pneumonia  and  dysentery  as  complications,  that 
caused  nearly  all  the  deaths  resulting  from  the  prevalence  of  measles  in 
the  military  camps  during  the  recent  war  in  this  country.  Another  com- 
plication that  occasionally  occurs,  though  less  frequently  than  in  connec- 
tion with  variola  and  scarlatina,  is  general  convulsions.  Such  attacks  are 
most  apt  to  occur  in  children  under  five  years  of  age,  and  just  at  the  stage 
when  the  eruption  is  first  beginning  to  appear  on  the  surface. 

Pathological  Anatomy. — As  this  disease  rarely  terminates  fatally, 
except  when  influenced  by  some  important  complication,  so  there  are  no 
structural  changes  to  be  found  after  death  peculiar  to  measles,  ex- 
cept the  eruption  which  appears  on  the  mucous  membrane  of  the  air 
passages,  causing  the  catarrhal  symptoms,  and  subsequently  upon  the 
cutaneous  surface.  This  does  not  differ  anatomically  from  the  efflores- 
cence in  scarlatina,  which  I  described  sufficiently  in  the  preceding 
lecture. 

Treatment, — As  rubeola    is    a  self-limited  disease,  tending  generally 


45  c.  c. 

|iss 

15  c.  c. 

fss 

60  c.  c. 

^ii 

240  EUBEOLA. 

to  the  recovery  of  the  patient,  there  is  no  need  of  very  active  medica- 
tion. The  same  attention  should  be  given  to  the  temperature,  cleanli- 
ness, and  ventilation  of  the  sick-room  as  in  scarlatina  ;  an.d  the  same 
avoidance  of  hot  stimulating  drinks  and  excessive  clothing.  As  we 
know  of  no  specific  remedy  capable  of  destroying  the  contagium  or 
essential  cause  so  as  to  arrest  the  progress  of  the  disease  in  its  early 
stage,  the  chief  objects  to  be  accomplished  are,  to  lessen  the  severity  of 
the  cough  and  soreness  in  the  chest,  and  promote  natural  secretory  actions. 
To  mitigate  the  cough  and  other  catarrhal  symptoms,  I  have  found  the 
following  combination  one  of  the  best : 

]J     Syrupus  Scillte  Compositi 
Tincturse   Sanguinariae 
Tincture  Opii    CamphoratEe 

Mix,  and  give  to  an  adult  four  cubic  centimeters  (fl  3i)  every  three  or  four 
hours,  in  a  tablespoonful  of  water.  In  cases  accompanied  by  very  severe 
headache,  16  grams  (3iv)  of  potassium  bromide  maybe  added  to  the  form- 
ula with  advantage.  Or  if,  as  sometimes  happens,  the  fever  is  unusually 
severe,  the  addition  to  the  same  formula  of  four  cubic  centimeters  (fl.  3i) 
of  the  tincture  of  veratrum  viride,  will  render  it  more  efficient  in  reliev- 
ing the  patient  during  the  first  three  or  four  days,  or  until  the  crisis  of  the 
disease  is  passed.  During  the  first  three  days  of  treatment,  if  the  fever  is 
active,  tongue  coated,  and  urinary  secretion  scanty,  I  give  an  anodyne  dose 
of  the  compound  powder  of  opium  and  ipecac  (Dover's  powder)  with  from 
six  to  twenty  centigrams  (gr.  i  to  iii)  of  calomel  each  night  and  follow  it 
by  some  mild  saline  laxative  in  the  morning.  In  the  milder  cases  this  is 
not  necessary.  After  the  third  day  of  the  eruption,  in  the  great  majority 
of  cases,  no  other  medicine  is  required  than  a  mild  anodyne  exjiectorant 
three  or  four  times  a  day  until  the  cough  disappears.  Those  rare  cases  of 
a  malignant  or  haemorrhagic  character,  when  encountered,  must  be  treated 
in  the  same  manner  as  I  indicated  when  speaking  of  the  management  of 
cases  of  malignant  variola.  If  capillary  bronchitis,  lobular  pneumonia,  or 
other  local  inflammations  supervene  as  complications  during  the  progress  of 
any  grade  of  rubeola,  they  must  be  treated  in  the  same  manner  as  similar 
grades  of  inflammation  occurring  under  other  circumstances. 

Seqiielm. — The  most  frequent  and  important  diseases  observed  to  fol- 
low attacks  of  measles,  are  chronic  inflammations  of  the  conjunctiva  and 
tarsus  of  the  eyelids,  chronic  bronchitis,  scrofulous  adenitis,  and  phthisis. 
It  is  probable  that  these  results  are  restricted  mostly  to  persons  who 
possessed  some  degree  of  hereditary  predisposition  to  scrofula  or  tuber- 
culosis, prior  to  the  attack  of  the  eruptive  fever.  But  there  appears  to 
be  something  in  the  nature  of  the  changes  produced  in  the  blood  and  the 
properties  of  the  tissues  during  the  progress  of  measles  that  directly  in- 
crease these  predispositions  and  strongly  tend  to  convert  them  from  a 
latent  to  an  actively  developing  progress.  For  this  reason,  we  find  many 
cases  of  well-developed  phthisis,  particularly  between  the  ages  of  twelve 
and  twenty  years,  in  which  the  cough  is  very  definitely  dated  back  to  the 
time  when  they  had  the  measles.  For  the  purpose  of  more  eflectually 
preventing  such  results,  the  attending  physician  should  look  closely  both 
to  the  family  tendencies  and  the  individual  temperament,  in  all  cases  of 
this  form  of  eruptive  fever.  And  when  either  scrofulous  or  tuberculous 
tendencies  are  discovered,  as  soon  as  the  febrile  stage  is  passed  and  con- 
valescence commenced,  the  patient  should  be  put  at  once  upon  such  rem- 
edies and  diet  as  are  best  calculated  to  counteract  such  tendencies.    Among: 


EOTHELN.  241 

the  remedies  usually  resorted  to,  I  know  of  none  better  for  this  class  of 
cases,  than  a  mixture  of  two  parts  of  the  syrup  of  iodide  of  calcium  with 
one  of  fluid  extract  of  hops,  given  in  doses  of  three  to  six  cubic  centi- 
meters (fl  3ss  to  3iss),  according  to  the  age  of  the  patient,  and  repeated  after 
each  meal-time.  The  lacto-pliosphate  of  calcium,  the  compound  syrup  of 
hypophosphites,  and  cod-liver  oil,  may  be  used  for  the  same  purpose.  As 
far  as  possible,  such  cases  should  live  in  dry,  well- ventilated  rooms;  take 
plenty  of  plain,  easily  digestible  food,  and  moderate  but  habitual  out-door 
exercise.  When  some  degree  of  cough,  with  moderate  loss  of  flesh,  con- 
tinues for  some  time  after  convalescence  is  completed,  a  change  to  a  mild, 
dry  climate  is  very  desirable. 

rOtheln. 

History. — From  the  close  of  the  fifteenth  century,  at  which  time  Ali 
Abbas  described  an  exanthematous  epidemic  prevalent  in  Venice,  to  the 
present  time,  it  is  possible  to  find  evidence  of  the  existence  of  a  conta- 
gious eruptive  fever,  closely  resembling  in  many  respects  scarlatina  and 
rubeola  and  often  confounded  with  them,  but  really  distinct  from  both. 
During  the  last  half  of  the  eighteenth  century,  the  disease  was  described  by 
German  physicians  under  the  name  of  rubeola,  while  during  the  same  period 
in  France  and  England  it  was  described  under  the  name  of  roseola,  and  in 
this  country  it  was  called  G-erman  measles,  false  measles  and  rose  rash.  In 
1874  it  prevailed  as  an  epidemic  in  New  York  City,  and  was  accurately 
described  by  Dr.  J.  Lewis  Smith  in  the  Sanitarian  for  July,  1874.  Since 
that  time  it  has  made  its  appearance  in  man}'  places  throughout  the  Mid- 
dle, Southern  and  Western  States.  It  prevailed  quite  extensively  in 
Charleston,  S.  C,  in  the  early  part  of  1880;  in  Philadelphia  and  New 
York,  in  the  winter  of  1880-81  ;  and  during  the  latter  period  and  the 
spring  of  1881,  it  was  prevalent  in  Chicago,  and  in  several  places  in  In- 
diana, Illinois,  Michigan,  Missouri,  and  Nebraska. 

Its  prevalence  in  Chicago  was  well  described  by  Drs.  0.  W.  Earle  and 
Roswell  Park,  in  brief  papers  read  to  the  meeting  of  the  Illinois  State 
Medical  Society  in  May,  1881.* 

Causes. — Nothing  is  known  concerning  the  etiology  of  this  disease, 
except  that  it  appears  to  prevail  most  under  the  same  conditions  of  climate, 
season  and  sanitary  regulations  that  favor  the  prevalence  of  measles  and 
scarlatina,  and  that  it  is  propagated  by  a  specific  contagium  entirely  dis- 
tinct from  the  contagiums  of  both  the  diseases  just  named.  Its  independ- 
ent character  is  proved  by  the  fact  that  it  attacks  those  who  have  pre- 
viously had  measles  and  scarlet  fever  as  readily  and  severely  as  it  does 
those  who  have  never  had  either.  This  fact  was  fully  illustrated  in  the 
cases  observed  by  Dr.  Park,  as  described  in  the  paper  already  alluded  to. 
A  large  majority  of  his  cases  were  observed  among  the  ii.mates  of  the 
Protestant  Orphan  Asylum  in  this  city,  where,  out  of  140  children,  95 
were  attacked  vpith  rOtheln,  a  large  proportion  of  whom  had  suffered 
attacks  of  true  measles  in  the  same  institution  only  one  year  previous. 
That  age  exerts  a  predisposing  influence  is  shown  by  the  fact  that  three- 
fourths  of  all  the  cases  noted  have  occurred  between  the  ages  of  two 
and  fifteen  years.  Of  130  cases  observed  by  Emminghaus,  only  six  were 
adults  ;  of  the  95  cases  seen  by  Dr.  Park  in  the  asylum,  two  were  adults; 
while  of  54  cases  seen  by  J.  Lewis  Smith,  six  were  adults. 

Symptoms. — After  a  period  of  incubation,  not  very  accurately  ascertain- 
ed, but  of  two  or  three  weeks  duration,  the  disease  called  rotheln  commen- 

*See  Transactions  of  the  Illinois  State  Medical  Society  for  1881,  pp.  292--301. 

16 


242  EOSEOLA. 

ces,  with  very  little  primary  fever;  generally  one  day  of  slight  feelings  of 
indisposition,  such  as  moderate  headache,  sense  of  weariness,  and  sensi- 
tiveness to  atmospheric  changes;  and  then  an  efflorescence  of  red  points 
begins  to  appear  on  the  surface  of  the  neck  and  upper  part  of  the  chest, 
and  rapidly  extends  over  most  of  the  cutaneous  surface,  accompanied  by 
some  itching  or  tingling,  with  slight  stuffing  of  the  nostrils  and  redness 
of  the  eyes.  The  pulse  is  only  slightly  increased  in  frequency,  and  the 
temperature  elevated  not  more  than  from  one  to  three  degrees  above 
the  natural  standard.  In  some  cases  there  is  moderate  redness  and 
soreness  of  the  fauces,  with  swelling  of  the  glands  in  the  neck,  but 
not  in  all.  The  eruption,  or  rash,  is  neither  papular  nor  vesicular,  but 
consists  of  small  red  points  intermediate  between  those  of  measles  and  scar- 
let fever,  being  smaller  and  less  clustered  in  groups  than  the  former,  and 
less  numerous,  with  more  natural  colored  skin  between  them  than  the  lat- 
ter. The  eruption  and  general  symptoms  usually  increase  moderately  for 
one  or  two  days,  and  then  begin  to  decline  with  such  rapidity  that  most 
of  the  patients  may  be  regarded  as  convalescent  at  the  end  of  the  first 
week.  I  have  seen  a  few  cases,  however,  in  which  the  soreness  of  the 
throat  and  inflammation  of  the  glands  behind  and  beneath  the  angles  of 
the  jaw,  were  sufficiently  severe  to  protract  the  sickness  until  the  end  of 
the  second  or  even  into  the  third  week. 

Prognosis. — From  the  description  I  have  given,  you  will  infer  that  the 
disease  called  rotheln  is  a  very  mild  form  of  exanthematous  fever,  of  short 
■duration,  and  uniformly  tending  to  recovery.  I  have  seen  no  fatal  cases, 
and  none  followed  by  important  sequelse.  Of  the  one  -hundred  cases  re- 
ported on  by  Dr.  R.  Park,  and  the  forty  mentioned  by  Dr.  Earle,  as  occur- 
ring under  their  observation  in  this  city  in  the  winter  and  spring  of  1881, 
:none  proved  fatal.  In  a  very  small  number  of  cases,  pneumonia,  and  gas- 
tric and  intestinal  irritations  have  occurred  as  complications,  but  not  in 
■sufficiently  severe  form  to  cause  a  fatal  termination. 

Diagnosis. — The  only  diseases  with  which  rotheln  is  likely  to  be  con- 
founded are,  rubeola,  scarlatina  and  roseola.  From  the  first  it  is  readily 
distinguished  by  the  almost  entire  absence  of  premonitory  or  primary 
fever,  and  of  all  bronchial  cough  or  severe  catarrhal  symptoms;  from  the 
second,  by  the  absence  of  primary  fever,  the  very  slight  disturbance  of 
pulse  and  temperature,  and  the  less  uniform  diffusion  of  the  rash  over  the 
whole  cutaneous  surface;  from  the  third,  by  the  fact  that  the  eruption  is 
in  the  form  of  small  red  points,  while  in  roseola  the  eruption  is  in  red 
spots,  varying  in  size  from  the  circumference  of  a  small  pea  to  that  of  a 
dime. 

Treatment. — The  great  majority  of  cases  of  rotheln  require  only  rest 
and  proper  attention  to  the  hygienic  conditions  connected  with  the  patient. 
A  few  of  the  more  severe  cases  may  be  treated  in  the  same  manner  as  I 
have  advised  for  scarlatina  simplex. 

ROSEOLA. 

Clinical  Sistory. — The  disease  properly  called  roseola  frequently 
occurs  simply  as  a  complication  of  other  affections,  as  gastric  derange- 
ments, articular  rheumatism,  the  primary  fever  of  variola  and  varioloid, 
and  as  the  result  of  taking  certain  kinds  of  food  and  medicines,  as  straw- 
berries, shell-fish,  balsam  copaiba,  iodide  of  potassium,  oil  of  turpentine, 
etc.  In  these  cases  it  has  been  styled  roseola  symptomatica,  and  requires 
no  attention  except  that  which  relates  to  a  removal  of  its  cause.  The 
disease  is  also  met  with  occasionally    as  a  mild  idiopathic  febrile  affection, 


PERTUSSIS.  243 

of  brief  duration  and  devoid  of  dano;er  to  the  patient.  It  is  neither  con- 
tao-ious  nor  communicable  by  inoculation,  but  sometimes  prevails  as  an 
epidemic.  The  initial  stage  is  usually  from  one  to  three  days'  duration, 
and  characterized  by  moderate  dull  pains  in  the  head,  back  and  limbs, 
■with  only  a  slio-ht  increase  in  the  frequency  of  the  pulse  or  elevation  of 
temperature,  and  but  little  disturbance  of  the  secretory  functions.  On 
the  second  or  third  day  the  eruption  appears  nearly  simultaneously  on  the 
body  and  extremities,  in  the  form  of  simple  red  spots,  varying  in  size 
from  two  to  ten  millimeters  in  diameter,  not  elevated,  and  from  which  the 
redness  temporarily  disappears  on  pressure.  The  color  varies  in  different 
cases  from  a  bright  red  to  a  purplish  hue.  These  rose  spots  are  accom- 
panied by  only  a  very  slight  sense  of  heat  or  itching,  and  they  generally 
disappear  in  two  or  three  days,  without  leaving  desquamation  or  rough- 
ness, and  the  patient  is  convalescent.  In  a  few  instances  the  convales- 
cence is  delayed  a  few  days  by  the  eruption  appearing  in  two  or  three 
successive  crops  two  or  three  days  apart.  Careful  attention  to  the  brief 
description  I  have  given  will  enable  you  to  distinguish  it  from  all  the  oth- 
er eruptive  fevers.  It  is  not  often  accompanied  by  any  important  compli- 
cations, neither  is  it  followed  by  any  characteristic  sequelae. 

Treatment.^ K.  large  majority  of  the  cases  require  only  proper  attention 
to  the  hygienic  conditions  influencing  the  patient,  but  when  called  to  the 
more  active  class  of  cases,  I  have  generally  directed  from  four  to  six  grams 
(3i  to  3iss)  of  the  bi-tartrate  of  potassium  to  be  dissolved  in  a  tumblerful 
of  cold  water,  to  which  a  little  sugar  may  be  added,  and  a  tablespoonful 
of  this  solution  taken  every  two  or  three  hours,  until  the  urinary  secretion 
})ecomes  free  in  quantity  and  the  bowels  a  little  relaxed.  In  malarious 
districts  it  may  be  well  to  give  the  patient  a  moderate  dose  of  sulphate  of 
quinia  once  or  twice  a  day  during  the  convalescence. 

}  PERTUSSIS. 

Pertussis,  or  whooping-cough,  though  not  an  eruptive  fever,  is,  never- 
theless, a  specific,  contagious  affection,  self-limited  in  duration,  and 
attacking  chiefly  children  and  youth.  It  has  been  recognized  and  ac- 
curately described  from  an  early  period  in  medical  history.  Though  pre- 
vailing chiefly  among  children,  and  occurring  but  once  in  the  same  indi- 
vidual, yet  no  agre  is  exempt  from  liability  to  an  attack,  and  second  attiicks 
in  -the  same  person  are  occasionallv  met  with. 

Causes. —  It  is  probable  that  whooping-cough  arises  solely  from  a  specific 
contagium,  generated  in  the  bodies  of  those  affected  with  the  disease,  and 
emitted  with  the  breath  from  the  air  passages,  and,  perhaps,  with  the  ex- 
halations from  the  skin  also,  during  the  whole  active  progress  of  the 
disease. 

Of  the  special  nature  of  this  contagium  we  have  no  satisfactory  knowl- 
edge. In  1871,  Setzerich  claimed  to  have  discovered  fungoid  germs  in 
the  epithelium  of  the  air  tubes,  which  he  was  disposed  to  regard  as  the 
specific  cause.*  Somewhat  similar  observations  have  been  made  by  Buhl, 
Oertel,  and  a  few  others,  but  not  sufficient  to  show  either  the  uniformity  of 
the  presence  of  such  germs  from  the  beginning  of  the  disease,  or  their  caus- 
ative agency  when  they  are  present.  A  large  majority  of  the  cases  occur 
in  children  under  eight  years  of  age;  the  susceptibility  to  the  action  of 
the  contagium  apparently  diminishing  with  the  advance  of  age  from  eight 
years  upward.     Statistics  also  show  a  larger  number  of  attacks  in  females 

*  See  Quarterly  Journal  of  Microscopical  Science,  April,  1871. 


244  PEETUSSIS. 

than  in  males.  It  may  occur  at  any  season  of  the  year,  and  in  any  climate, 
but  epidemics  have  been  observed  to  occur  more  frequently  in  the  transi- 
tion seasons  of  the  year. 

Syrnptoms. — After  a  period  of  incubation,  varj-ing  from  one  to  two 
weeks,  the  initial  symptoms  develop  gradually,  and  consist  of  slight  gen- 
eral fever,  the  temperature  being  from  one  to  three  degrees  above  natural, 
skin  dry,  face  flushed,  pulse  from  ninety  to  ninety-five  per  minute  ;  a  sense 
of  tightness  and  soreness  in  the  chest,  hoarseness,  and  a  moderate  degree 
of  cough.  In  some  cases  the  symptoms  commence  with  chilliness,  followed 
by  headache,  in  addition  to  the  other  symptoms  just  named.  The  aggre- 
gate of  symjDtoms  I  have  named  usually  increase  through  the  first  week, 
at  the  end  of  which  the  general  febrile  phenomena  have  reached  their 
acme  ;  the  local  soreness  in  the  chest  and  air  passages  has  increased  ;  and 
the  cough  has  become  more  frequent,  and  shows  in  a  more  marked  degree 
the  characteristic  feature,  which  consists  in  a  rapid  succession  of  short, 
quick,  spasmodic  coughs,  without  inspiration,  until  the  collapse  of  the 
chest  is  complete,  when  the  inspiratory  act  is  caught  full,  either  with  or 
without  a  loud,  stridulous  sound,  called  the  whoop.  No  sooner,  however,  is 
the  chest  again  filled  by  the  inspiration  than  another  succession  of  rapid 
coughs  occur,  until  the  air  is  exhausted  and  the  face  becomes  very  red,  when 
another  protracted  inspiration  re-supplies  the  exhausted  air  cells.  At  this 
stage  the  paroxysms  of  coughing  usually  consist  of  only  one  or  two  series 
of  these  rapidly  repeated  acts  of  coughing,  ending  in  a  prolonged  inspira- 
tion, with  congestion  of  blood  in  the  face  and  eyes  during  the  parox- 
ysm. The  expectoration  is  still  scanty,  tenacious,  and  difficult  to  dislodge. 
During  the  second  week  the  general  febrile  symptoms  remain  stationarj^, 
or  rather  decline,  but  the  paroxysms  of  coughing  steadily  increase  in  fre- 
quency and  severity,  until,  at  the  end  of  the  week,  each  paroxysm  consists 
m  three  or  four  series  of  the  very  rapid,  spasmodic  hacks  or  coughs,  with  the 
rough,  stridulous,  whooping  inspiration  between  them,  until  the  face  be- 
comes turgid  and  even  purple,  and  the  little  suft'erer  appears  extremely 
weary.  Sometimes,  especially  in  very  young  children,  the  severe  par- 
oxysms of  coughing  and  strangling  end  in  a  reversal  of  the  action  of  the 
stomach,  and  free  vomiting. 

Yet  in  a  few  minutes  the  fullness  and  redness  of  the  face  subsides,  the 
feeling  of  weariness  passes  away,  and  the  patient  resumes  his  play  and 
cheerfulness  until  the  approach  of  the  next  paroxysm.  During  the  third 
week,  although  there  remains  no  fever  and  but  little  derangement  of  the 
secreting  and  excreting  functions,  yet  the  paroxysms  of  cou2:hing  maintain 
their  frequency  and  full  degree  of  severity,  causing  the  face  to  look  con- 
stantly more  or  less  bloated  and  pufi"y  around  the  eyes;  the  expectoration 
more  abundant  and  opaque  or  puruloid,  and  the  patient  to  look  wearx^, 
pale,  and  somewhat  emaciated.  With  the  close  of  the  third  week,  the  dis- 
ease generally  begins  to  decline. 

The  paroxysms  of  coughing  become  graditally  less  frequent  and 
severe;  the  appetite  begins  to  improve;  the  mind  is  more  cheerful;  the 
sleep  at  night  more  continuous;  and  by  the  end  of  the  fifth  or  sixth  week 
all  the  characteristic  s^-mptoms  of  the  disease  have  disappeared.  When 
left  to  pursue  its  own  course,  the  average  duration  of  whooping-cough  is 
five  or  six  weeks;  but  I  have  seen  very  mild  cases  terminate  in  three,  and 
unusually  severe  ones  continue  from  nine  to  twelve  weeks.  AVhile  the 
symptoms  I  have  detailed  are  those  which  essentially  characterize  the  sev- 
eral stages  of  the  disease,  particular  cases  present  additional  symptoms 
and  complications  requiring  attention.  In  some,  during  the  first  one  .or 
two  weeks  which   constitute  the  febrile   stage,  the  soreness   in  the    chest, 


DIAGNOSIS    AND    PATHOLOGY.  245 

shortness  of  breath,  and  frequency  of  pulse,  are  accompanied  by  a  mixture 
of  moist  and  dry  rales  in  one  or  both  sides  of  the  chest,  vvithout  dullness  on 
percussion,  and  indicate  an  unusually  active  bronchitis.  When  those  same 
symptoms  are  accompanied  by  a  still  higher  febrile  heat,  a  short  expiratory 
act,  and  some  dullness  over  certain  portions  of  the  chest,  they  indicate 
bronchitis  with  lobular  pneumonia,  a  dangerous  complication,  more  fre- 
quent in  very  young  children,  than  in  older  patients.  When  the  cough 
reaches  its  greatest  severity,  which  is  generally  during  the  third  week,  the 
protracted  repetition  of  the  act  of  coughing  forces  the  expiratory  act  to 
such  extreme  that  the  circulation  is  temporarily  arrested  in  the  pulmonary 
capillaries,  causing  fullness  of  the  right  cavities  of  the  heart,  distension 
of  the  veins  of  the  neck  and  face,  giving  rise,  not  only  to  the  turgid  and 
swollen  condition  of  the  face,  but  in  some  free  bleeding  from  the  nose;  in 
others  vertigo,  with  great  sense  of  exhaustion  for  a  few  moments  after  each 
paroxysm;  and  in  a  very  few,  general  convulsions. 

The  last  named  accident  or  complication  seldom  occurs  except  in  such 
children  as  are  hereditarily  predisposed  to  scrofula  or  phthisis.  I  have 
seen  a  few  cases  of  this  class,  in  which  there  occurred  an  occasional  con- 
vulsion, and  in  the  fourth  and  fifth  weeks  they  become  pale  and  much 
worn ;  the  eyes  lost  their  paralellism,  they  became  subject  to  frequent 
spells  of  choking,  accompanied  by  spasmodic  movements  of  the  eyeballs, 
and  when  the  fontanelles  had  not  fully  closed,  the  head  slowly  enlarg-ed, 
showing  unmistakeable  evidence  of  serous  effusion  between  the  pia  mater 
and  arachnoid  membranes.     Such  cases  usuallj^  terminate  fatally. 

JP^'ognosis. — Very  few  cases  of  uncomplicated  whooping-cough  termi- 
nate fatally.  Cases  have  been  reported  in  which  death  appeared  to  re- 
sult from  suffocation  or  direct  collapse  of  the  lungs  during  the  violent 
paroxysms  of  coughing.  In  other  cases  the  strong  determination  of 
blood  to  the  head  during  the  coughing  has  induced  such  a  degree  of 
capillary  congestion  of  the  brain  as  to  cause  speedy  death  from  apo- 
plexy or  paralysis.  No  cases  of  this  kind  have  come  under  my  observa- 
tion, and  I  apprehend  their  occurrence  is  very  rare.  Most  of  the  deaths 
attributed  to  whooping-cough  in  the  bills  of  mortality  are  the  result  of 
capillary  bronchitis,  pneumonia,  or  cerebral  disease. 

In  the  summer  se.ason,  the  disease  in  young  children  often  becomes 
complicated  with  ilio-colitis  or  serous  diarrhoea,  under  the  influence  of 
which  they  emaciate  rapidly  and  sometimes  die  from  exhaustion. 

Diagnosis. — During  the  first  or  febrile  stage  of  whooping  cough,  the 
symptoms  are  so  much  like  those  of  a  sub-acute  bronchitis,  that  it  is  not 
always  easy  to  make  a  positive  diagnosis.  But  generally  the  cough  and 
fever,  even  during  this  stage,  are  out  of  proportion  to  the  physical  signs 
of  bronchitis.  And  a  little  later,  when  the  fever  and  the  physical  signs 
of  bronchitis  are  both  declining,  if  the  paroxysms  of  coughing  are  increasing 
in  severity,  and  assuming  more  the  spasmodic,  rapid  repetitional  character, 
there  can  be  no  doubt  concerning  the  true  nature  of  the  disease. 

Special  Pathology. — That  the  contagium  or  specific  cause  of  the  disease 
develops  its  morbid  effects  mainly  upon  the  par  vagus  and  pneumogastric 
nerves,  there  can  be  no  doubt.  And  yet  there  is  also  a  certain  degree  of 
irritation  of  the  bronchial  mucous  membrane,  so  uniformly  present  as  to 
constitute  a  necessary  part  of  the  pathological  conditions  constituting  the 
disease.  In  some  fatal  cases,  some  of  the  bronchial  glands  were  found  en- 
larged, which  gave  rise  to  the  idea  that  all  the  phenomena  of  the  disease 
were  caused  by  the  pressure  of  such  enlarged  glands  on  the  nerves.  But 
there  is  no  proof  that  such  enlargements  generally  exist  in  cases  of  this 
disease,  or  that  when  observed  they  are  any  more  than  accidental  com- 
plications. 


45  c.  c. 

fiss. 

15      " 

|ss. 

60      " 

§ii. 

246  PERTUSSIS. 

Treatment. — Viewing  the  disease  as  an  irritation  of  the  nerves  just 
mentioned,  and  of  the  bronchial  mucous  membrane,  caused  by  a  specific 
poison,  for  which  we  know  of  no  reliable  antidote,  the  practical  indications 
for  treatment  are,  to  lessen,  as  far  as  possible,  the  irritative  effects  of  the 
specific  cause  on  the  nervous  and  membranous  structures  involved,  and  to 
prevent  the  more  important  complications.  During  the  febrile  stage, 
embracing  the  first  one  or  two  weeks,  I  have  long  been  in  the  habit  of 
using  the  following  combination  : 

Yf.      Svrupus   ScilUe    Compositi, 
Tincturfe  Sanguinarise, 
Tinctura?  Opii  Caraphoratge, 
Potassii  Bromidi,  15  grams      fss. 

Mix.  Of  this  I  give  to  children  five  years  of  age,  1.33  cubic  centimeters  (min. 
xx)  everj-  three,  four,  or  six  hours,  according  to  the  activity  of  the  symp- 
toms, and  to  adults,  four  cubic  centimeters,  or  (fl.  3i.)  at  the  same  inter- 
vals. Each  dose  should  be  mixed  with  a  little  additional  sweetened  watpr 
when  taken.  In  this  mixture  we  have  a  mild  anodyne  expectorant,  well 
calculated  to  allay  bronchal  irritation,  and  an  efficient  sedative  to  nervous 
excitability.  In  cases  presenting  a  coated  tongue,  dry  skin,  high  colored 
urine,  with  considerable  elevation  of  temperature,  I  give  a  single  dose  of 
thirteen  centigrams  of  calomel  (gr.  ii.)  with  two  decigrams  of  sodium  bi- 
carbonate (gr.  iii.)  for  a  child  from  four  to  six  years  of  age,  and  if  it  does 
not  move  the  bowels  freely  in  six  or  eight  hours,  follow  it  by  some  mild 
laxative,  and  subsequently  give  a  moderate  dose  of  quinine  each  night  and 
morning.  After  the  first  two  weeks  have  passed  atid  the  paroxyms  of 
coughing  have  assumed  their  full  spasmodic  character  unaccompanied  by 
general  fever,  I  have  found  no  remedies  more  efficient  in  lessening  the  se- 
verity of  the  paroxyms,  and  shortening  the  duration  of  the  disease,  than  bel- 
ladonna, given  in  such  doses  and  at  such  intervals  as  to  keep  its  effects  just 
below  that  which  would  dilate  the  pupils  and  cause  unpleasant  dryness  of 
the  mouth  and  throat,  and  one  moderate  anti-periodic  dose  of  sulphate  of 
quinine  each  morning  and  evening.  A  great  variety  of  remedies  have 
been  recommended,  such  as  chloral  hydrate,  ammonium,  bromide,  loljeba. 
musk,  camphor,  cochineal,  nitric  acid,  nitrite  of  amyl,  and  the  iiiiialat.on 
of  various  anodyne  or  anti-spasmodic  vapors  ;  and  when  judiciously 
used,  nearly  all  of  them  are  capable  of  doing  some  good.  If  during  all 
the  middle  and  later  stages  of  the  disease,  you  so  direct  your  rem- 
edies as  to  sustain  the  tone  of  the  digestive  organs,  ward  ofi"  important 
complications,  and  keep  the  patient  moderately  under  the  influence  of 
quinine  and  such  anti-spasmodics  as  more  especially  lessen  the  excita- 
bility of  the  respiratory  system  of  nerves,  you  will  rarely  fail  to  con- 
duct your  patients  to  a  good  and  comparatively  early  convalescence. 
After  the  first  week,  or  the  stage  of  most  fever,  the  patients  should  be 
allowed  a  liberal  diet  of  plain  food ;  encouraged  to  go  out  freely 
in  the  open  air,  taking  care  only  that  they  be  so  clothed  as  to  protect 
them  as  well  as  possible  from  sudden  and  severe  atmospheric  changes; 
but  they  should  never  be  kept  closely  confined  within  doors  or  shut  up 
in  over  heated-rooms.  If  complications,  such  as  pneumonia,  gastric  and 
intestinal  irritations,  cerebral  congestion  or  convulsions,  occur,  they  must 
be  treated  on  the  same  principles,  and  with  the  same  remedies  as  would 
be  appropriate  for  these  several  affections  under  any  other  circumstances. 
A  certain  degree  of  sensitiveness  of  the  stomach,  giving  rise  to  ready 
vomiting  during  the  more  severe  paroxysms  of  coughing,  is  present  in  ma- 


PAROTITIS.  247 

ny  cases,  espr-cially  in  young  children,  and  instead  of  beinj^  prejudicial, 
rather  cuts  short  the  paroxysms  and  helps  to  relieve  the  patient. 

Sequehe. — The  more  important  afiPections  liable  to  follow  vvhooping- 
coufh  are,  phthisis,  emphysema,  chronic  capillary  bronchitis,  scrofulous  en- 
largement of  the  glands  of  the  neck,  and  hydrocephalus.  When  these  affec- 
tions become  actually  devoloped,  their  management,  hygienic  and  medical, 
must  be  the  same  as  would  be  proper  under  any  other  circumstances. 

But  much  can  be  done  during  the  later  stages  of  the  disease  and  through 
the  ordinary  period  of  convalesence  to  prevent  the  development  of  these 
affections  if  due  attention  is  given  at  the  proper  time.  It  is  chiefly  in 
children  and  young  persons  who  are  predisposed,  by  hereditary  influences 
or  otherwise,  to  scrofula  or  tuberculosis  that  we  find  the  diseases  named 
as  sequelre  of  "whooping-cough.  Consequently,  whenever  called  to  pa- 
tients with  such  predispositions,  the  practitioner  should  be  on  the  alert 
and  commence  as  early  as  practicable  to  counteract  the  unfavorable  ten- 
dency by  the  use  of  such  remedies  as  the  hypophosphites,  extract  of  malt, 
cod-liver  oil,  a  change  of  air,  aud  all  those  hygienic  influences  that  are 
calculated  to  improve  nutrition  and  the  general  tone  of  health. 

MUMPS. 

Parotitis  contagiosa,  or  mumps,  is  a  mild,  febrile  affection,  accompanied 
by  a  specific  or  peculiar  grade  of  inflammation  of  the  parotid  glands,  run- 
ning a  definite  self-limited  course,  and  dependent  for  its  propagation  on  a 
contagion  generated  in  the  bodies  of  the  sick.  Of  the  nature  or  form  of 
such  contagion  nothing  is  definitely  known.  The  disease  has  often  pre- 
vailed in  an  epidemic  form,  attacking  large  numbers  in  a  community  with- 
in a  limited  period  of  time.  The  period  of  life  most  susceptible  to  its  at- 
tacks is  from  fifteen  to  thirty  years  of  age.  Males  are  more  susceptible 
than  females.  Cases  have  been  observed  at  all  periods  of  life,  from  in- 
fancy to  old  age.  The  disease  very  rarely  attacks  the  same  individual  a 
second  time. 

The  period  of  incubation  between  the  reception  of  the  poison  and  the 
commencement  of  active  symptoms,  is  variously  stated,  from  one  to  three 
weeks,  but  I  think  it  is  in  the  great  majority  of  cases  between  nine  and 
fourteen  days. 

Syrnptoms. — The  active  symptoms  are  usually  ushered  in  by  slight  chil- 
liness, followed  in  a  short  time  by  moderate  general  fever,  indicated  by 
some  pains  in  the  head,  back,  and  limbs;  increase  of  one  or  two  degrees 
in  temperature;  some  increased  frequency  of  pulse;  lessening  of  cuta- 
neous and  urinary  secretions;  and  generally  slight  feeling  of  soreness  or 
stiffness  of  the  parts  behind  the  angle  of  the  jaw.  In  from  twelve  to 
twenty-four  hours  after  the  commencement  of  the  general  symptoms,  a  dis- 
tinct swelling,  accompanied  by  some  pain  and  tenderness,  appears  in  one 
or  both  of  the  parotid  regions,  caused  by  an  inflammation  of  the  parenchy- 
ma of  the  gland  itself.  The  swelling  and  other  local  symptoms  increase 
for  two  days,  when  the  disease  is  at  its  height.  The  swollen  gland  stands 
out  prominently  behind  the  angle  of  the  jaw,  lifting  out  the  lobe  of  the 
ear  and  obstructing  the  opening  of  the  mouth.  Deglutition  is  also  more 
or  less  impeded  and  often  accompanied  by  sharp  pains  darting  in  the  di- 
rection of  the  ears,  especially  in  swallowing  acid  substances.  During  the 
third,  fourth  and  fifth  days,  more  or  less  serous  infiltration  takes  place 
into  the  areolor  tissue,  around  and  below  the  parotid  gland,  adding  to  the 
area  of  swelling  and  giving  it  a  semi-oedematious  feel,  more  pai-ticularly 
in  the    sub-maxillary  region.     By  the    end  of  the   fourth   day  the  general 


248  PAROTITIS. 

febrile  symptoms  have  usually  disappeared,  and  the  decline  of  the  local  in- 
flammation and  swelling  follows  with  such  rapidity  that  the  patient  is  fully 
convalescent  at  the  end  of  the  week.  In  some  cases  the  inflammation  at- 
tacks only  one  parotid  gland  first,  and  when  this  has  nearly  completed  its 
course,  the  other  gland  becomes  involved  in  the  same  manner,  and  the  sick- 
ness is  thus  prolonged  through  the  greater  part  of  the  second  week. 

In  rare  instances  an  inflammation,  similar  to  that  of  the  parotid  gland, 
attacks  one  or  both  testicles  in  the  male,  and  the  mammary  glands  and 
ovaries  in  the  female.  It  is  generally  supposed  that  these  erratic  or  mis- 
placed inflammations  result  from  a  sudden  recession  or  transference  from 
the  parotid  to  the  other  parts;  but  in  the  very  few  cases  that  have  come 
under  mv  observation,  the  orchitis  supervened,  while  the  inflammation  and 
swelling  was  still  progressing  in  the  parotid  regions  as  usual.  When  the 
testicles  are  attacked  they  become  painful,  very  tender  to  the  touch,  and 
much  swollen,  and  the  general  febrile  symptoms  are  much  increased.  In 
one  case,  to  which  I  was  called  about  the  fifth  day  after  the  commence- 
ment of  the  disease,  I  found  both  parotid  regions  still  swollen,  hard  and 
tender,  and  both  testicles  were  swollen  to  three  or  four  times  their  natural 
size,  accompanied  by  high  fever  and  some  delirium.  The  inflammation  of 
the  testicles  usually  increases  in  intensity  during  the  first  three  days,  re- 
mains stationary  one  or  two  days,  and  then  rapidly  declines,  leaving  the 
organs  in  most  instances  in  their  natural  condition,  but  sometimes  atro- 
phied and  impaired  in  function.  I  have  not  met  with  a  case  of  mumps  in 
which  the  mammary  glands  or  ovaries  were  attacked  with  inflammation ; 
and,  though  such  cases  are  on  record,  I  think  they  occur  very  rarely. 
Equally  rare  is  it  that  the  inflammation  is  transferred  to  the  brain,  pro- 
ducing all  the  symptoms  of  acute  meningitis. 

Diagnosis. — The  diagnosis  of  this  disease  is  not  generally  difficult.  It 
is  distinguished  from  ordinary  cases  of  adenitis  or  inflammation  of  the 
glands  of  the  neck,  first  by  the  occurrence  of  distinct  general  febrile  symp- 
toms preceding  the  local  swellings,  and  second  by  the  location  and  shape 
of  the  swelling  itself.  The  swelling  in  mumps,  consisting  principally  in 
an  enlargement  of  the  whole  parenchyma  of  the  parotid  gland,  not  only 
bulges  out  directly  behind  the  ramus  of  the  jaw,  but  soon  somewhat  over- 
laps, a  little  the  ramus  and  always  lifts  out  the  lobe  of  the  ear.  The  latter, 
is  peculiar  to  swelling  of  the  parotid  gland;  and,  as  acute  inflammation 
and  rapid  swelling  of  this  gland  is  very  rare,  except  when  caused  by  the 
contagion  of  mumps,  it  affords  a  reliable  diagnostic  mark  of  that   disease. 

Prognosis. — I  have  never  known  a  case  of  this  disease  to  terminate 
fatally.  Its  tendency  is  uniformly  towards  recovery,  unless  it  becomes 
complicated  with  meningitis  or  inflammation  of  some  other  important  in- 
ternal organ.  It  is  not  often  that  the  disease  is  followed  by  important 
sequelae.  Atrophy  of  the  testicle  sometimes  follows  the  acute  stage  of 
orchitis,  and  sometimes,  though  very  rarely,  suppuration  takes  place, 
forming  abscesses  in  the  testicles.  This  last  result  occurs  only  in  such 
patients  as  are  strongly  predisposed  to  scrofula  or  tuberculosis. 

Treatment. — In  simple  uncomplicated  cases  of  mumps,  no  general  med- 
ication is  required.  Simply  remaining  within  doors  to  avoid  exposure  to 
fatigue  and  cold,  as  well  as  to  prevent  communicating  the  disease  to  oth- 
ers, is  desirable  in  all  cases.  The  swollen  glands  may  be  bathed  often 
with  a  liniment  composed  of  three  parts  of  camphorated  soap  liniment  and 
one  part  of  tincture  of  belladonna;  if  there  be  much  headache  and  restless- 
ness, a  fair  dose  of  bromide  of  potassium  may  be  given  every  evening, 
and  on  the  second  or  third  day,  if  the  bowels  have  not  moved,  a  mild 
saline  laxative  may  be  given  with  advantage.     The  diet  should  be  light 


CHRONIC    GENERAL    DISEASES.  249 

and  unstimulating  dui'ing  the  active  prog-ress  of  the  case,  but  the  same  as 
ordinary  after  convalescence  commences.  This,  gentlemen,  completes 
the  consideration  of  the  very  important  class  of  acute  general  diseases. 
At  the  next  lecture  hour  I  shall  commence  the  discussion  of  chronic  gen- 
eral diseases,  better  known  as  constitutional  affections. 


LECTUEE  XXVII. 

Chronic  General  Diseases— Diseases  included  under  this  head — Circumstances  common  to  them 
all — General  Etiological  and  Pathological  considerations  concerning  them — General  Treatment 
etc. 

GENTLEMEN  :  Having  completed  the  consideration  of  the  acute 
general  diseases,  I  now  invite  your  attention  to  the  second  division 
of  general  diseases  called  chronic  or  constitutional  affections.  Under  this 
head  belong  scrofula,  tuberculosis,  leucocythfemia,  pernicious  anaemia, 
Addison's  disease,  carcinoma,  constitutional  syphilis,  rheumatism  and  gout. 

Diverse  from  each  other  as  some  of  these  diseases  may  appear  to  be, 
they  nevertheless  have  a  sufficient  number  of  circumstances  in  common 
to  justify  their  being  grouped  together. 

First.  They  are  all  characterized  by  a  very  persistent,  if  not  permanent, 
alteration  of  the  natural  properties  of  the  tissues,  giving  rise  to  certain 
morbid  tendencies  or  predispositions  to  the  development  of  special  local 
affections  both  of  a  functional  and  structural  character. 

Second.  They  are  all  capable  of  being  transmitted  from  parent  to 
child — in  other  words,  of  being  perpetuated  by  hereditary  influence. 

Third.  So  far  as  relates  to  the  general  or  constitutional  morbid  condi- 
tion, there  is  no  tendency  to  a  self-limited  duration. 

Fourth.  They  all  arise  from  causes  acting  with  feeble  intensity,  but 
persistently,  through  long  periods  of  time,  and  of  such  a  nature  as  to  mod- 
ify one  or  both  of  the  elementary  properties  of  living,  organized  matter. 

In  all  these  particulars,  this  group  of  constitutional  diseases  stand  in  di- 
rect contrast  with  the  class  of  acute  general  diseases  which  we  have  already 
passed  in  review.  You  have  observed  that,  in  all  the  latter,  the  morbid 
manifestations  are  of  an  active  character,  leading  rapidly  to  functional  and 
structural  changes  of  limited  duration,  are  incapable  of  hereditary  trans- 
mission, and  arise  from  causes  acting  with  more  intensity,  but  of  limited 
duration,  one  full  impression  of  which  often  destroys  the  suscepti- 
bility to  any  further  action  of  the  same  cause.  On  the  contrary,  the 
diseases  I  am  about  to  discuss,  are  based  on  such  changes  in  the  proper- 
ties of  the  primary  organic  molecules  entering  into  the  various  structures 
of  the  body,  as  give  such  molecules  certain  tendencies  to  deviate  from  the 
natural  standard  or  type  of  development,  leading,  if  not  counteracted  by 
adverse  influences,  sooner  or  later,  to  such  alterations  in  the  molecular 
movements  constituting  nutrition  and  disintegration  as  to  develop  struct- 
ural changes,  consisting  of  local  hypertrophies,  atrophies,  tissue  degener- 
ations, or  morbid  growths,  according  to  the  degree  and  direction  of 
the  primary  deviations. 


250  CHEONIC    GENERAL   DISEASES. 

So  slight  and  occult  are  the  original  changes  in  the  properties  of  the 
organic  atoms  or  cells  that  the  constitutional  vice  or  defect  may  exist  for 
years  without  any  appreciable  structural  changes,  as  we  see  in  those  he- 
reditarily predisposed  to  pulmonary  tuberculosis,  carcinoma,  etc.,  and  yet 
if  at  any  time  during  the  life  of  such  individuals,  ordinary  exciting  causes 
chance  to  induce  local  irritation  or  inflammation,  the  presence  of  the  latent 
or  constitutional  condition  is  made  manifest  by  the  unusual  persistence  of 
the  local  morbid  action  and  the  special  tendency  to  degenerative  changes 
in  the  exudations  or  other  products  resulting  therefrom.  For  instance,  a 
child  possessing  the  scrofulous  diathesis  or  constitutional  condition,  if  ex- 
posed to  a  current  of  cold  air  upon  the  neck  may  have  inflammation,  exuda- 
tion, and  tumefaction  of  the  lymphatic  glands,  ending  either  in  permanent 
hyijertrophv,  caseous  degeneration,  or  destructive  suppuration;  when  the 
same  cause  provoking  a  similar  degree  of  inflammation  in  a  strictly  healthy 
child,  would  have  caused  but  a  temporary  exudation  and  swelling,  to  be 
followed  in  a  few  days  by  resolution  and  a  return  to  the  natural  condition. 
So  an  adult  with  the  tuberculous  diathesis  or  constitutional  condition,  at- 
tacked with  pneumonia  followed  by  the  usual  exudation,  will  be  likely  to 
have  such  exuditive  material,  undergo  either  purulent  degeneration  con- 
stituting diifuse  suppuration,  or  caseous  degeneration  and  early  phthisis, 
instead  of  resolution  and  re-absorption,  as  usual  in  subjects  previously 
healthy. 

That  the  primary  and  esseatial  pathological  condition  constituting  a 
chronic  general  disease,  constitutional  vice,  cachexia,  or  diathesis,  as  it  is 
variously  called  by  different  authors,  consists  in  a  morbid  condition  of 
one  or  both  of  the  inherent  properties  of  organized  living  matter* 
is  proved  both  by  its  liability  to  hereditary  transmission,  and  its 
persistence  indefinitely  with  a  well-known  tendency  to  develop,  sooner 
or  later,  specific  nutritive  changes  in  some  of  the  structures  of 
the  bod}'.  As  the  germinal  cell  or  aggregation  of  bioplasm  fur- 
nished by  the  female,  and  the  spermatozoa  furnished  by  the  male,  are 
both  living  organized  materials,  it  is  reasonable  to  suppose  that  they 
will  partake  of  the  same  properties,  whether  perfect  or  imperfect,  that 
belong  to  all  the  other  organized  atoms  of  the  bodies  in  which 
the}"  were  developed  ;  and  consequently  in  their  independent  subse- 
quent growth,  they  will  generalK  develop  the  same  morbid  tendencies 
as  were  possessed  by  the  parent.  The  modifications  of  the  properties  of 
the  germ  may  be  so  strong  as  to  lead  to  manifest  errors  of  nutrition  dur- 
ing the  development  of  the  foetus  in  utero,  or  at  any  time  during  the 
period  of  subsequent  growth,  or  so  feeble  as  not  to  cause  their  appear- 
ance until  after  the  climax  of  adult  life  in  the  early  stage  of  physical  de- 
cline. While  the  essential  pathology  of  all  this  class  of  diseases  consists  in 
some  modification  of  the  elementary  properties  that  govern  the  molecular 
changes  constituting  nutrition  and  growth,  these  modifications  not  only 
differ  in  degree  in  different  cases  in  the  same  constitutional  affection,  Imt 
they  also  differ  in  kind  or  direction  in  each  affection  from  all  the  others; 
so  that  the  local  manifestations  of  disease  developed  from  time  to  time 
during  the  progress  of  any  given  case,  are  peculiar  to  the  special  constitu- 
tional affection  to  which  the  case  belongs. 

For  instance,  the  general  morbid  condition  constituting  scrofula,  never 
grlves  rise  to  the  local,  functional  or  structural  changes  characteristic  of 
syphilis,  carcinoma,  or  leucocythgemia  and  vice  ve7\sa.  Neither  do  you  find 
the  rheumatic  constitution  giving  rise  to  the  local  inflammations  of  gout,  or 

*  See  Lecture  VI  of  the  present  course,  pp.  48-9. 


PATHOLOGY.  251 

the  reverse.  This  affords  further  proof  that  the  primary  or  fundamental 
patholoo^ical  condition  consists  in  som3  deviation  from  the  natural  condi- 
tion of  the  properties  inhering  in  the  organized  tissue  elemonts,inasmuch  as 
it  shows  obedience  to  the  universal  law  of  living  matter,  namely,  that  like 
begets  like.  It  is  true,  that  constitutional  syphilis  may  be  established  in  a 
sul)ject  already  scrofulous,  or  by  a  sufficient  exposure  to  the  proper  causes 
and  modes  of  living,  gouty  affections  may  be  engrafted  upon  a  previously 
rheumatic  diathesis;  but  this  in  no  proper  sense  invalidates  the  law  just 
stated  in  regard  to  the  fixed  tendencies  of  each  constitutional  disease. 
Another  fact  of  much  pathological  importance  is,  that  the  local  affections 
which  are  liable  to  appear  during  the  unrestrained  progress  of  any  one  of 
the  general  diseases  included  in  the  class  under  consideration,  are  not  ac- 
cidental complications,  but  natural  or  necessary  outgrowths  resulting  from 
the  progress  of  tiie  constitutional  vice.  They  may  be  hastened  in  their 
appearance,  or  rendered  more  severe  by  the  intervention  of  special  excit- 
ing causes,  or  the  influence  of  bad  sanitary  conditions.  And,  on  the  other 
hand,  their  development  may  be  retarded  or  entirely  prevented  by  the 
coml)ined  influence  of  good  climatic,  hygienic  and  sanitary  regulations. 

And  yet,  in  a  large  majority  of  cases,  it  is  the  local  morbid  develop- 
ments that  chiefly  occupy  the  attention  of  the  patient,  and  on  account  of 
which  he  seeks  the  aid  of  his  physician.  The  local  developments  resulting 
from  the  progress  of  the  scrofulous  diathesis,  appear  most  frequently  in  some 
part  of  the  adenoid  or  lymphatic  glandular  system,  and  next  in  the  cutaneous 
suiiace.  Those  of  the  tuberculous,  which  is  colsely  allied  to,  if  not  a  mere 
modification  of  the  scrofulous,  may  be  met  with  in  any  of  the  more  vascular 
structures  of  the  body,  but  are  most  frequent  in  the  lungs,  and  next  in  the 
mucous  membranes  and  lymphatic  glands.  In  leucoc3''thaemia  and  pseu- 
do-lencocythfemia,  the  almost  uniform  tendency  is  to  develop  hypertrophy 
or  increased  growth  of  the  lymphatic  glands  and  spleen. 

Etiology. — There  is  no  doubt  but  a  large  proportion  of  the  cases  of  the 
several  diseases  included  in  this  group  have  their  origin  primarily  in  heredi- 
tary influence.  This  I  have  endeavored  to  explain  already  ;  but  cases  are 
also  met  with  in  relation  to  which  no  hereditary  influence  can  be  traced. 
These  appear  to  have  had  their  origin  from  certain  causes  which  had 
been  permitted  to  act  steadily  through  long  periods  of  time,  and  yet  with 
so  moderate  a  degree  of  intensity  as  to  avoid  exciting  acute  general  dis- 
turbances. One  class  of  these  causes  produce  their  deleterious  effects  by 
acting  primarily  on  the  processes  of  digestion,  assimilation  and  nutrition  ; 
another  class  exert  their  influence  on  the  processes  of  disintegration  and 
elimination  of  waste  material.  To  the  first,  belong  insufficient  or  unwhole- 
t-ouie  food;  inadequate  supply  of  light,  heat,  and  pure  air  and  want  of 
proper  exercise.  To  the  latter,  belong  all  those  agents  and  influences 
that  slowly  but  persistently  retard  retrograde  metamorphosis  in  the  tissues, 
or  interfere  with  the  elimination  of  the  products  of  such  metamorphosis 
through  the  proper  excretory  organs,  such  as  continued  exposure  to  cold 
and  damp  air  ;  deficient  physical  exercise  ;  depressing  mental  emotions  ; 
the  habitual  use  of  alcoholic  drinks  ;  and  the  occupation  of  rooms  over- 
crowded, or  inadequately  supplied  with  air  and  sunlight.  Food  may  be 
insufficient  in  quantity,  or  in  the  variety  of  its  nutritive  constituents,  or 
of  such  quality  as  to  render  it  indigestible,  and  in  either  case,  the  blood 
will  become  more  and  more  defective  in  the  proportion  of  its  nutritive 
elements,  and  some  of  the  tissues  will  be  correspondingly  impoverished. 

There  are  but  few  persons  in  this  country  who  suffer  from  inability  to 
procure  a  sufficient  amount  of  food.  In  the  feeding  and  training  of  chil- 
dren, however,  errors  of  much  importance  are  frequent  among  all  classes. 


252  CHEOisric  general  diseases. 

Among  the  poor  we  often  find  large  families  living  on  the  coarser  and 
cheaper  articles  of  food,  with  but  little  variety  from  week  to  week,  and  at 
the  same  time  occujjying  damp,  uncleanly,  and  ill-ventilated  apartments  ; 
and  glandular  swellings,  chronic  ophthalmias,  caries  of  the  bones,  and 
other  local  evidences  of  scrofulous  and  tubercular  tendencies  are  com- 
mon among  them.  Quite  as  often  among  the  rich  and  fashionable  we 
find  the  infants  and  young  children  committed  to  the  care  of  nurses,  kept 
much  within  the  limits  of  the  nursery,  and  indulged  so  freely  in  the  use  of 
saccharine  matter,  consisting  of  sugar,  candies,  sweet-meats,  and  sweet- 
cakes,  at  any  and  all  times  of  the  day,  that  they  lose  all  relish  for  plain 
bread,  milk,  meat  and  other  nitrogenous  food.  The  result  is  that  thev 
grow  delicate,  slender,  thin  in  muscles,  with  narrow  chests,  unusual 
mental  vivacity,  and  extreme  susceptibility  to  all  kinds  of  impressions. 
The  anxious  mothers  always  assert  that  they  are  so  delicate  they  will  take 
cold  every  time  they  are  allowed  to  go  out.  It  is  among  the  children  so 
trained  that  we  find  many  of  the  best  samples  of  the  scrofulous  constitu- 
tional condition,  accompanied  by  frequent  temporary,  and  sometimes  per- 
manent, enlargement  of  the  lymphatic  glands  of  the  neck.  And  of  those 
belonging  to  the  same  class  who  live  beyond  childhood  and  youth,  there  are 
many  who  become  tuberculous  between  the  ages  of  eighteen  and  thirty 
years. 

Nothing  is  more  certainly  proved  by  abundant  observation,  than  the 
fact  that  long  continued  living  on  food  deficient  in  some  of  the  elements 
needed  for  healthy  growth  and  repair  of  living  structure,  is  capable  of 
modifying  the  assimilative  processes  in  such  a  way  as  to  develop  imperfect 
cells  and  other  tissue  elements.  And  if  to  the  use  of  food  thus  deficient, 
there  be  added  living  and  sleeping  in  inadequately  ventilated  apartments, 
too  little  habitual  exercise  of  the  muscles  of  the  chest  and  upper  extremi- 
ties, and  clothing  either  inadequate  for  protection  against  sudden  and  ex- 
treme atmosjDheric  changes  or  so  adjusted  as  to  impede  the  free  expansion 
of  the  chest,  you  have  a  combination  of  influences,  which,  if  long  continued 
are  certain  to  so  modify  the  properties  of  the  blood  and  organized  tissues 
of  the  body,  as  to  establish  some  one  of  the  special  diatheses  or  morbid 
constitutional  conditions,  whether  it  be  scrofulous,  tuberculous,  leucocythae- 
mic,  or  rheumatic.  It  is  also  true,  that  a  morbid  constitutional  condition 
thus  acquired,  if  well  established,  is  capable  of  being  transmitted  from  pa- 
rent to  child,  and  thus  start  a  new  line  of  hereditary  influence. 

A  somewhat  careful  study  of  the  etiology  of  constitutional  diseases,  has 
led  me  to  the  conclusion  that  the  habits  of  a  people  in  regard  to  diet,  drinks, 
dress,  occupations,  and  the  construction  and  cleanliness  of  houses,  have  far 
more  to  do  with  the  production  and  propagation  of  the  scrofulous,  tubercu- 
lous, leucocythgemic,  cancerous  and  gouty  diatheses,  than  the  elements  and 
influences  included  under  the  head  of  climate;  while  the  latter  exert  a  con- 
trolling influence  in  the  formation  of  the  rheumatic  predisposition.  While 
the  protracted  influence  of  low  temperature  and  dampness,  combined  with 
either  impure  air  or  insufficient  food,  tends  strongly  to  produce  the  scrofulous 
and  tuberculous  affections  ;  a  climate  characterized  by  low  temperature 
with  a  high  degree  of  moisture,  and  accompanied  by  frequent  thermomet- 
ric  changes,  without  other  bad  influences  by  habitually  interfering  with  the 
natural  exhalations  from  the  cutaneous  surface,  and  consequently  retain- 
ing certain  acid  constituents  in  excess  in  the  blood,  equally  tends  to 
create  the  rheumatic  diathesis.  The  excretory  material  thus  re- 
tained evidently  acts  as  an  irritant,  increasing  the  susceptibility  of  the 
fibrous  tissues,  and  the  plasticity  of  the  blood,  and  thus  placing  the  indi- 
vidual in  the  most  favorable  condition  for  the  development  of  active  rheu- 


ETIOLOGY.  253 

matic  inflammation,  with  general  fever  from  the  temporary  action  of  any 
exciting  cause  ;  or  without  any  such  intervention,  by  long  continuance,  in- 
ducing those  slow  hypertrophies  and  indurations  of  the  fibrous  and  connect- 
ive tissues,  in  different  parts  of  the  body,  that  constitute  the  purely 
chronic  rheumatic  affections  so  frequently  met  with  in  all  cold,  damp  and 
variable  climates. 

The  most  prominent  characteristics  of  the  climate  in  the  whole  North- 
ern belt  of  our  own  country,  from  the  eastern  foot  of  the  Rocky  Moun- 
tains to  the  Atlantic  Coast,  are  long  and  very  variable  transition  seasons 
(spring  and  autumn),  with  a  predominance  of  cold  and  dampness.  And 
it  is  exactly  over  this  same  belt  of  country  that  the  population  furnishes 
the  highest  ratio  of  the  prevalence  of  both  rheumatic  and  catarrhal  dis- 
eases, as  shown  many  years  since  in  the  admirable  work  on  the  dim  te 
and  diseases  of  the  United  States,  by  Dr.  Samuel  Forrey,  formerly  of  the 
medical  staff  of  the  United  States  Army,  and  confirmed  by  the  statistics  of 
Dr.  Daniel  Drake,  in  the  first  volume  of  his  work  on  the  topography  and 
diseases  of  the  great  interior  valley  of  this  continent.  While  it  is  true 
that  the  rheumatic  diathesis  is  generally  the  result  of  habitual  reten- 
tion of  excretory  products  capable  of  increasing  the  excitability  of  the 
organized  tissues  and  the  plasticity  of  the  blood,  such  retention  is  not 
always  the  result  of  unfavorable  atmospheric  or  external  impressions. 
On  the  contrary,  I  have  seen  numerous  instances  in  which  the  same  patho- 
logical conditions  were  reached,  in  some  cases  by  protracted  muscular  ex- 
ercise by  which  the  products  of  tissue  metamorphosis  were  developed 
faster  than  they  could  be  eliminated  through  the  natural  channels  ;  and  in 
others,  by  such  changes  in  habits  or  occupation  that  a  previous  habit  of 
active  out-door  physical  exercises  sufficient  to  excite  daily  increased  cu- 
taneous exhalation,  was  exchanged  for  one  of  confinement  or  purely  pas- 
sive exercise,  and   consequently  less    activity    in    the  cutaneous    surface. 

The  gouty  constitution  or  dithesis,  like  the  rheumatic,  involves  an  in- 
crease of  susceptibility  in  the  fibrous  or  connective  tissues,  but  with  less 
plasticity  of  the  blood  and  more  tendency  to  deficiency  of  the  red  corpus- 
cles; and  the  causes  most  efficient  in  producing  it,  are  such  as  directly  les- 
sen the  action  of  oxygen  in  the  natui-al  processes  of  tissue  metamorphosis, 
and  the  evolvement  of  those  products  that  are  eliminated  by  the  kidneys, 
instead  of  the  cutaneous  structure.  The  presence  of  alcohol  in  the  blood 
lessens  the  interchang-e  ofoxvoren  and  carbonic  acid  gas  through  the  luno-s, 
and  retards  the  molecular  changes  in  the  tissues;  consequently  its  moder- 
ate daily  use  in  the  form  of  wine  and  other  fermented  drinks,  keeps  the 
blood  in  a  state  of  imperfect  decarbonization,  diminishing  the  action  of 
oxygen  on  the  carbonaceous  elements  of  the  tissues,  and  favoring,  first,  fat- 
ty accumulations  and  subsequently,  fatty  degenerations.  If  the  individual 
thus  habitually  using,  moderately,  alcoholic  drinks,  at  the  same  time  in- 
dulges the  appetite  for  animal  food,  and  takes  very  little  muscular  exercise, 
he  will  fail  to  eliminate  the  elements  of  urea,  uric  acid  and  the  salts  of 
sodium  through  the  kidneys  sufficiently  fast  to  prevent  the  blood  and  tis- 
sues from  retaining  them  in  excess.  It  is  the  habitual  presence  of  this 
excess  of  elements  naturally  excreted  by  the  kidneys,  in  connection  with 
the  imperfect  oxygenation  and  decarbonization  of  the  blood,  that  induces 
those  changes  in  the  properties  of  the  tissues  which  constitute  the  special 
gouty  diathesis;  and  that  every  now  and  then  cause  the  accumulation  of 
such  an  amount  of  uric  acid  and  urate  of  sodium  as  to  excite  the  charac- 
teristic local  inflammations  of  acute  and  chronic  gout.  In  some  instances 
the  pathological  conditions  just  mentioned  as  constituting  the  gouty 
diathesis,  have    been  produced   by  habitual  indulgence  in  the  use  of  rich 


254  CHKONIC   GENERAL    DISEASES. 

food,  and  the  avoidance  of  all  active  physical  exercise,  without  the  use 
of  either  fermented  or  distilled  liquors.  But  such  cases  are  very  rare;  and 
so  far  as  they  have  come  under  my  observation  there  has  been  reason  to 
suspect  some  degree  of  hereditary  predisposition  derived  from  the  more 
remote  ancestry. 

Pathological  Inferences. — From  what  I  have  now  said  in  regard  to  the 
causes  capable  of  favoring  the  formation  of  constitutional  diseases  and 
their  mode  of  action,  you  may  deduce  the  following  iDathological  conclu- 
sions : 

First.  That  all  the  affections  of  this  class  involve  as  a  primary  patholog- 
ical condition,  such  a  modification  of  the  properties  of  the  organized 
structures  of  the  body  as  to  render  them  morbidly  susceptible  to  impres- 
sions and  to  alter  the  molecular  movements  concerned  in  the  processes  of 
assimilation,  nutrition,  and  metamorphosis  of  tissues. 

Second.  The  modification  of  properties  just  mentioned  may  result  from 
hereditary  transmission,  or  from  the  moderate  but  long  continued  action 
of  such  causes  as  are  capable  of  either  impairing  the  processes  of  assimila- 
tion and  nutrition;  or  those  of  tissue  metamorphosis  and  the  execretion  of 
waste  products. 

Third.  In  scrofula,  tuberculosis,  Addison's  disease,  and  pernicious  ansemia 
the  special  modification  of  tissue  properties  is  such  as  to  increase  the  sus- 
ceptibility by  which  the  patients  become  morbidly  sensitive  or  unduly  in- 
fluenced by  almost  every  kind  of  external  impression,  and  such  an  im- 
pairment of  vital  affinity  that  the  formative  processes  by  which  the  ele- 
ments of  tissues  are  evolved  in  the  blood  and  attracted  to  their  proper 
places  in  tissue  growth  and  repair,  are  rendered  imperfect  and  result  in 
the  formation  of  aplastic  or  cacoplastic  material,  as  found  in  the  caseous 
and  tuberculous  deposits  and  degenerations  ;  or  so  greatly  impaired  as  to 
arrest  the  formative  pn  cesses  altogether,  as  in  the  pernicious  annemia. 

Fourth.  In  leucocythsemia  and  carcinoma  there  is  less  alteration  of  the 
susceptibility  or  excitability,  but  such  an  alteration  of  the  vital  affinity,  or 
force,  controlling  the  formative  processes,  as  to  result  in  an  increase  of  the 
leucocytes  and  lymphoid  cells,  leading  in  the  one  disease  to  their  marked 
excess  in  the  blood,  with  hypertroph}^  of  the  adenoid  glandular  structures 
in  different  parts  of  the  body,  and  in  the  other,  to  a  more  specific  and  lo- 
calized cell  and  fibrous  development,  constituting  the  varieties  of  cancerous 
tumors  capable  of  development  chiefly  in  the  dermoid  and  glandular  struct- 
ures containing  epithelium. 

Fifth.  In  rheumatism  or  gout,  the  general  diathesis  or  modification  of  tis- 
sue properties  is  such  as  to  increase  in  a  marked  degree  the  susceptibility 
or  general  irritability  of  the  organized  structures,  and  to  so  modify  the  mo- 
lecular movements  in  the  metamorphic  and  excretory  processes  as  to  cause 
the  retention  and  consequent  accumulation  in  the  blood,  of  an  excess  of 
certain  excretory  products,  which,  by  their  action  on  the  already  morbidly 
susceptible  tissues,  are  capable  of  exciting  the  specific  local  inilammations 
of  rheumatism  and  gout.  In  the  present  status  of  pathological  investiga- 
tions, I  may  state  it  as  probable  that  the  retained  excretory  or  morbid 
products  in  rheumatism  are  chiefly  lactic  acid,  and  the  lactic  acid  salts  ; 
and  in  gout,  the  uric  acid  and  urates. 

Principles  of  Treatment. — From  the  statements  I  have  made  concern- 
ing the  causes  and  general  pathology  of  the  whole  class  of  constitutional 
diseases,  you  will  readily  perceive  that  their  practical  management  involves 
two  distinct  objects,  namely  :  the  removal  ot  the  general  constitutional  vice 
or  predisposition,  and  the  treatment  of  the  various  local  affections  that 
may  appear  from  time  to  time  during  the  jDrogress  of  each  individual  case. 


PRINCIPLES    OF    TREATMENT.  255 

The  accomplishment  of  the  first  object  will  depend,  mainly,  on  our  ability 
to  remove  the  patient  from  the  further  action  of  those  causes  and  influences 
that  favor  the  developinent  of  the  particular  diathesis  in  question,  and  to 
substitute  in  their  place  such  hygienic  and  sanitary  measures  as  will  bring 
a  strong  influence  in  the  opposite  direction.  As  ail  these  diatheses,  when 
not  hereditary,  are  the  result  of  influences  acting  moderately  through  long 
periods  of  time,  so  they  can  be  removed  only  by  influences  acting  witli 
equal  persistence  in  such  direction  as  to  induce  an  opposite  effect.  In  all 
these  affections,  so  far  as  the  constitutional  condition  is  concerned,  a  resort 
to  active  temporary  medication  of  any  kind,  is  both  unphilosophical  and 
useless.  And  yet,  there  are  some  medicines  capable  of  affording  material 
aid  to  the  patient,  if  properly  selected,  given  in  moderate  doses  and  con- 
tinued for  a  long  time.  One  of  the  chief  difficulties  in  treating  success- 
fully all  constitutional  diseases  and  defects,  is  the  inability  of  the  patient 
and  his  friends  to  appreciate  the  necessity  for  persistence  in  the  use  of 
whatever  remedial  agents  or  influences  are  deemed  necessary.  It  seems 
difficult  for  them,  and  sometimes  even  for  the  physician,  to  realize  the  fact 
that  morbid  conditions  and  processes  which  have  been  years  in  developing, 
or  may  have  been  inherited,  can  not  be  removed  or  permanently  corrected 
by  the  use  of  this  or  that  remedy  for  a  few  days,  or  by  a  vacation  from 
school  or  business,  and  a  change  of  air,  exercise,  or  climate,  for  a  few 
weeks,  or  at  most,  a  few  months. 

Consequently  we  see  but  few  well  devised  and  persistently  executed 
plans  of  treatment  adopted  for  either  preventing  or  curing  the  constitu- 
tional conditions  now  under  consideration.  As  a  general  rule,  you  see 
the  children  of  scrofulous,  tuberculous,  cancerous,  syphilitic,  and  gouty 
parents,  receiving  no  more  attention  in  regard  to  their  physical  training 
than  those  of  healthy  parents.  Yet,  it  is  during  the  period  of  childhood 
and  youth,  while  the  structures  of  the  body  are  undergoing  active  develop- 
ment, that  we  have  the  best,  if  not  the  only,  opportunity  to  correct  such 
morbid  tendencies  as  result  from  hereditary  influence.  And  every  physi- 
cian should  regard  it  as  one  of  his  most  important  professional  duties  to 
note  the  special  morbid  tendencies  of  all  the  families  who  rely  upon  him 
for  medical  services,  and  be  as  careful  to  point  out  the  means  for  correct- 
ing them,  as  he  is  to  prescribe  medicines  when  they  are  actively  sick. 
The  family  physician  should  realize  that  he  is  the  guardian  of  the  health 
of  the  families  by  whom  he  is  employed  ;  and  he  should  so  far  interest 
himself  in  the  welfare  of  the  children,  especially,  that  in  his  professional 
intercourse  he  should  make  such  suggestions  from  time  to  time  regarding 
the  physical  exercise,  diet,  dress,  and  education  of  the  children  as  may  be 
necessary  to  correct  hereditary  defects  or  acquired  morbid  tendencies 
during  the  years  when  such  corrections  are  possible.  I  can  not  too 
strongly  impress  upon  each  one  of  you  the  importance  of  this  subject. 

As  the  leading  pathological  or  morbid  elements  of  the  scrofulous  and 
tuberculous  diatheses  are  undue  excitability,  coincident  with  impairment 
of  vital  affinity  or  formative  force,  and  possibly  deficiency  of  the  phos- 
phatic  and  calcium  compounds  in  the  blood,  so  the  remedial  measures 
adopted  should  be  such  as  are  most  efficient  in  lessening  the  former  and 
in  increasing  the  two  latter.  Among  the  most  important  of  these 
measures  is  a  plentiful  supply  of  dry  pure  air,  at  a  genial  temperature  for 
out-door  exercise  or  exposure  ;  a  sufficient  quantity  and  variety  of  nutri- 
tious and  easily  digestible  food  ;  clothing  of  such  quality  and  so 
adjusted  as  will  best  protect  the  cutaneous  surface  from  sudden  and 
severe  atmospheric  changes,  and  leave  all  the  important  movements  and 
functions  of    the    body  free  from    mechanical    interference  ;    and     such 


256  CHRONIC   GENERAL    DISEASES. 

habitual  daily  muscular  or  physical  exercises  as  tend  to  increase  the  develop- 
ment and  strength  of  the  muscular  structures  generally,  and  especially 
those  of  the  chest  and  upper  extremities. 

The  heads  of  all  families  should  be  fully  advised  by  their  physician  of  the 
necessity  of  free  ventilation  in  every  part  of  their  dwellings,  and  especially 
in  their  sleeping-rooms.  Neither  children  nor  adults  should  be  allowed  to 
sleep  in  cellar  or  basement  rooms,  or  rooms  anywhere  that  do  not  admit 
of  free  ventilation  and  sunlight,  and  afiord,  when  closed,  at  least  800  cu- 
bic feet  of  air  space  for  each  person  occupying  them.  The  physiological 
law,  that  regular  habitual  exercise  within  certain  limits,  increases  the 
amount  and  improves  the  quality  of  nutrition,  is  one  of  ]:H-iraHry  impor- 
tance, as  affording  a  means  for  correcting  the  defects  and  inequalities  of 
development,  whether  hereditary  or  acquired,  which  exist  in  a  large  pro- 
portion of  all  the  varieties  of  constitutional  disease.  By  good  air,  a  fair 
variety  of  good  food,  and  regular  daily  exercise,  weak  and  slender  muscles 
can  be  made  compact  and  strong  ;  narrow  chests  with  deficient  air  space 
can  be  made  broader  and  more  capacious  ;  and  with  a  more  complete  oxy- 
genation and  decarbonization  of  the  blood,  will  come  healthier  secretory 
actions  and  more  perfect  digestion,  assimilation  and  nutrition.  Thus,  a 
bad  constitution,  or  decided  predisposition  to  disease,  can  be  changed  into 
one  healthy,  and  even  strong.  But  it  requires  much  time,  judicious  di- 
rection, and  undeviating  steadiness  of  purpose  in  the  daily  execution  of 
the  work  or  play  directed.  And  when  the  morbid  conditions  or  defects 
have  become  w"ell  developed,  and  the  period  of  growth  nearly  or  quite 
completed,  before  the  systematic  work  of  correction  has  been  commenced, 
it  may  become  necessary  to  add  to  the  hygienic  and  sanitarj^  measures  al- 
ready alluded  to,  a  change  of  climate,  either  temporary  or  permanent.  As 
a  o-eneral  rule,  you  will  find  it  most  beneficial  to  send  those  who  have 
been  habitually  living  in  interior  valleys,  of  moist  and  alluvial  formation, 
either  to  dry,  mild,  and  elevated  mountain  ranges,  or  to  the  sea  shore  or 
on  sea  voyages. 

Those  whose  chief  defects  consist  in  slender  muscles,  narrow  chests,  and 
undue  sensitiveness  of  the  respiratory  organs,  will  do  best  in  the  mild,  dry, 
and  pure  air  of  the  mountains;  while  those  whose  defects  are  chiefly  in 
the  functions  of  the  digestive  and  assimilative  organs,  will  do  best  in  the 
more  stimulating  and  alterant  atmosphere  of  the  ocean.  And  yet  those 
who  have  either  inherited  or  acquired  defects  while  permanently  residing 
near  the  sea,  will  often  be  equally  benefited  by  a  change  either  to  the  in- 
terior valleys  or  mountains. 

If,  in  the  management  of  the  scrofulous,  tuberculous,  and  kindred 
diatheses,  medicinalagents  are  resorted  to,  they  should  be  of  such  a  nature 
as  to  be  capable  of  diminishing  the  general  excitability  and  of  promoting  the 
efficiency  of  the  assimilative  processes.  In  other  words  they  should  l)e  sooth- 
ino-,  tonic,  and  corrective,  or  mildly  alterant.  In  former  times  small  doses 
of  the  aqueous  solution  of  iodine,  given  in  some  mildly  sedative  vegetable 
infusion  soon  after  each  meal-time,  were  much  used  and  with  good  effect. 
The  vegetable  infusions  most  used  were  those  of  the  sarsaparilla,  jDrunus 
vircriniana,  cimicifuga  racemosa,  and  pipsissewa.  During  the  last  fifteen 
or  twent3'years  I  have  had  frequent  occasion  to  recommend  for  the  same 
purposes"  a  combination  of  two  parts  of  the  syrup  of  iodide  of  calcium  with 
one  part  of  the  fluid  extract  of  humulus  lupulus,  or  hop.  To  patients  over 
fifteen  years  of  age,  four  cubic  centimeters  (fl.  3i)  of  this  mixture  may  be 
given  just  after  each  regular  meal-time.  To  younger  children  the  dose 
should  be  proportionately  less.  If  the  patient  becomes  weary  of  taking 
this,  I  substitute  the  syrup  of  lacto-phosphate  of  calcium  for  two  or  three 
weeks,  after  which  the   other  can    be  resumed. 


PRINCIPLES    OF    TREATMENT.  257 

But  in  counteract] iTi^  the  constitutional  predispositions  now  under  con- 
sideration, no  medicines,  however  long  their  use  may  be  continued,  can  be 
relied  upon  to  the  exclusion  or  neglect  of  the  hygienic  and  climatic  influ- 
ences to  which  I  have  referred. 

The  diathesis  or  constitutional  condition  favoring  the  development  of  the 
various  forms  of  cancerous  or  malignant  growths  is  one  of  the  most  obscure 
in  the  list  of  chronic  general  diseases.  I  am  aware  that  many  of  the  pa- 
thologists and  practical  surgeons  of  the  present  day  regard  all  this  class  of 
morbid  structural  developments  as  primarily  local,  and  claim  that  the  gen- 
eral cachexia  or  diathesis  is  secondary,  and  the  result  of  the  diffusion  of 
the  cancer  cells  or  germs  originating  in  the  local  affection,  But  the  fact 
that  the  predisposition  to  the  disease  is  capable  of  hereditary  transmission, 
while  the  local  development  of  cancerous  structure  is  often  postponed  un- 
til after  the  middle  period  of  life,  shows  that  there  must  be  some  devia- 
tion from  the  strictly  healthy  condition  of  the  properties  that  govern  the 
combinations  of  organic  matter  in  the  development  of  tissue  elements, 
prior  to  the  first  germ  of  local  morbid  structure.  Again,  the  fact  that  in 
a  very  large  majority  of  cases,  cancerous  growths  re-appear  after  the  ear- 
liest and  most  complete  removal  of  the  first  unhealthy  structure,  points  to 
the  same  conclusion.  I  have  assumed,  therefore,  that  there  is  a  cancerous 
diathesis,  or  constitutional  predisposition  which,  if  not  removed,  will  in 
due  time  lead  to  the  development  of  some  variety  of  cancerous  structure. 
In  a  large  proportion  of  cases  this  diathesis  is  the  result  of  hereditary  in- 
fluence ;  but  that  it  may  be  acquired  without  such  influence  is  also  proved 
by  the  history  of  many  cases  in  which  no  prior  existence  of  this  form  of 
disease  can  be  traced  in  either  line  of  ancestry. 

By  what  circumstances  connected  with  diet,  drinks,  modes  of  living,  or 
climate,  the  formation  of  such  a  diathesis  is  favored  or  counteracted,  very 
little  is  known.  In  1866  my  colleague  in  the  department  of  surgery. 
Dr.  E.  Andrews,  by  a  careful  and  accurate  examination  of  the  mortality 
statistics  of  this  country  as  returned  by  the  United  States  census  for 
1860,  found  a  much  higher  ratio  of  deaths  from  cancerous  diseases  in  the 
six  New  England  States,  and  next  in  New  York,  Pennsylvania,  New 
.Jersey  and  Delaware  ;  the  ratio  steadily  diminishing  as  he  progressed 
south  through  the  Atlantic  States  to  the  peninsula  of  Florida.  The  ratio 
was  higher  in  the  States  occupying  the  northern  part  of  the  interior 
valley  of  the  continent  than  in  those  farther  south,  the  lowest  ratio  of  all 
being  in  the  extreme  southwest,  embracing  the  States  of  Texas,  Mis- 
souri, Louisiana,  Arkansas,  and  New  Mexico.  The  last  named  State  re- 
turned only  one  death  from  cancer  to  two  hundred  and  seventy  from  all 
diseases,  while  Vermont  returned  one  from  cancer  to  forty  from  all 
diseases.  These  figures  would  appear  to  show  that  the  prevalence  of 
cancerous  affections  was  favored  by  a  cold,  variable,  and  damp  climate, 
such  as  that  which  characterizes  the  northeastern  and  northern  belt  of 
the  United  States,  and  to  be  opposed  by  one  that  is  mild  and  dry. 

A  more  thorough  examination  of  this  part  of  the  subject  will  probably 
demonstrate  the  proposition  that  cancerous  affections  prevail  most  wher- 
ever a  cold  and  variable  climate  co-exists  with  density  of  population,  there- 
by following  very  nearly  the  same  law  of  prevalence  as  scrofula  and  tu- 
berculosis.* Many  facts  have  come  under  my  own  observation  favoring 
the  idea  that  a  liberal  use  of  meat  coupled  with  in-door  occupations  or 
sedentary  habits,  had  a  tendency  to  increase  the  cancerous  predisposition, 

*  See  Relations  of  Cancer  and  Cnusumption  to  Climate  in  tlie  United  States.  By  E.  Andrews  M.  D, 
Chicago  Medical  Examiner,  Vol.  VII.  p.  737.  18G6. 

17 


258  SCROFULA. 

as  it  certainly  does  the  local  cancerous  growths  after  they  have  com- 
menced. In  the  present  state  of  m'^dical  knowledge,  perliaps  the  best 
advice  you  can  give  to  parties,  who,  from  known  hereditary  predisposition 
or  otherwise,  are  desirous  of  counteracting  the  development  of  cancerous 
disease  in  any  of  the  structures  of  the  body,  is,  that  they  shall  live  in  a  mild, 
dry  climate,  remote  from  and  elevated  above  the  sea;  to  take  free  exercise  in 
the  open  air;  to  use  meat  only  sparingly;  and  wholly  avoid  all  use  of  al- 
coholic drinks  and  tobacco.  The  principles  that  should  govern  us  in  the 
manao^ement  of  the  rheumatic  and  gouty  diatheses  are  plainly  inferable 
from  what  I  have  already  said  regarding  their  mode  of  development:  and 
the  details  of  their  application  will  be  further  explained,  when  1  come  to 
sjDeak  of  the  active  local  developments  of  these  affections.  Having  com- 
pleted what  I  deem  important  to  say  regarding  the  general  management 
of  constitutional  diseases,  I  shall  reserve  the  consideration  of  the  treatment 
necessary  after  local  affections  have  become  apparent,  until  I  call  your 
attention  to  each  of  the  several  diseases  included  in  this  group  separately. 


LECTURE  XXYIII. 

Scrofula— Varieties  of  Local  Developmeat ;    Symptoms,  Progress  and  Results ;  Special  Pathologi- 
'cal  Changes,  and  Treatment. 

GENTLEMEN:  I  invite  your  attention  daring  the  present  hour,  to 
those  local  developments  of  disease  which  are  connected  with,  and 
more  or  less  dependent  on,  the  general  scrofulous  diathesis  as  described  in 
the  preceding  lecture. 

The  local  affections,  to  which  I  allude,  are  inflammatory  in  their  char- 
acter, and  are  most  frequently  developad  in  the  lymphatic  glands,  the 
mucous  membranes,  more  especially  of  the  eyes,  nose  and  intestines,  the 
skin,  and  the  periosteum. 

Adenitis. — In  the  ordinary  field  of  general  practice,  you  will  meet  with 
inflkmmation  and  enlargement  of  the  lymphatic  glands  very  frequently, 
especially  in  children  and  youth.  In  a  large  majority  of  cases,  the  gland- 
ular affection  is  seen  only  in  the  neck  ;  in  other  cases  in  the  axillae  and 
groin  ;  and  more  rarely  in  other  parts  of  the  body.  As  the  scrofulous 
constitution  diflFers  much  in  the  degree  of  its  development  in  different 
cases,  so  the  aff'ections  of  the  lymphatic  glands  accompanying  such  consti- 
tutional conditions,  vary  much  in  the  activity  of  their  development, 
progress  and  results.  For  convenience  of  description,  I  may  include  them 
all  in  three  groups.  The  first  group  includes  all  cases  of  chronic  enlarge- 
ment or  hypertrophy  of  the  glands  from  sclerosis  of  the  connective  tissue, 
and  increase  of  the  lymphoid  cells  without  caseous  degeneration.  The 
second,  such  cases  as  are  equally  chronic  or  slow  in  development,  but  in 
which  the  exudation  in  the  central  part  of  the  glands  undergo  caseous 
degeneration  and  ultimate  purulent  softening.  The  third  includes  cases 
of  a  more  acute  character,  in  which  the  glands  become  more  rapidly  en- 
larged with  exudative  material  that  quickly  degenerates,  forming  some 
caseous  matter,  mixed  directly  with  pus,  causing  the  substance  of  the 
gland  to  be   early  converted  into   an   abscess,   which,  when  discharged, 


DEVELOPMENT.  259 

usually  manifests  a  strong  tendency  to  extend  the  opsninf^  into  an  ulcer, 
with  excavated  edges,  and  but  little  tendency  to  fill  up  with  heaithy  gran- 
ulations. 

The  cases  belonging  to  the  first  group  are  met  with,  most  frequently, 
in  children  between  the  ages  of  five  and  fifteen  years,  who  are  delicate 
and  usually  spare  in  flesh,  but  in  whom  the  scrofulous  diathesis  is  only 
moderately  developed.  In  some  instances,  the  first  swelling  of  the  giauds 
is  traceable  to  exposure  to  cold,  or  to  an  attack  of  measles,  scarlatina,  or 
diphtheria,  but  in  a  much  larger  number  of  cases  the  glandular  affection 
commences  without  known  cause,  and  without  sufficient  pain  or  soreness 
to  attract  the  attention  of  the  patient.  They  generally  appear  in  the 
form  of  smooth,  firm,  round  tumors,  varying  in  size  from  that  of  a  pea  to 
a  hickory-nut  ;  very  movable  under  the  skin,  and  without  tenderness  to 
the,  touch.  They  are  apt  to  appear  first  along  the  margin  of  the  upper 
third  of  the  sterno-cleido-mastoid  muscle,  but  miy  be  found  along  any 
part  of  the  side  of  the  neck,  from  the  mastoid  process  to  the  outer  third 
of  the  clavicle,  or  in  the  groin. 

You  may  find  only  one  or  two  in  some  cases,  and  in  others  a  dozen  or 
more,  forming  a  chain  along  the  whole  coarse  of  the  muscle  just  named. 
They  are  distinguished  from  all  forms  of  malignant  growth,  bv  their  mod- 
erate firmness  or  density,  smoothness  of  surface,  rounded  form,  and  free 
mobility  under  the  skin. 

A  large  proportion  of  these  glandular  enlargements,  after  attainingf,  by 
slow  growth,  a  size  varying  from  that  of  a  large  pea  to  that  of  a  hickory- 
nut,  remain  nearly  stationary  for  many  months,  and  sometimes  years,  and 
finally  disappear  by  resolution. 

On  the  other  hand,  they  are  liable  at  any  time,  by  sudden  exposure  to 
cold  currents  of  air,  or  other  irritating  influences,  to  become  more  actively 
inflamed,  tender  to  the  touch,  and  more  swollen,  when  in  many  instances 
suppuration  ensues,  the  interior  of  the  gland  becomes  a  simple  accumula- 
tion of  pus,  the  free  discharge  of  which  is  soon  followed  by  cicatrization, 
and  a  more  or  less  permanent  scar. 

Cases  of  the  second  group  are  more  frequently  developed  in  persons 
between  twelve  and  twenty  years  of  age.  Their  beginning  is  very  gen- 
erally traceable  to  some  direct  exposure  to  cold,  damp  currents  of  air,  to  the 
efl^ects  of  some  one  of  the  eruptive  fevers,  or  to  an  attack  of  diphtheria. 
There  may  be  only  one  or  many  glands  involved  at  the  same  time  ;  more 
frequently  there  are  two  or  more  forming  a  cluster  of  swollen  glands  be- 
low the  parotid  region,  and  often  extending  forward  below  the  angle  of 
the  jaw  and  backward  to  the  mastoid  region.  They  are  generally  smooth, 
rounded,  and  more  or  less  tender  to  the  touch,  especially  in  the  early 
stage.  After  one  or  two  weeks,  in  many  cases,  the  tenderness  to  the  touch 
disappears,  the  glands  cease  to  enlarge,  and  some  of  the  smaller  ones  be- 
gin slowly  to  disappear  by  resolution.  The  larger  ones  appear  to  remain 
stationary  for  several  weeks,  or  even  months,  exhibiting  a  little  tender- 
ness, and  perhaps  increased  swelling  for  a  few  days  at  a  time,  vvhen  the 
patient  is  unduly  exposed  or  suffering  from  any  general  febrile  disturb- 
ance. Sooner  or  later,  however,  you  can  begin  to  feel  in  one  or  more  of 
the  more  prominent  glands,  a  sense  of  softening  or  semi-fluctuation. 

This  softening  is,  in  some  instances,  felt  only  on  the  most  prominent 
part  of  the  gland,  and  as  though  the  fluid  was  not  far  from  the  surface, 
while  the  deeper  parts  of  the  gland  remain  hard,  giving  it  the  appearance 
of  a  small  abscess  resting  on  a  broad,  hard  base.  A  week  or  two  later  the 
sense  of  fluctuation  will  have  become  plainer,  the  skin  and  subcutaneous 
tissues  more   adherent  to  the  enlarged  gland,  but  the  base   is  still  hard. 


260  SCEOFULA. 

If  allowed  to  go  on  without  interference,  the  matter  in  the  gland  will  con- 
tinue very  slowly  to  approach  the  surface  ;  the  skin  becomes  slightly  red 
or  purplish  color  over  the  most  prominent  part  of  the  swelling,  and  event- 
ually from  one  to  four  small  openings  will  form,  through  which  the  thinner 
pai-t  of  the  matter  will  discharge. 

Sometimes  these  openings  will  gradually  enlarge  until  several  unite  in 
one  large  023ening  with  thin,  excavated  edges,  and  exposing  the  bottom  or 
base  of  the  gland,  generally  covered  with  a  layer  of  white  material,  with 
no  appearance  of  healthy  granulations.  In  most  cases  there  are  little 
masses  of  caseous  material  that  escape  with  the  thinner  pus  before  the 
abscess  becomes  converted  into  an  open  sore.  If  proper  measures  are 
taken  to  improve  the  general  health,  the  hard  base  of  these  sores  gradually 
disappears,  the  discharge  improves  in  quality  and  lessens  in  quantity; 
granulations  spring  up  which  are  very  prone  to  become  large  and 
spongy,  but  cicatrization  is  eventually  completed,  and  almost  always  leaves 
a  permanently  irregular,  depressed  and  unseemly  scar. 

The  third  group  of  cases  to  which  I  have  alkided,  differ  from  the  second 
chiefly  in  their  more  acute  character  and  greater  tendency  to  involve,  in 
the  suppurative  stage,  the  adjacent  areolar  or  connective  tissue  and  the 
skin.  The  glands  primarily  attacked  enlarge  rapidly,  are  less  movable, 
quite  tender  to  the  touch,  and  present  early  a  blush  of  redness  on  the 
surface.  If  several  glands  are  attacked  at  the  same  time,  as  frequently 
happens,  especially  in  the  neck  and  groin,  the  pulse  will  be  accelerated 
and  the  temperature  elevated  from  two  to  three  degrees  above  the  natural 
standard,  constituting  a  moderate  general  febrile  condition.  This  usually 
oontinues  one  or  two  weeks,  or  until  the  suppurative  stage  is  completed 
■end  the  resulting  abscesses  discharged,  either  spontaneously  or  by  free  in- 
cision. As  this  group  of  cases  often  involves  much  of  the  connective 
tissue  surrounding  the  glands,  when  several  are  affected  near  each  other, 
the  skin  becomes  extensively  undermined  by  the  extent  of  the  suppuration, 
and  each  opening  enlarges  into  a  spreading  ulcer  with  copious  purulent 
discharge.  It  is  only  a  few  weeks  since  I  saw  a  young  woman  with  four 
of  these  large  open  ulcers  on  the  upper  part  of  the  side  of  the  neck,  vary- 
ing in  size  from  twelve  to  thirty  millimeters  in  diameter,  leaving,  in  some 
places,  only  narrow  strips  of  skin  between  them.  I  have  seen  other  cases 
presenting  similar  sores  along  the  upper  side  of  the  clavicle  from  its  junc- 
tion with  the  sternum  to  the  acromion  process  of  the  scapula,  and  smaller 
isolated  sores  in  other  parts  of  the  body  and  on  the  extremities.  In  all 
these  cases  the  patients  were  spare  in  flesh,  pale,  easily  fatigued,  with 
variable  appetite  and  imperfect  digestion.  A  small  proportion  of  them 
presented  also  slight  cough  and  the  physical  signs  of  crude,  tubercular  de- 
posits in  the  upper  part  of  one  or  both  lungs.  But  I  have  not  found  pul- 
monary tuberculosis  a  frequent  accompaniment  of  scrofulous  disease  of 
the  lymphatic  glandular  system.  All  the  forms  of  disease  I  have  described 
as  affecting  the  lymphatic  glands  externally,  are  met  with,  but  less  fre- 
quently, in  the  same  class  of  glands  in  the  internal  cavities,  and  in  the 
glands  of  the  mesentery,  constituting  what  the  older  writers  termed  "  tabes 
mesenterica."  I  have  seen  some  cases  in  children  in  which  the  abdomen 
became  much  distended  from  the  enlargement  and  caseous  degeneration  of 
the  glands  of  the  mesentery.  In  one  of  these  cases,  a  bov  nearly  three  years 
of  age,  two  of  the  enlarged  masses  became  adherent  to  the  anterior  walls 
of  the  abdomen,  ulcerated  through  and  discharged  a  large  amount  of  thin 
pus  mixed  with  many  lumps  of  caseous  matter  ;  but  the  patient  finally 
died  from  extreme  emaciation  and  exhaustion.  More  recently  I  saw  in 
consultation  a  young  woman,  sixteen  years  of  age,  whose  abdomen  had 


PATHOLOGICAL   ANATOMY.  261 

become  filled  up  with  these  large  glandular  tumors,  one  of  the  largest  of 
which  had  gradually  softened  and  finally  discharged  its  contents,  composed 
of  sero-purulent  fluid  and  curds  of  caseous  matter,  into  the  intestines. 
Only  partial  or  temporary  relief  followed  these  discharges,  and  the  patient 
after  lingering  many  months,  died. 

Pathological  Anatomy. — The  pathological  changes  which  take  place  in 
the  adenoid  or  glandular  structures  when  affected  by  scrofulous  disease, 
are  first  simple  increase  of  both  connective  tissue  and  lymphoid  cells, 
causing  increased  growth  or  hypertrophy  of  the  glands. 

This  is  the  condition  represented  by  the  first  group  of  cases.  In  the 
second  and  third  groups  the  same  changes  occur,  but  in  addition  there 
are  also  formed  large  cells  with  many  nuclei,  called  giant  cells,  and  exu- 
dations of  granular  matter,  all  .of  which  undergo  caseous  degeneration, 
atid  ultimately  partial  or  complete  conversion  into  pus.  In  many  of  the 
specimens  are  found  accumulations  identical  in  appearance  with  the 
structure  of  tubercle,  affording  another  evidence  that  there  is  a  very  close 
relationship,  if  not  identity,  between  scrofula  and  tuberculosis. 

Treatment. — In  the  management  of  all  the  forms  and  stages  of  gland- 
ular scrofula,  the  most  careful  and  persevering  attention  must  be  given  to 
the  improvemeiit  of  the  general  constitutional  condition  or  diathesis  of  the 
patient.  Without  this,  all  remedies  addressed  directly  to  the  local  gland- 
ular erdargements  will  have  but  little  effect.  Therefore  all  that  I  said  in 
the  preceding  lecture  in  regard  to  the  hygienic  and  sanitary  measures 
necessary  for  mitigating  or  removing  the  scrofulous  and  tuberculous  dia- 
theses, you  must  give  full  heed  to,  in  the  treatment  of  the  particular  forms 
of  disease  now  under  consideration.  In  addition,  however,  to  the  fa^ith- 
ful  attention  necessary  for  securing  to  the  patient,  good  air,  good  food, 
suitable  clothing,  sunlight,  and  well-regulated  exercise,  as  described  in 
the  preceding  lecture,  the  long-continued  internal  use  of  small  doses  of 
iodine  is  a  measure  of  much  importance.  The  best  form  for  its  adminis- 
tration is  the  aqueous  solution,  of  which  the  following  is  a  convenient 
formula  : 


lodini. 

0.50  grams. 

gr.   viii 

Potassii  lodidi 

2.00      " 

gr.    XXX 

Aquae  Uistillatge 

45.00  c.  c. 

|iss 

Mix.  To  patients  fifteen  years  of  age  and  over,  0.60  c.  c.  (min.  x) 
may  be  given  at  each  meal  time,  in  from  one  to  two  tablespoon fuls  of 
sweetened  water.  To  younger  patients  the  dose  should  be  proportion- 
ately less,  but  it  should  always  be  given  largely  diluted  with  water.  To 
obtain  its  full  curative  influence  its  use  must  be  continued,  with  only  oc- 
casional interruptions  of  three  or  four  days  at  a  time,  from  one  to  six 
months.  If  the  foregoing  treatment  is  commenced  while  the  glands  are 
simply  enlarged  from  an  increase  of  the  connective  tissue  and  lymphoid 
cells  without  caseous  degeneration,  and  is  continued  with  the  proper  hy- 
gienic regulations,  in  a  large  majority  of  the  cases  the  enlargements  will 
slowly  disappear  and  the  health  will  be  restored. 

But  if  the  central  part  of  the  diseased  glands  has  already  undergone 
caseous  degeneration,  and  especially  if  there  is  an  intermixture  of  tuber- 
culous matter,  as  in  many  of  the  cases  that  I  have  described  as  belonging 
to  the  second  and  third  groups,  it  is  rare  that  resolution  can  be  effected 
by  any  treatment.  Even  in  such  cases,  however,  the  treatment  judicious- 
ly adjusted  will  aid  in  promoting  the  general  health,  lessening  the  extent 
of  the  suppuration,  and  rendering  the  reparative  processes  more  efficient. 


0.06       grains 

gr.  i 

90.00     c.  c. 

liii 

15.00     c.  c. 

3iv 

15.00     c.  c. 

3iv 

262  SCROFULA. 

Whenever  scrofulous  glands  do  suppurate,  it  is  better  to  discharge  the 
matter  by  an  early  incision,  than  to  wait  for  a  spontaneous  opening  ;  inas- 
much as  the  former  is  usually  followed  by  a  smaller  and  more  regular  cica- 
trix than  the  latter.  In  some  cases  attended  by  extensive  suppuration 
and  a  disposition  to  the  formation  of  open  ulcers  with  irregular  and  exca- 
vated edges,  I  have  seen  the  most  satisfactory  improvement  result  from 
the  internal  use  of  small  doses  of  the  bichloride  of  mercury  dissolved  in 
the  compound  tincture  of  cinchona,  as  in  the  following  formula  : 

]J      Hydrargyri  Chloridi  Corrosivi 
Tinctura3  Cinchonaa  Composite 
Extracti  Conii  Fluidi 
Syrupus  Simplicis       J  ..     ; 

Mix.  Shake  the  vial  and  give  four  cubic  centimeters  (fl.  3')  to  an 
adult,  mixed  with  a  tablespoon:ul  of  water,  and  repeat  it  before  breakfast, 
dinner  and  supper.  I  have  repeatedly  seen  thoroughly  scrofulous  patients 
gain  in  flesh,  strength,  appetite,  and  their  sores  heal,  while  using  this  com- 
bination, who  had  previously  taken  cod-liver  oil,  malt,  hypophosphites,  and 
preparations  of  iron  for  several  months  without  improvement. 

It  rarely  produces  any  perceptible  soreness  of  the  gums  or  mouth, 
even  when  its  use  is  continued  uninterruptedly  for  six  or  eight  weeks. 
Like  the  iodine,  the  bichloride  of  mercury  is  a  general  alterant,  capable  of 
so  modifying  the  properties  and  molecular  movements  as  to  counteract 
the  tendency  to  fatty  and  caseous  degenerations,  and  to  increase  assimila- 
tion and  healthy  hferaatosis.  It  is  a  common  practice  to  apply  iodine  ex- 
ternally to  the  swollen  glands,  either  in  the  form  of  tincture  painted  over 
the  surface  of  the  swelling,  or  mixed  with  camphorated  soap  liniment,  two 
or  three  parts  to  one  of  the  tincture  of  iodine,  and  applied  more  freely  morn- 
ing and  evening.  I  have  seldom  seen  any  marked  benefit  from  these  or 
any  other  external  applications  in  the  treatment  of  scrofulous  swellings. 

Applications  of  the  undiluted  tincture  of  ii)dine  soon  destroy  the 
cuticle,  and  so  inflame  the  skin  as  to  render  the  subsequent  applications 
very  painful.  For  th  s  reason  I  have  generally  preferred  its  dilution  with 
camphorated  soap  liniment  sujfficient  to  allow  of  free  wetting  of  the  sur- 
face, morning  and  evening,  without  pain.  When  the  texture  of  a  gland 
has  began  to  soften  from  the  formation  of  pus,  if  any  external  applica- 
tions are  made,  they  should  be  of  an  emolient  character. 

Scrofulous  Inflamviation  of  Mucous  Membrane^  efc.— Children  and  youth 
of  decided  scrofulous  tendency,  are  very  liable  to  attacks  of  inflammation  in 
the  schneiderian  membrane,  conjunctiva,  the  tarsus  of  the  eyelids,  the 
cornea,  and  sometimes  the  lining  of  the  meatus  of  the  ear.  In  the  latter, 
it  sometimes  presents  the  form  of  impetiginous  pustules  which  soon  ma- 
ture, discharge  a  drop  or  two  of  matter,  and  disappear;  or  the  eruption 
may  assume  a  chronic  form,  extending  by  the  addition  of  new  pustules 
out  upon  the  tragus  and  lobe  of  the  ear;  the  matter  in  the  pustules  drying 
into  light  brown  scabs,  and  giving  to  the  meatus  and  parts  surrounding,  a 
sore  and  untidy  appearance,  and  not  unfrequently  an  off"ensive  odor.  In 
other  cases,  instead  of  an  eruption,  the  inflammation  invades  the  sub-cuta- 
neous tissue,  causing  swelling  and  much  pain  in  the  meatus  and  ending  in 
the  formation  of  one  or  more  small  abscesses.  The  pain  usually  ceases 
with  the  opening  or  breaking  of  the  abcess,  but  in  many  instances  more 
or  less  purulent  discharge  continues  several  weeks.  In  other  cases  the 
discharge  ceases  in  three  or  four  days,  only  to  be  followed,  in  one  or  two 
weeks,    by  a   renewal   of  the    pain    and  another    abscess,  until   the  lit.le 


INFLAMMATION    OF    MUCUS    MEMBRANE.  263 

patients  become  pale,  fretful,  restless  at  night,  and  very  sensitive  to  at- 
mospheric and  all  other  external  impressions. 

The  same  class  of  children  are  much  subject  to  chronic  inflammation 
of  the  membrane  lining  the  nostrils,  causing  a  purulent  and  often  ofl'ensive 
discharge,  constituting  a  form  of  ozena.  In  some  of  these  cases  erup- 
tions appear  on  the  margins  of  the  anterior  nares  and  the  middle  section 
of  the  upper  lip,  similar  to  those  already  described  as  occurring  in  the 
meatus  and  adjacent  parts  of  the  ear,  giving  to  the  upper  lip  and  wings 
of  the  nose  a  sore  and  swollen  appearance.  Still  more  frequently,  per- 
haps, you  will  find  the  same  grades  of  inflammation  attacking  the  tarsus 
of  the  eyelids  involving  both  the  conjunctival  lining  of  the  lids  and  the 
follicles  and  glandular  structures  imbedded  in  the  edge  of  the  tarsus. 
The  inflammation  may  be  so  slight  as  to  cause  only  a  little  thickening  of 
tlie  edge  of  the  tarsus,  with  the  escape  of  a  small  amount  of  a  gluey  ex- 
udation, that  dries  into  hard  masses  at  the  root  of  the  eyelashes,  and  some- 
times causes  the  edges  of  the  lids  to  be  stuck  together  on  awakening  in  the 
morning,  with  slight  morbid  sensitiveness  to  light,  and  the  occasional  forma- 
tion of  a  pustule  or  sty  in  the  edge  of  the  tarsus.  If  left  to  its  own  tend- 
encies, this  condition  of  the  eyelids  may  continue,  with  but  little  varia- 
tion, for  many  months,  or  even  years.  In  some  of  the  more  severe  cases, 
all  the  structures  entering  into  the  tarsus  of  the  lids  become  hypertrophied, 
giving  to  the  edges  of  the  eyelids  a  thickened  and  indurated  condition, 
with  irregular  growth  of  the  eyelashes,  and  sufficient  inversion  or  entropion, 
to  bring  some  of  the  smaller  and  less  perfect  eyelashes  in  contact  with 
the  surface  of  the  cornea,  with  all  the  symptoms  of  a  foreign  body  in  the 
eye,  and  the  establishment  of  slow  corneitic  inflammati-on  and  dimin- 
ished transparency. 

In  another  series  of  cases,  the  inflammation  attacks  primarily  the  ciliary 
processes  and  cornea,  causing  constant  photophobia,  profuse  flow  of  tears, 
a  red  zone  around  some  part  of  the  margin  of  the  cornea,  composed  of 
distended  blood-vessels  running  strictly  parallel  with  each  other,  and  at 
first  terminating  abruptly  at  the  margin  of  the  cornea,  but  subsequently 
traceable  into  or  upon  the  cornea,  as  if  slowly  progressing  toward  a 
common  center. 

In  mo6t  of  the  cases,  at  the  same  time  that  the  red  vessels  are  seen 
entering  the  cornea,  one  or  more  small  and  superficial  ulcers  niay  be 
seen  on  the  surface  of  the  latter,  looking  like  simple  indentations.  If  not 
interfered  with  by  proper  treatment,  the  ulcers  slowly  extend  both  in  cir- 
cumference and  depth,  until  they  perforate  all  the  layers  of  cornea,  and 
allow  the  delicate  membrane  lining  the  anterior  chamber  of  the  eye  to 
protrude  like  a  hernia  through  the  opening  ;  and,  in  some  instances,  this 
membrane  is  also  perforated,  allowing  the  aqueous  humor  to  escape,  with 
partial  collapse  of  the  eyeball,  adhesions  of  the  iris,  and  permanent  loss  of 
vision.  In  other  cases,  the  ulcers  penetrate  only  through  the  external 
layer  of  the  cornea,  while  efi"usion  adds  to  the  aqueous  humor,  causing  the 
weakened  cornea  to  yield  to  the  internal  pressure  by  protruding  forward 
and  assuming  a  conical  shape,  with  diminished  transparency.  In  a  large 
majority  of  the  cases,  however,  the  ulcers  neither  penetrate  through  the 
cornea,  nor  lead  to  alterations  of  its  shape,  but  remain  superficial,  some- 
times almost  disappearing  spontaneously  with  corresponding  improvement 
in  all  the  other  sympttms,  and  then  increasing  again  without  any  appre- 
ciable  cause  ;  thus  causing  the  patients  to  suff'er  from  more  or  less  photo- 
phobia and  inability  to  use  the  eyes,  either  for  the  purposes  of  work  or 
education,  through  an  indefinite  period  of  time.  In  former  years  I  have 
seen  and  treated  many  of  these  cases  of  irritable  scrofulous  ophthalmia^ 


264  SCROFULA. 

in  all  their  grades  and  stages  ;  and,  among  them,  it  has  been  not  uncom- 
mon to  find  here  and  there  a  child,  presenting  at  one  and  the  samj  time, 
the  aflFections  I  have  described,  equally  developed  in  the  ears,  nose  and 
eyes.  When  scrofulous  inflammation  attacks  the  cutaneous  tissue,  it  may 
appear  in  the  form  of  bullae  or  vesicles  of  pemphigus,  which  after  breaking 
and  discharging  the  serum  or  drying  up  and  forming  thin  scabs,  fail  to 
cicatrize,  and  soon  present  large,  superficial  and  irritable  ulcers,  with  little 
or  no  disposition  to  heal.  Or,  what  is  more  common,  is  the  appearance  of 
one  or  more  inflamed  places,  varying  in  size  from  six  to  eighteen  milli- 
meters (one  to  three-quarters  of  an  inch)  in  diameter,  dark  or  purplish 
red  in  color,  not  acutely  painful,  but  tender  to  the  touch,  harder  than 
natural,  and  extending  into  the  subcutaneous  tissue,  as  though  there 
might  be  a  tendency  to  the  formation  of  a  small  abscess.  The  hard  lump 
or  swelling  thus  formed,  usually  changes  very  slowly. 

It  neither  undergoes  resolution  nor  progresses  to  the  formation  of  an  ab- 
scess, but  remains  nearly  stationary  for  several  weeks,  during  which  the 
skin  over  the  central  part  of  the  swelling  becomes  corrugated,  partially 
covered  with  laminge  of  cuticle,  and  finally  develops  a  brown  scab,  which 
on  falling  oft'  leaves  an  open  sore.  In  some  cases  the  ulcer  is  superficial, 
presenting  just  enough  purulent  secretion  to  favor  the  formation  of  a 
scab;  in  others,  its  surface  is  irregular  or  nodulated,  and  covered  with  a 
layer  of  white  lymph,  and  destitute  of  granulations.  As  it  progresses,  the 
nodules  are  found  to  consist  largely  of  caseous  material,  which  disinte- 
grates slowly  and  sometimes  separates  in  masses,  causing  the  ulcer  to  be- 
come deeper  and  larger  until  the  diseased  tissue  has  all  disappeared.  The 
inflammations  I  have  described,  more  frequently  attack  the  arms  and  legs 
and  lower  part  of  the  neck  in  the  vicinity  of  the  clavicle,  or  over  the  upper 
part  of  the  scapula,  but  may  occur  on  any  part  of  the  cutaneous  surface. 
I  have  met  with  them  chiefly  among  the  children  of  the  poor,  living  in  the 
•midst  of  bad  sanitary  conditions,  more  especially  in  damp,  uncleanly  and 
imperfectly  ventilated  houses.  The  only  afi'ections  with  which  they  are 
liable  to  be  confounded,  are  those  resulting  from  constitutional  syphilis. 
If  careful  attention  is  given  to  the  individual  and  family  history  of  each 
case,  together  with  the  fact  that  nearly  all  chronic  sores  and  ulcers  result- 
ing from  constitutional  syphilis,  present  edges  of  a  coppery,  instead  of 
brownish  or  livid  hue,  the  diagnosis  can  be  established  with  reasonable  cer- 
tainty. There  is  but  one  remaining  form  of  local  trouble  connected  with 
the  scrofulous  diathesis  to  which  I  will  direct  your  attention  at  this  time- 
It  is  that  which  affects  the  periosteum  and  sometimes  leads  to  caries  or 
necrosis  of  the  bones.  It  is  probable  that  many  of  the  cases  of  coxalgia 
or  hip-joint  disease,  and  of  caries  and  angular  curvature  of  the  spine,  are 
given  their  special  direction  and  development  by  the  prior  existence  of  a 
true  scrofulous  constitutional  condition  of  the  patient. 

These,  however,  are  so  fully  within  the  domain  of  surgery,  that  I  shall 
make  no  further  allusion  to  them  here.  The  cases  of  scrofulous  periostitis 
that  will  come  more  directly  under  the  care  of  the  physician,  and  in  which 
an  early,  correct  diagnosis  is  very  important,  may  be  included  in  two 
groups.  The  first  group  embraces  such  cases  as  commence  in  the  articu- 
lations, and  in  which  the  local  inflammation  involves  coincidently,  the 
periostum  covering  the  ends  of  the  bones,  the  cartilages,  and  often  the 
ligaments  with  which  they  are  connected.  The  cases  of  this  kind  are 
most  frequently  seen  in  the  ankle  and  arch  of  the  foot,  the  knees,  the 
wrists,  and  the  elbows.  It  generally  commences  with  moderate  difl'used 
swelling  of  the  part,  accompanied  by  some  pain,  which  is  increased  by  motion 
and  pressure,  slight  increase  of  heat,  but  with  little  or  no  change  of  color 


SCROFULOUS    PERIOSTITIS.  265 

upon  the  surface.  The  swelling,  pain  and  tenderness  slowly  but  persist- 
ently increase,  and  after  several  weeks  or  months,  suppuration  is  estab- 
lished, and  whether  incisions  are  made  or  the  matter  is  allowed  to  find  its 
exit  spontaneously,  the  openings  once  formed  remain  fistulous;  or,  if 
they  temporarily  close,  the  pressure  of  the  purulent  accumulations  cause 
them  to  re-open,  or  new  ones  to  form  in  their  place.  A  careful  probing  of 
these  openings,  now,  will  show  that  the  structures  intervening  between 
the  bony  surfaces  have  been  largely  destroyed,  either  by  softening  and  in- 
terstitial absorption  or  by  suppuration,  and  that  more  or  less  of  the  bony 
surfaces  are  denuded  of  their  periosteum  and  rough.  In  the  meantime,  the 
patients  have  become  much  reduced  in  flesh  and  strength,  and  not  unfre- 
quently  present  all  the  phenomena  of  hectic  fever,  with  latent  tubercular 
deposits  in  the  lungs  or  follicles  of  the  intestines,  or  in  both.  It  is  of 
much  practical  importance  to  make  a  correct  diagnosis  in  the  first  stage  of 
all  these  cases,  because  the  appropriate  treatment  may  arrest  their  progress 
and  prevent  those  changes  which,  if  allowed  to  continue,  may  occasion  the 
loss  of  a  limb  or  the  sacrifice  of  a  life.  In  the  early  stage  many  of  these 
cases  are  mistaken  .for  sub-acute  rheumatism  until  suppuration  or  other 
destructive  changes  become  so  far  developed  as  to  correct  the  error.  If 
you  will  give  due  attention  to  the  fact  that  the  scrofulous  inflammation 
usually  commences  without  any  reference  to  sudden  atmospheric  changes, 
progresses  slowly,  and  persistently  holds  its  position  in  the  locality  where 
it  commences,  while  sub-acute  rheumatism  is  always  markedly  influenced 
by  atmospheric  conditions,  is  migratory  or  moving  from  one  articulation 
to  another,  and  very  rarely  fails  to  attack  several  localities,  either  simul- 
taneously or  in  regular  succession,  you  will  seldom  mistake  one  of  these 
affections  for  the  other.  In  the  second  group  of  cases  of  scrofulous  peri- 
ostitis the  disease  commences  on  some  part  of  the  body  or  shaft  of  the 
bone,  and  is  most  frequently  seen  on  the  phalanges  of  the  fingers,  the  ulna, 
the  clavicle,  the  sternum,  and  the  long  bones  of  the  lower  extremities.  It 
is  manifested,  first,  by  a  dift'used  swelling  or  thickening  of  the  periosteum, 
usually  with  only  a  dull  pain  and  moderate  tenderness  to  pressure,  but 
neither  redness  nor  heat.  If  not  interfered  with  by  treatment,  the  swell- 
ing slowly  increases  and  extends  more  around  the  circumference  of  the 
bone,  the  surface  shows  a  more  dull  red  or  purplish  color  and  more  tender 
to  the  touch.  After  several  weeks  of  very  slow  progress,  some  one  or  two 
places  become  more  prominent  and  present  a  semi-fluctuating  feeling;  the 
skin  at  these  points  is  deeper  or  more  livid  red  and  more  sensitive  to 
pressure.  If  a  free  incision  is  made,  it  generally  gives  exit  to  a  small 
amount  of  pus,  and  is  not  followed  by  any  considerable  diminution  of  the 
swelling,  but  remains  open  and  often  enlarges  into  a  deep,  ill-conditioned 
ulcer,  sometimes  from  sloughing,  and  other  times  from  simple  disintegration 
of  the  tissues.  If  an  incision  is  not  made,  one  or  more  small  openings 
eventually  form,  giving  exit  to  a  small  quantity  of  thin  pus  or  sero-purulent 
fluid,  after  which  they  extend  in  the  same  manner  as  in  case  of  an  incision. 
In  some  cases,  several  of  these  openings  form  over  the  surface  of  the 
same  bone.  Sometimes  the  periosteum  is  destroyed,  and  the  naked,  rough 
surface  of  the  bone  may  be  seen  or  touched  with  a  probe  at  the  bottom  of 
the  sores.  In  one  girl,  about  seven  years  of  age,  there  were  three  deep, 
indolent  sores  on  the  side  of  the  neck,  in  place  of  destroyed  lymphatic 
glands,  two  over  the  surface  of  the  clavicle,  and  one  over  the  upper  seg- 
ment of  the  sternum.  Several  years  since,  a  boy  about  five  years  of  age 
came  under  my  observation,  who  had  nearly  all  the  phalanges  of  his  fingers 
attacked  at  difl"erent  times  with  scrofulous  periostitis.  In  three  fingers  of 
one  hand,  and  two  of  the  other,  the  periosteal  inflammation  gradually  ex- 


266  LOCAL   SCEOFULA. 

tended  over  the  whole  length  of  Ihe  middle  phalange,  separating  and  de- 
stroying it  to  such  a  degree  as  to  cause  necrosis  of  the  whole  bone,  neces- 
sitating its  removal,  and  leaving  each  finger  much  shortened  and  its  use- 
fulness impaired.  Yet  he  subsequently  recovered  fair  health.  In  many 
of  this  class  of  cases  you  may  find  some  difficulty  in  maintaining  a  def- 
inite line  of  distinction  between  them  and  the  periosteal  inflammations 
dependent  on  constitutional  syphilis.  The  latter  usually  occur  in  adult 
life,  are  much  the  more  frequently  connected  with  the  tibia,  bones  of  the 
cranium,  nose  and  ulna,  and  suppurate  slowly,  leading  to  caries  of  the 
bones  ;ind  fistulous  openings,  but  seldom  to  large  open  sores.  The  scrof- 
ulous jiffection  is  manifested  chiefly  in  children  under  fifteen  years  of 
age — more  frequently  attacks  the  fingers,  clavicle,  sternum,  and  parts  en- 
tering into  the  articulations,  suppurates  more  readily,  and  in  doing  so,  in- 
volves to  a  greater  extent  all  the  soft  tissues  lyn.g  over  the  seat  of  disease. 
These  facts,  with  strict  attention  to  the  history  of  the  patient  and  his  he- 
reditary predisposition,  will  enable  you  to  make  a  correct  diagnosis  in  all 
ordinary  cases.  It  has  been  claimed  by  some  members  of  the  profession, 
of  great  eminence,  however,  that  all  the  forms  of  scrofula  are  only  the  more 
remote  manifestations  of  constitutional  and  hereditary  syphilis.* 

Treatment. — The  same  principles  of  treatment,  both  hygienic  and  medi- 
cal, are  applicable  in  the  management  of  the  scrofulous  afi'ections  of  mu- 
cous membranes,  skin,  periosteum,  etc.,  as  I  have  already  explained  to  you 
in  speaking  of  the  treatment  of  glandular  scrofula.  The  same  careful 
attention  to  good  air,  appropriate  food,  and  such  exercise  as  the  patient 
will  bear,  is  essential  to  the  success  of  any  plan  of  treatment  that  may  be 
devised;  and  in  most  cases,  a  limited  and  judicious  use  of  iodine  or  the 
bichloride  of  mercurj",  or  Ijoth  alternately,  as  general  alterants,  will  be 
found  necessary.  In  almost  all  cases  they  should  be  given  coincidently 
with  the  preparations  of  peruvian  bark  or  other  bitter  tonics.  In  the 
scrofulous  ophthalmia  of  children,  characterized  by  irritable  ulcerations  of 
the  cornea  and  great  photophobia,  I  have  found  no  other  treatment  so 
certain  to  arrest  the  progress  of  the  disease  and  ultimately  restore  the  pa- 
tient to  health,  as  the, use  of  the  formula  I  have  given  you  containing  the 
bichloride  of  mercury,  compound  tincture  of  cinchona,  etc.,  in  doses  suited 
to  the  age  of  the  patient,  with  only  very  mild  anodyne  applications  exter- 
nally, or  none  at  all.  In  all  of  this  class  of  cases  the  eyes  should  be  shaded 
from  the  direct  rays  of  light,  but  should  not  be  closely  covered  nor  the 
patient  confined  to  a  dark  room.  In  nearly  all  the  cases  of  indolent,  non- 
granulating  scrofulous  ulcers  in  the  skin,  and  in  the  periosteal  affections  I 
have  described,  I  have  succeeded  best  by  giving  the  formula  containing  the 
bichloride  of  mercury  for  the  first  two  weeks  of  the  treatment  and  then 
substituting  the  iodine.  You  may  be  ready  to  ask  why  I  do  not  use  the 
combinations  of  mercury  and  iodine,  in  the  forms  of  proto  or  bin-iodides, 
in  these  cases.  My  answer  is,  that  simple  clinical  experience  has  shown 
me  that  I  do  not  get  the  same  good  effects  from  them,  while  they  are  much 
more  liable  to  disturb  the  stomach  or  bowels.  Neither  have  I  ever  ob- 
tained any  perceptible  good  effects  from  the  internal  administration  of 
the  iodides  of  potassium,  sodium  and  ammonium,  in  true  scrofulous  afi'ec- 
tions. On  the  contrary,  if  given  in  the  usual  liberal  doses,  they  soon  be- 
gin to  impair  the  appetite,  lessen  the  activity  of  nutrition,  and  create  in- 
creased feelings  of  weakness,  with  no  improvement  in  the  local  affections. 
This  constitutes  a  marked  distinction  between  the  effects  of  remedies  in 
the  treatment  of  true  scrofula  and   constitutional  syphilis. 

*See  Address  on  Surgery,  by  S.  D.  Gross,  M.  D.,  LLD.,  etc.    Transactions  of  the  American  Medical 
Association,  Vol.  25,  p.  219  to  2'J2.— 187-1. 


TKEATMENT.  267 

Local  Applications. — In  all  the  forms  of  scrofulous  ulcers,  except  those  in 
the  cornea  or  other  parts  of  the  eye-ball,  slightly  stimulating  and  antiseptic 
applications  once  or  twice  a  day  will  generally  do  some  good.  Weak  solu- 
tions of  iodine,  permanganate  of  potassium,  carbolic  acid,  and  benzoic, 
acid,  are  among  the  best.  They  may  be  applied  morning  and  evening 
and  the  sores  covered  in  the  interval  with  lint  smeared  with  cosmoline  or 
vaseline.  In  those  cases  of  purely  chronic  inflammation  and  thickening  of 
the  tarsus  of  the  eyelids,  with  the  exudation  of  a  gummy  substance, 
causing  the  lids  to  adhere  to  each  other  in  the  morning,  I  have  obtained 
much  benefit  from  the  application  of  the  following  salve  : 

5.      Hydrargyri  Oxidi  Rubri  1  gram  gr.  xv. 

Powder  finely  and  add 
Cerati  Simplicis  30  grams  |i. 

Mix  thoroughly,  and  apply  a  little  to  the  edges  of  the  eyelids  just  be- 
fore going  to  bed  each  night. 

Care  must  be  exercised  to  have  the  salve  accurately  applied  simply  to  the 
margin,  and  not  to  the  inner  surface  of  the  lids.  Very  much  more  might 
be  said  in  regard  to  the  use  of  remedies  in  the  treatment  of  the  various 
local  afi'ections  connected  with  the  scrofulous  diathesis  ;  but  I  have  given 
you  the  results  of  a  long  and  ample  experience,  during  which  I  have  tried 
almost  every  variety  of  treatment  hitherto  pro[)Osed  in  this  troublesome 
class  of  affections,  and  I  am  satisfied  that  the  suggestions  I  have  made,  if 
judiciously  applied,  will  give  you  the  bestresults  attainable  in  the  present 
state  of  medical  science. 


LECTURE  XXIX. 

LeucocythEemia.  Pseudo-Leucocythasmia,  Pernicious  Anjemia  and  Addison's  Disease— Their  His- 
tory,  Causes,  Symptoms,  Special  Pathology,  Diagnosis,  Prognosis  and  Treatment. 

GENTLEMEN: — If  I  were  to  follow  strictly  the  order  given  in  my  enu- 
meration of  the  diseases  included  in  the  class  now  under  consideration, 
I  should  next  consider  the  local  developments  of  tub-^rculosis.  But  such 
of  these  developments  as  are  not  intimately  connected  with  the  local 
scrofulous  affections  considered  during  the  preceding  lecture  hour,  are  so 
uniformly  connected  with  the  lungs,  constituting  a  form  of  pulmonary 
phthisis,  or  with  the  membranes  of  the  brain  leading  to  a  form  of  menin- 
gitis, that  I  shall  consider  them  in  connection  with  the  other  local  affec- 
tions of  the  respiratory  organs  and  membranes  of  the  brain.  I  do  this 
chiefly  because  a  proper  study  of  their  diagnosis  involves  a  close  compar- 
ison between  them  and  the  d.fferent  grades  of  inflammation  in  the  same 
structures.  Passing  by  the  local  manifestations  of  tuberculosis  for  the 
present,  I  shall  now  consider  briefly  the  diseases  recently  named  Leuco- 
cythfemia,  pseudo-leucocythaemia,  etc.  These  names  have  been  used  to 
designate  forms  of  disease  very  closely  related  to  each  other,  and  to  the 
adenoid  or    glandular  form    of   scrofula.     Indeed,  until    a   comparatively 


268  LEUCOCYTH^MIA. 

recent  period,  the  cases  included  under  these  heads  were  generally  regarded 
as  only  different  forms  of  scrofula.  In  1845,  Dr.  Hughes  Bennett  first  called 
attention  to  the  fact  that  a  certain  group  of  cases  were  uniformly  charac- 
terized by  a  large  excess  of  white  corpuscles  in  the  blood,  coupled  with 
hypertrophy  or  hyperplasia  of  the  spleen,  and  a  large  number  of  the  lym- 
phatic glands  in  different  parts  of  the  body;  and  he  gave  to  them  the 
name  of  leucocyth^emia.  About  the  same  time  Virchow  described  a 
similar  group  of  cases  and  called  the  disease  leukemia,  or  leucaemia,  mean- 
ing white  blood.  Both  identified  and  described  the  same  form  of  disease, 
but  the  name  chosen  by  Bennett,  meaning  excess  of  white  corpuscles  in- 
stead of  white  blood,  is  the  most  appropriate.  Although  never  diflferenti- 
ated  from  other  forms  of  anaemia  and  scrofula  until  done  by  Bennett  and 
Virchow  in  1845,  yet  the  disease  now  called  leucocythjemia  has  occurred 
in  all  civilized  countries  from  an  early  period  of  medical  history.  Its  pos- 
itive and  accurate  diagnosis  could  not  be  established,  however,  until  the 
application  of  the  microscope  to  the  study  of  minute  anatomy  had  become 
familiar  to  the  profession.  The  names  chosen  by  Bennett  and  Virchow 
are  suggested  solely  by  the  altered  condition  of  the  blood.  But  the 
spleen  and  lymphatic  glandular  structures  are  apparently  as  constantly 
and  extensively  altered  from  their  natural  condition  as  is  the  blood. 
Hence  Trousseau  calls  the  disease  adenie;  Gresinger,  anaemia  splenica; 
Jaccoud,  a  lymphagenic  diathesis;  and  others  have  used  the  terms 
anaemia  lymphatica;  splenic  leucocythaemia;  maduUo-splenic  disease,  etc. 

Causes. — The  essential  causes  of  leucocythasmia  are  so  obscure  as  to 
have,  thus  far,  eluded  observation.  Literally,  nothing  is  known  concern- 
ing the  etiology  of  the  disease.  It  occurs  most  frequently  during  the 
active  period  of  adult  life,  from  twenty  to  forty  years  of  age.  But  cases 
have  been  observed  at  all  stages  of  life,  from  childhood  to  old  age.  It 
has  beer  seen  much  more  frequently  in  the  male  than  in  the  female  sex. 
It  has  beer  claimed  that  excessive  mental  and  physical  labor,  and  the  oc- 
cupation of  damp  and  poorly  ventilated  dwellings,  acted  as  predisposing 
causes.  If  they  do  so,  it  is  probably  only  by  lessening  the  general  tone 
of  health,  and  thereby  impairing  the  resistance  to  all  morbid  impres- 
sions. 

Symptoms. — The  early  symptoms  of  the  disease  are  very  obscure  and 
ill-defined.  They  consist  chiefly  in  diminished  power  of  endurance,  or 
unusual  weariness,  from  either  mental  or  physical  exercise,  variable 
appetite,  with  slight  impairment  of  dig 'stion,  imperfect  or  disturbed 
sleep,  nervous  excitement  and  increased  cardiac  action  from  slight  causes, 
and  a  gradually  increasing  paleness  or  anaemic  hue  of  the  surface.  These 
equivocal  and  variable  symptoms  may  be  noticeable  for  several  months 
before  the  development  of  any  swelling  or  enlargement,  either  in  the 
spleen  or  lymphatic  glands.  Generally,  however,  in  from  six  to  twelve 
months,  the  patient  begins  to  present  a  decidedly  angemic  look,  and  finds 
so  much  shortness  of  breath,  palpitation,  and  sense  of  weariness  from 
very  moderate  attempts  to  exercise,  that  he  is  obliged  to  abandon  all  active 
business.  He  now  has  frequent  temporary  paroxysms  of  fever,  with  dis- 
order of  the  stomach  and  bowels,  wandering  pains  in  his  head,  back,  limbs 
— sometimes  vertigo,  with  dimness  of  vision,  and  the  urinary  secretion  is 
very  variable  in  quantity,  being  sometimes  abundant  and  pale — at  other 
times  less  than  natural,  and  deeper  color,  but  without  the  presence 
of  either  albumen  or  sugar.  A  careful  examination  of  the  patient  will  now 
detect  plain  anaemic  or  soft  blowing  sounds  over  the  base  of  the  heart  and 
in  the  course  of  the  aorta,  with  habitual  frequency  and  softness  of  the 
pulse;  but  no  physical  signs  of  structural  change,  either  in  the  heart  or 


MOEBID    ANATOMY.  269 

lungs.  In  a  majority  of  cases  there  will  be  unnatural  fullness  of  the  left 
hypocliondrao  region,  which  can  be  traced  by  palpation  and  percussion,  to 
enlargement  of  the  spleen.  In  a  largo  proportion  of  the  cases,  at  this  stage, 
there  are  found  enlargements  of  the  lymphatic  glands  in  the  groins,  often 
extending  in  a  chain  up  the  course  of  the  iliac  vessels,  into  the  abdomen; 
and  in  some  cases  the  same  class  of  glands  are  enlarged,  both  in  the  axilla 
and  neck.  From  this  time  or  stage  in  the  development  of  the  disease, 
the  health  of  the  patient  fails  more  rapidly.  The  ansemia,  glandular 
swellings,  shortness  of  breath,  and  palpitations  from  slight  exertion,  all 
steadily  increase.  The  glandular  swellings  are  generally  rounded,  freely 
movable,  less  hard  or  dense  than  the  glandular  enlargements  in  scrofula, 
and  varying  in  size  from  that  of  a  pea  to  a  hen's  egg.  The  spleen  usu- 
ally continues  to  increase,  until  it  sometimes  fills  the  v^^hole  left  side  of  the 
abdomen,  and,  except  the  natural  indentations  along  the  edge,  its  surface 
is  smooth  and  but  little  tender  to  the  touch.  In  some  cases,  the  liver  also 
becomes  enlarged,  especially  in  the  advanced  stage  of  the  disease.  The 
patient  has  more  frequent  attacks  of  diarrhoea  or  vomiting,  and  sometimes 
both.  Haemorrhages,  especially  from  the  nostrils,  and  in  some  cases  from 
the  gums,  bowels,  uterus,  and  kidneys,  are  of  frequent  occurrence. 
Petechial  spots  appear  on  the  surface,  and  sometimes  considerable  extra- 
vasations of  blood  take  place  into  the  subcutaneous  areolar  tissue.  In 
some  instances,  death  takes  place  suddenly  from  extravasation  of  blood 
into  some  part  of  the  brain.  More  frequently  death  results  from  serous 
or  dropsical  effusions,  not  only  into  the  areolar  tissues  and  serous  cavities, 
but  into  the  parenchyma  of  the  lungs  and  other  organs,  or  from  persistent 
diarrhoea.  Some,  however,  linger  long,  and  die  from  asthenia,  or  simple 
exhaustion.  Cases  differ  much  in  the  rapidity  of  their  progress.  Some 
reach  a  fatal  result  in  five  or  six  months,  while  others  continue  as  many 
years.  The  average  duration,  as  indicated  by  such  cases  as  have  been  col- 
lated by  different  writers,  is  about  two  years. 

Morbid  Anatomy. — Post  mortem  examinations  have  revealed  important 
changes  resulting  from  the  progress  of  this  disease,  both  in  the  blood  and  in 
several  of  the  structures  of  the  body.  The  most  important  and  characteristic 
change  in  the  blood,  consists  of  a  large  increase  in  the  number  of  white 
corpuscles  or  leucocytes,  and  a  corresponding  diminution  of  the  red  blood 
discs.  So  great  is  this  change  that  in  some  cases  the  number  of  white  cor- 
puscles actually  exceeds  those  of  the  red.  In  the  great  majority  of  cases, 
however,  the  relative  proportion  varies  from  one  of  the  white,  to  ten,  fif- 
teen, or  twenty  of  the  red  corpuscles.  Notwithstanding  the  great  increase 
of  the  white  corpuscles,  the  decrease  of  the  red  ones  is  relatively  still 
greater;  thereby  causing  the  aggregate  of  corpuscular  elements  in  the  blood 
to  be  much  less  than  in  health. 

The  greater  number  of  white  corpuscles  appear  of  their  natural  size,  but 
some  are  sm  iller,  and  a  few  are  found  much  larger  and  filled  with  nuclei 
or  granular  matter,  much  like  the  ordinary  giant  cells  of  the  lymphoid  tis- 
sues. These  changes  make  the  blood  look  much  paler  than  natural;  and 
the  clots  that  form  to  be  of  a  light  yellowish  color  and  small;  but  the  pro- 
portion of  fibrine  is  moderately  increased. 

The  composition  of  the  secretions  generally  does  not  differ  in  a  marked 
degree  from  that  of  health.  The  urine  generally  contains  an  excess  of  uric 
acid;  and  in  a  small  proportion  of  cases,  traces  of  formic  and  lactic  acids  and 
hypoxanthin  have  been  found.  These  same  substances,  together  with 
leucin,  tyrosin,  and  minute,  colorless  octohedral  crystals,  first  described  by 
Charcot,  have  been  detected  in  the  blood  in  some  instances.  But  their 
presence  is  not  constant  either  in  the  blood  or  urine;  neither  are  they  pe- 


270  LEUCOCYTH^MIA. 

culiar  to  this  disease.  Next  to  the  blood,  the  most  marked  and  constant 
chan2;es  are  found  in  the  spleen,  lymphatic  glands,  and  medulla  or  marrow 
of  the  bones.  These  changes  are  quite  uniform  in  kind  but  differing  much 
in  degree  in  different  cases.  They  consist  of  an  increase  of  the  lymphoid 
cells  and  reticulated  tissue  and  consequent  enlargement  or  h^^pertrophy  of 
the  glandular  structures  without  material  alteration  of  constituents;  but 
the  marrow  of  the  bones  being  inclosed  in  such  a  way  as  to  prevent  en- 
largement, the  increase  of  lymphoid  cells  causes  the  disappearance  of  the 
natural  fatty  matter,  and  gives  to  the  medulla  a  reddish  or  greenish  yellow 
color  and  creamy  consistence.  It  is  chiefly  in  the  medulla  or  marrow  of 
the  long  bones  of  the  extremities,  and  of  the  ribs  and  vertebrae,  that  these 
changes  have  been  observed.  The  excess  of  lymphoid  cells  in  all  these 
structures  vary  much  in  size,  some  being  smaller  and  others  larger  than 
natural.  As  a  rule,  the  smaller  ones  predominate  in  the  lymphatic  glands, 
and  the  larger  nucleated  and  granular  cells  are  more  numerous  in  the  me- 
dulla of  the  bones  and  in  the  ]3ulp  of  the  spleen.  The  changes  and  lym- 
phoid cell  accumulations  are  not  limited  entirely  to  the  spleen,  lymphatic 
glands,  and  medulla  of  the  bones,  but  in  very  many  cases  are  found  to  have 
occurred  in  a  less  degree,  in  the  lobules  of  the  liver,  the  kidneys,  the  gland- 
ular structures  of  the  mucous  membrane  of  the  alimentary  canal,  the  brain, 
the  retina  of  the  eye,  and  the  testicles.  These  structural  changes  are  not 
found  -equally  developed  in  all  the  structures  involved  in  each  case.  For 
instance,  in  many  cases  they  will  be  very  prominent  in  the  spleen,  and 
comparatively  slight  in  all  other  parts.  These  have  been  called  splenic- 
leucocythaemia.  In  other  cases,  the  lymphatic  glands  generally  have  be- 
come prominently  affected  Avith  hyperplasia,  while  the  spleen  is  only  slight- 
ly altered.  These  have  been  called  lymphatic-leucocythasmia.  In  a  smaller 
number  of  cases  the  changes  have  chiefly  occurred  in  the  medulla  of  the 
bones,  with  but  little  in  either  the  sp'een  or  lymphatic  glands;  and  these 
have  been  called  raedulla-leucocytlifemia.* 

Special  Pathology. — The  nature  of  the  primary  morbid  actions  from  which 
result  the  progressive  and  persistent  alterations  in  the  blood  and  struct- 
ures, such  as  T  have  just  described,  are  involved  in  obscurity,  on  account 
of  our  imperfect  knowledge  of  the  physiological  processes  by  which  the 
corpuscular  elements  of  the  blood  are  formed  in  health.  That  white  cor- 
puscles appear  in  the  chyle  during  and  after  its  passage  through  the  mes- 
enteric glands,  and  in  the  lymphatic  vessels  that  take  up  the  colorless 
fluids  from  the  several  tissues  of  the  body,  and  that  such  corpuscles  are  in- 
creased during  the  passage  of  this  fluid  through  the  lymphatic  glands, 
are  facts  familiar  to  all  of  you.  But  how  and  where  the  red  corpuscles  are 
formed  is  still  undetermined.  For  a  long  time  they  were  supposed  to  be 
formed  in  the  spleen.  More  recently  several  observers  have  discovered 
these  bodies  in  what  appeared  to  be  different  stages  of  formation  in  the 
medulla  or  marrow  of  the  bones;  and  consequently  have  regarded  this  as 
the  seat  of  their  formation.  This  view  was  thought  to  be  corroborated  by 
the  fact  that  the  marrow  of  the  bones  was  found  to  have  undergone  marked 
changes  of  structure  in  many  of  the  cases  of  leucocytiisemia.  If  post 
mortem  examinations  had  shown  a  constant  correspondence  between  the 
changes  in  the  bone  marrow  and  the  degree  of  diminution  of  red  corpuscles, 
the  evidence  would  have  been  of  much  value.  But  such  is  not  the  fact. 
On  the  contrary,  in  many  cases  of  extreme  leucocythaemic  anaemia,  very 
little  change  has  been  observed  in  the  marrow  of  the  bones;  and  in  a  few, 
none  that  was  ajDpreciable. 

*  See  Nauman,  in  Berlin  Klin.  Wochenschrift,  No  6, 1878. 


DIAGNOSIS.  271 

My  own  observations  have  led  me  to  think  that  there  are  two  kinds  of 
white  corpuscles,  both  formed  as  a  part  of  the  assimilative  changes  which 
take  place  in  the  reticulated  tissue  or  lymphatic  vessels  and  glands.  One 
kind  constitute  the  true  migrating  corpuscles  that  accumulate  so  readily  in 
the  vessels  of  inflamed  parts,  permeate  freely  the  walls  of  capillary  ves- 
sels, and  enter  directly  into  the  nutrition  of  the  various  organized  struct- 
ures. The  other  kind  have  less  ameboid  movement,  often  attain  a  larger 
size  and  look  more  granular,  and  somewhere  in  their  progress,  they  become 
])ermeated  with  the  haamoglobin  and  are  transformed  into  red  corpuscles. 
Whether  this  latter  change  is  completed  while  they  are  passing  through 
the  marrow  of  the  bones,  the  pulp  and  malpighian  vessels  of  the  spleen,  or 
while  floating  in  the  mass  of  the  blood,  cannot  be  positively  determined  in 
the  present  state  of  physiological  science.  Be  this  as  it  may,  however,  I 
am  satisfied  that  the  first  and  essential  step  in  the  pathology  of  leucocythae- 
mia  consists  in  the  failure  to  complete  the  transformation  of  white  into  red 
corpuscles.  Whether  this  results  from  some  imperfection  in  the  properties 
of  the  white  corpuscles  by  which  they  fail  to  attract  the  hEemoglobin;  or 
whether  the  latter  is  itself  deficient,  cannot  be  readily  determined.  The 
failure  to  complete  the  conversion  of  the  white  corpuscles  into  the  red,  al- 
lows the  former  to  accumulate  in  the  blood  and  in  the  adenoid  or  reticulat- 
ed tissues,  causing  slow  hypertrophy  of  some  part  or  all  of  the  latter,  as 
seen  in  the  ultimate  enlargements  of  the  spleen,  lymphatic  glands,  mar- 
row of  the  bones,  etc.  At  the  same  time,  as  new  red  corpuscles  cease  to 
develop,  and  those  already  existing  slowly  disappear,  the  resulting  im- 
poverishment brings  steaddy  increasing  paleness,  muscular  weakness,  in- 
capacity for  active  exertion,  shortness  of  breath,  palpitations,  and  general 
functional  derangements. 

That  the  diminution  of  the  red  corpuscles  is  the  result  of  failure  in  some 
part  of  the  processes  by  which  they  are  developed,  and  not  from  an  in- 
crease in  the  rapidity  of  their  destruction,  is  evident,  from  the  fact  that  at 
no  stage  of  the  disease  do  we  find  an  increase  of  the  products  of  such  de- 
struction in  the  form  of  dark  granules  or  melanotic  deposits,  such  as  appear 
so  abundant  when  they  are  undergoing  increased  destruction  from  malari- 
ous infiuence. 

Diagnosis. — In  its  early  stage,  leucocythpenia  is  liable  to  be  confounded 
with  various  other  spansemic  conditions  of  the  blood,  and  impairments  of 
nutrition;  such  as  scrolula,  chlorosis,  pernicious  anasmia,  etc.  From  all 
these,  however,  it  is  distinguished  with  much  certainty  by  the  presence  of 
an  increased  number  of  white  corpuscles,  and  a  corresponding  diminution 
of  the  red,  as  shown  on  the  field  of  the  microscope.  As  the  relative  pro- 
portion of  both  red  and  white  corpuscles,  varies  much  in  difi'erent  indi- 
viduals and  in  difi'erent  morbid  conditions,  it  becomes  desirable  to  deter- 
m'ne  the  degree  of  change  that  shall  be  regarded  as  certainly  indicating 
the  ]5resence  of  the  diseasp  under  consideration.  If  a  proper  examination 
of  the  blood  shows  the  presence  of  one  white  to  twenty  red  corpuscles, 
most  writers  regard  it  as  sufficient  evidence  of  the  presence  of  leucocy- 
thaeinia. 

But  the  ratio  of  the  white  to  the  red  corpuscles  in  healthy  blood,  does 
not  exceed  one  in  from  five  hundred  to  one  thousand;  and  if  you  have  a 
patient  with  the  early  general  symptoms  of  leucocythtemia,  and  on  exam- 
ining the  blood  you  find  one  white  to  fifty  red  globules,  and  at  two  or 
three  subsequent  examinations  at  intervals  of  one  or  two  weeks,  you  find 
a  progressive  ratio  of  increase  in  the  number  of  white  ones,  you  will  be 
safe  in  regarding  the  diagnosis  as  established.  For  the  steadily  increas- 
ing ratio    of   the  one    relatively    to  the  other,  through  a  given   period    of 


272  LEUCOCYTH^MIA. 

time,  is  quite  as  important  in  a  diagnostic  point  of  view,  as  any  arbitrary 
standard  of  such  ratio. 

jPrognosis. — Whatever  may  be  the  nature  of  the  morbid  condition  by 
which  the  white  corpuscles  are  prevented  from  further  development  into 
red  ones,  when  once  established,  it  usually  persists  in  opposition  to  all 
efforts  hitherto  made  for  remedying  it,  until  the  life  of  the  patient  is  de- 
stroyed. The  most  obvious  fault,  is  the  failure  in  the  production  of 
haemoglobin  and  its  union  with  the  other  elements  of  the  colored  corpus- 
cles. But  no  methods  of  treatment  have  yet  been  successful  in  remedy- 
ing this  defect,  or  in  materially  modifying  the  progress  of  the  disease. 
Consequently,  the  prognosis  in  well  marked  cases  of  leucocythgemia  must 
be  regarded  as  uniformly  unfavorable. 

Treatment. — Seeing  the  pallor  and  general  weakness  of  the  patient, 
you  will  naturally  turn  with  some  confidence  to  the  use  of  fresh  air,  good 
food  and  ferruginous  tonics,  as  in  other  forms  of  anjemia,  with  the  expecta- 
tion of  improving  the  nutritive  processes  and  checking  the  progressive 
impoverishment  of  the  blood.  At  the  same  time  the  enlarged  spleen  and 
lymphatic  glands  will  suggest  the  use  of  iodine,  quinine,  arsenic,  and 
other  alteratives.  But,  gentlemen,  all  these  remedies,  and  many  more, 
aided  l)y  change  of  air  and  climate,  have  been  perseveringly  used,  with- 
out obtaining  any  permanent  control  over  the  progress  of  the  disease. 
Those  who  regard  the  disease  as  having  its  origin  in  the  spleen,  have  re- 
sorted to  a  liberal  use  of  quinine,  ergotine,  iron,  iodine,  mercurial  inunction 
and  electricity,  with  the  hope  of  reducing  the  size  of  that  organ,  and 
thereby  arresting  the  further  involvement  of  the  system  generally.  Find- 
ing remedies  unavailing,  the  spleen  has  been  extirpated  in  several  cases, 
but  with  uniformly  fatal  results,  either  from  haemorrhage  or  peritonitis. 
Remedies  addressed  to  the  lymphatic  glandular  enlargements  have  been 
attended  by  no  better  results.  In  the  present  state  of  knowledge  on  this 
subject,  I  can  give  you  no  better  advice,  than  to  examine  carefully  the 
sanitary  history,  habits  and  surroundings  of  your  patient,  with  a  view  to 
the  detection  and  removal  of  all  influences  that  could  affect  unfavorably, 
either  the  assimilative  or  excretory  functions,  or  the  healthful  tone  of 
the  nervous  system.  Let  the  sleeping  room  be  of  good  size,  dry,  well 
lighted  and  well  ventilated.  Let  the  diet  be  plain,  easily  digestible,  and 
embracing  sufficient  variety  for  supplying  all  the  elements  necessary  for 
perfect  hfematosis  and  nutrition.  Let  the  exercise  be  habitually  in  the 
open  air,  by  riding  or  walking,  as  best  suits  the  strength  and  comfort  of 
the  patient;  and  after  every  ride  or  walk,  let  there  be  at  least  half  an  hour 
of  full  rest  in  the  recumbent  position.  If  the  patient  has  long  resided  in 
the  interior  and  has  the  means  for  traveling,  let  him  visit,  and  tarry 
during  the  warm  months  at  the  seaside.  If  his  residence  is  near  the 
sea,  let  him  change  to  the  mountains;  or  if  on  a  damp  and  malarious 
soil,  let  him  move  permanently  to  one  moderately  elevated  and  dry.  So 
far  as  possible,  let  the  social  surroundings  of  the  patient  be  such  as  to 
promote  mental  cheerfulness  and  hope.  All  these  items  are  worthy  of 
the  most  careful  attention,  especially  in  the  earlier  stages  of  the  dis- 
ease. 

For  direct  medication  I  should  rely  much  upon  the  tonic  and  alterant  in- 
fluences of  the  following  formulae  : 

'^     Hydrargyri  Chloridi  Corosivi  0.066  grams  gr.  I 

Tincturse  Cinchonse  Compositse        90.000  c.  c.      §iii 
Elixir  Simplicis  30.000  "  "        31 

Mix.     Give  four  cubic  centimeters,  (fl  3i)  in  a  little  water  just  before 


PSEUDO-LEUCOCYTH^MIA.  273 

breakfast,  dinner  and  supper.  To  supply  materials  for  the  haemoglobin  I 
give  lialf  an  hour  after  each  meal,  an  ordinary  dose,  of  either  the  syrup  of 
lacto-phosphate  of  iron,  the  pyrophosphate  of  iron,  or  the  compound  syrup 
of  the  hypophosphites.  One  of  these  may  be  given  until  the  patient  be- 
comes weary  of  the  same  impression  and  then  exchanged  for  another.  And 
to  lessen  the  danger  of  inducing  any  effect  of  the  mercurial  on  the  mouth 
or  salivary  glands,  the  bichloride  may  be  omitted  from  the  formula  I  just 
gave,  during  every  third  week. 

Another  measure  worthy  of  persevering  use,  is  the  application  of  elec- 
tricity. This  should  be  done,  sometimes  by  insulating  the  patient  and 
charging  the  system  moderately,  and  more  frequently  by  giving  the  pa- 
tient the  positive  pole  in  one  hand,  the  operator  taking  the  negative  in  one 
of  his,  and  then  making  the  connection  by  frictions  with  the  other  over  the 
spleen  and  the  various  lymphatic  glandular  enlargements.  To  obtain  the 
maximum  of  influence,  the  applications  should  be  continued  from  ten  to 
twenty  minutes  once  each  day.  Such  is  the  general  course  of  management 
which  I  have  found  most  beneficial  in  the  limited  number  of  cases  that 
have  come  under  my  own  observation.  Of  course  due  attention  must  be 
given  to  the  palliation  of  some  of  the  more  distressing  symptoms  as  they 
occur.  Hasmorrhages,  diarrhoeal  attacks,  palpitations,  etc.,  must  be  tem- 
porarily met  by  appropriate  remedies;  and  in  malarious  districts  the  judi- 
cious use  of  quinine,  either  alone,  or  in  combination  with  iron  and  strychnia 
may  be  of  great  advantage. 

PSEUDO-LEUCOCYTH^MIA. 

Very  closely  allied  to  the  disease  I  have  just  considered,  if  indeed  it  be 
not  a  mere  variety  of  the  same,  is  the  pseudo  or  false  leucocythjemia  of 
recent  writers.  It  was  first  described  as  a  distinct  disease,  and  differenti- 
ated from  ordinary  scrofulous  affections  by  Dr.  Hodgkin  in  1832. 

His  descriptions,  however,  included  all  cases  in  which  there  were  as- 
sociated special  enlargement  of  the  spleen,  with  more  or  less  hypertrophy 
of  the  lymphatic  glands.  It  was  not  until  thirteen  years  later,  that  Ben- 
nett and  Virchow  separated  the  cases  characterized  by  excess  of  white  cor- 
puscles in  the  blood  from  those  having  no  such  excess,  and  gave  to  the  first 
the  name  of  leucocythaeraia  or  leukfemia,  and  leaving  the  latter  to  be 
called  pseudo-leucocythjemia  or  Hodgkin's  disease.  The  clinical  his- 
tory, or  symptoms  and  progress,  of  the  two  diseases,  present  no  constant  or 
essential  differences.  In  the  pseudo-leucocythaemic  form  of  disease,  3'ou 
have  the  same  obscure  beginning,  and  subsequently  the  same  progressive 
anaemia  or  impoverishment  of  the  red  corpuscles  of  the  blood,  loss  of 
strength,  shortness  of  breath,  palpitations,  and  hypertrophies  of  the  spleen 
and  lymphatic  glands;  and  in  the  advanced  stage,  hEsmorrhages,  diarrhoeas, 
dropsical  effusions,  etc.;  and  the  same  persistent  tendency  to  a  fatal  result. 
The  only  positive  condition  on  which  a  differential  diagnosis  can  be  based, 
is  the  want  of  a  sufficient  number  of  white  corpuscles  in  the  blood  to 
come  within  the  rule  adopted  as  necessary  to  constitute  true  leucocyth®- 
mia.  In  a  majority  of  the  cases  classed  as  Hodgkin's  disease  there  is  more 
extensive  hypertrophy  of  the  lymphatic  glands  and  reticulated  or  adenoid 
tissues  throughout  the  system,  except  in  the  medulla  of  the  bones;  which 
latter,  however,  has  not  yet  received  as  much  attention  as  Nauman  and 
others  have  bestowed  upon  it  in  the  cases  of  leucocythsemia.  The  densi- 
ty of  the  enlarged  glandular  structures  differs  much  in  different  cases.  In 
some  they  are  comparatively  soft,  while  in  others  they  are  quite  hard  and 

18 


274  PERxicrous  anjsmia. 

round.  In  the  softer  cases  the  increased  growth  is  owing  mostly  to  the 
accumulation  of  lymphoid  cells  with  but  little  increase  of  the  fibrous  or 
connective  tissue,  while  in  the  hard  variety  the  reverse  is  the  case.  But 
in  neither  is  there  any  deposits  or  new  material  differing  from  the  natural 
elements  belonging  to  the  lymphatic  or  reticulated  tissues;  and  both  are 
distinguished  from  the  scrofulous  enlargements  by  the  absence  of  all  ten- 
dency to  either  caseous  or  purulent  degeneration,  and  from  cancerous 
growths  by  the  absence  of  any  tendency  to  permeate  and  absorb  into  the 
tumors  any  and  all  surrounding  structures,  or  to  end  in  open  offensive  ulcer- 
ated surfaces.  The  fact  that  in  pseudo-leucocythasinia  the  spleen, lymphatic 
glands  and  other  adenoid  structures,  are  even  more  enlarged  from  the  ac- 
cumulation of  white  corpuscles  and  lymphoid  cells,  than  in  leucocythjemia, 
while  the  blood  itself  contains  no  notable  increase  of  these  bodies,  would 
seem  to  show  that  their  existence  in  the  blood  in  such  excess  in  cases  of  the 
last  named  disease,  is  not  owing  to  their  having  been  developed  in  these 
hypertrophied  tissues  and  pushed  out  into  the  blood,  as  supposed  by  many 
writers;  because  careful  examinations  have  shown  that  the  vessels  and 
ducts  of  the  glandular  structures  are  as  free  for  them  to  make  their  exit  in 
the  one  form  of  disease,  as  in  the  other. 

From  a  careful  comparison  of  the  clinical  history  and  morbid  anatomy 
of  these  two  diseases,  I  am  satisfied  that  they  are  only  varieties  or  grada- 
tions of  one  and  the  same  general  morbid  condition.  There  is  the  same 
failure  in  the  production  of  haemoglobin  and  red  corpuscles  in  both;  while 
in  the  cases  classed  as  leucocythaemia  the  white  corpuscles  continue  to 
be  formed  faster  than  they  can  be  used  in  the  excessive  growth  of  the 
glandular  structures,  and  consequently  accumulate  in  the  blood;  and  in 
tiiose  classed  as  pseudo-leucocythsemia  the  growth  of  the  glandular  and 
adenoid  structures  absorb  them  as  fast  as  they  are  formed.  This  does 
not  indicate  that  the  latter  disease  is  any  milder  than  the  former.  On  the 
contrary,  its  average  duration  before  reaching  a  fatal  result,  is  somewhat 
less.  As  there  is  nothing  more  known  concerning  the  causes,  pathology, 
and  treatment,  of  the  pseudo,  than  of  the  true  leucocythtemia,  all  that  I 
have  said  in  regard  to  the  h^-gienic  and  remedial  management  of  the  lat- 
ter is  equally  applicable  to  the  former.  Under  the  impression  that  the 
disease  had  its  primary  seat  in  the  lympho-sarcomatous  tumors  or  hyper- 
trophied glands,  some  efforts  have  been  made  to  reduce  these  by  electrol- 
ysis, but  without  encouraging  results.  Under  the  same  impression,  some 
surgeons  have  extirpated  the  entire  growths,  without  percejDtibly  in- 
terfering with  the  progress  of  the  disease.  The  only  cases  in  which  sur- 
gical operations  are  justifiable,  are  those  presenting  some  one  or  more 
tumors,  so  situated  that  their  pressure  directly  interferes  with  some  im- 
portant function,  as  when  they  crowd  upon  the  larynx,  trachea,  or  oesoph- 
agus. 

PERNICIOUS  ANEMIA. 

Cases  are  occasionally  met  with,  presenting  the  same  persistent  anasmic 
condition,  or  loss  of  the  hjeraoglobin,  as  in  the  two  diseases  just  described, 
but  without  the  increase  of  white  corpuscles  seen  in  leucocythgemia,  and 
without  the  enlargements  of  the  spleen  and  lymphatic  glands  accompany- 
ing pseudo-leu?ocythsemia.  These  have  been  grouped,  by  most  recent 
writers,  under  the  name  of  perrdrJoxis  anaemia.  They  occur  most  fre- 
•quently  between  the  ages  of  twenty  and  thirty-five  years,  and  somewhat 
more  frequent  in  females  than  in  males.  It  has  been  alleged,  that  fre- 
quently recurring  pregnancies,  protracted  nursing,  severe  haemorrhages, 
insufl&cient   food,  and  too  much  exposure   to  wet  and  cold,  act  as  causc:i 


SYMPTOMS.  275 

favoring  the  development  of  this  form  of  anajmia.  At  most,  however, 
tliey  can  only  be  regarded  as  predisposing  influences,  while  the  efficient 
cause  is  unknown.  Indeed,  one  of  the  chief  characteristics  of  this  group 
of  cases,  as  alleged  by  most  writers,  is  that  the  condition  of  the  patient  is 
not  to  be  explained  by  the  presence  or  action  of  any  of  the  well  known 
causes  of  simple  ansemia.  The  disease  was  mentioned  by  Andral  as  early 
as  1823,  but  was  first  accurately  and  fully  det-cribed  by  Addison,  under 
the  name  of  idiopathic  anaemia.  Lebart  called  it  "essential  anfemia;" 
Beismer,  ''progressive  pernicious  anaemia,"  while  Flint,  Pepper,  and 
others,  with  more  propriety,  call  it  "pernicious  anaemia." 

Many  writers  regard  it  only  as  an  extreme  or  unusually  severe  form  of 
ordinary  an^,mia,  and  it  must  be  acknowledged  that  there  is  no  very  clear 
line  of  distinction,  either  in  the  symptoms  or  in  the  pathological  changes 
between  the  simple  and  the  pernicious. 

Practically,  the  diagnosis  is  based  mainly  on  the  fact  that  ordinary  cases 
of  anseraia  are  traceable  directly  to  some  prior  pathological  condition,  such 
as  excessive  loss  of  blood,  insufficient  food,  malaria,  amenorrhoea,  etc., 
while  those  called  pernicious  arise  without  any  such  manifest  preceding 
conditions. 

Symptoms.- — Consequently,  if  you  see  a  patient  with  pallid  counte- 
nance, soft,  quick  pulse,  pale,  clean  tongue,  variable  appetite,  with  oc- 
casional nausea  and  temporary  turns  of  diarrhoea,  loud  blowing  sounds 
over  the  base  of  the  heart  and  aorta,  synchronous  with  the  systole;  short- 
ness of  breath  on  attempting  active  exercise,  great  sense  of  weakness, 
with  occasional  feelings  approaching  syncope,  and  learn  that  these 
symptoms  have  developed  gradually  and  persistently  without  any  manifest 
cause,  you  will  be  justified  in  regarding  the  disease  as  pernicious 
anasmia,  and  may  reasonably  expect  all  the  symptoms  connected  with  res- 
piration, circulation  and  haematosis  to  increase,  regardless  of  your  treat- 
ment, until  temporary  exacerbations  of  fever,  haemorrhages  and  dropsi- 
cal effusions  determine  a  fatal  result,  or  the  patient  dies  suddenly  from 
failure  of  the  action  of  the  heart.  In  the  advanced  stage  of  this  variety 
of  anaemia,  hEemorrhagic  extravasations  not  unfrequently  take  place  in 
the  retina,  causing  suddenly,  partial  or  complete  blindness.  In  the 
same  stage,  the  muscular  force  of  the  heart  becomes  so  impaired  and 
irregular,  in  many  cases,  that  the  slightest  exertion  brings  vertigo,  ring- 
ing in  the  ears,  nausea  and  approaching  syncope. 

Morbid  Anatomy.- — Post  mortem  examinations  reveal  apparently  the 
same  changes  in  the  blood  as  in  pseudo-leucocythasmia,  only  more  ex- 
aggerated. The  corpuscular  elements,  both  white  and  red,  are  extremely 
reduced  in  number,  while  those  remaining  of  the  latter,  contain  one-third 
less  of  haemoglobin  than  natural.  In  two  or  three  instances  reported, 
the  spleen  was  moderately  enlarged,  but  in  none  have  the  lymphatic 
glands  been  materially  altered  from  the  natural  size.  Fatty  degenera- 
tion of  the  muscular  structure  of  the  heart  has  been  found  in  a  large 
proportion  of  cases,  and  sometimes  dilatation  with  thinning  of  the  walls 
of  the  ventricles.  Several  investigators  have  reported  changes  in  the 
marrow  of  the  bones  similar  to  those  found  after  death  from  leucocy- 
thaemia.* 

Changes  of  less  importance  have  been  found  in  many  other  structures, 
but  only  such  as  are  common  in  all  cases  of  extreme  anaemia. 

Treatment. — The  general  indications  for  treatment,  both  hygienic  and 
medical,  are  the  same  as  I  have  detailed  in  regard  to  the  management  of 

*  See,  paper  by  Dr.  Wm.  Pepper,  in  Amer.  Journal  of  Med.  Sciences  for  April,  1877. 


276  Addison's  disease. 

leucocytlifemia.  The  absence  of  spleenic  and  glandular  enlargements, 
leaves  less  indication  for  the  use  of  iodine  and  mercurials,  either  inter- 
nally or  for  local  application.  But  in  all  other  respects  the  treatment 
must  be  essentially  the  same.  Transfusion  of  blood  has  been  tried  in 
several  cases,  both  in  this  country  and  in  Europe.  Dr.  C.  Carey  reports  a 
case  in  the  Buffalo  Medical  and  Surgical  Journal  for  January,  1881, 
which'recovered,  after  receiving,  by  transfusion,  two  fluid  ounces  of  human 
blood.  In  nearly  all  the  cases,  however,  in  which  this  measure  has  been 
resorted  to,  no  apparent  benefit  was  obtained.  In  a  communication  to 
the  Medical  Press  a^nd  Circular  for  October,  1879,  Dr.  Austin  Welden 
claims  to  have  cured/bwr  cases  by  the  intravenous  injection  of  milk.  To 
complete  a  brief  consideration  of  the  group  of  persistently  fatal  anjemias, 
I  must  direct  your  attention  to  one  more  aspect  which  they  assume,  as 
first  diiferentiated  and  accurately  described  by  Dr.  Thomas  Addison,  in 
1855,  and  by  him  called  ^ron^ec?  sA'm  c?/sease,  but  since, generally  called 

ADDISON'S  DISEASE,  OR  MELASMA  SUPRA-RENALIS. 

This  form  of  disease  occurs  most  frequently  in  the  early  part  of  adult 
life,  and  much  oftener  in  males  than  in  females.  Since  the  publication  of 
Dr.  Addison's  views,  the  disease  has  been  carefully  investigated  by  Drs. 
Wilks,  Greenhow,  LetuUe,  and  others,  but  without  adding  materially  to 
our  knowledge  concerning  its  causes,  pathology,  or  treatment.  Its  early 
stage  is  characterized  by  the  same  obscure  symptoms  as  in  pernicious 
anaamia.  The  patient  experiences  a  gradual  loss  of  strength,  or  ability  to 
endure  either  mental  or  physical  exercise;  his  appetite  becomes  variable, 
with  occasional  turns  of  nausea  or  diarrhoea;  he  gets  shortness  of  breath, 
palpitation,  and  sometimes  vertigo,  from  slight  exertion,  without  any  ap- 
pearance of  emaciation;  his  countenance  becomes  pale,  his  pulse  frequent 
and  weak,  with  slight  anaemic  cardiac  murmurs,  yet  the  tongue  remains 
moist  and  clean,  and  the  secretions  generally  natural.  In  many  cases, 
there  are  dull  pains  in  the  back  and  limbs,  with  temporary  paroxysms  of 
fever.  The  only  symptom  that  will  enable  you  to  distinguish  these  cases 
from  all  the  other  forms  of  anaemia,  is  the  development  of  dark,  bronze- 
colored  spots  on  the  cutaneous  surface.  They  generally  appear  early  in 
the  progress  of  the  disease,  and  are  most  noticeable  on  the  forehead,  front 
part  of  the  chest  and  abdomen,  and  on  the  backs  of  the  hands.  They  are 
at  first  light  brown,  and  vary  much  in  size  and  shape,  but  they  generally 
increase  in  size,  and  deepen  in  coloi-,  as  the  disease  advances,  until,  in 
some  cases,  a  large  part  of  the  whole  cutaneous  surface  is  a  deep  bronzed 
hue.  In  other  cases  the  spots  are  small  and  few  in  number,  but  equally 
characteristic  in  color.  Similar  discolored  spots  also,  in  some  cases,  ap- 
pear in  the  mucous  membrane  of  the  mouth  and  fauces. 

In  the  majority  of  cases  the  disease  advances  steadily,  causing  the  sense 
of  exhaustion,  the  disturbances  of  circulation  and  breathing,  and  the  turns 
of  gastric  and  intestinal  irritation,  to  be  more  frequent  and  severe  until 
the  patient  dies  fi'om  asthenia  in  from  six  months  to  two  years;  the  average 
duration  being  about  eighteen  months.  Yet  occasionally  a  case  occurs  in 
which  the  progress  of  the  symptoms  is  apparently  suspended  for  several 
months  at  a  time,  thereby  protracting  the  whole  duration  to  five  or  six  years. 
Two  such  cases  have  come  under  my  own  observation.  Both  were  men 
between  35  and  40  years  of  age.  One  of  them  had  been  exposed  to  much 
hardship  and  confinement  in  close  air,  on  board  one  of  the  iron  monitors 
in  active  service  during  the  recent  war. 

Some  symptoms  of  the  disease  appeared  soon  after  the  war   closed,  as 


PATHOLOGY.  2?  7 

early  as  1865.  But  they  progressed  so  slowly,  with  several  periods  of  ap- 
parent suspension,  that  the  fatal  result  was  not  reached  until  1875.  I  did 
not  see  him  until  near  the  fatal  result.  The  discolorations  of  the  skin 
over  the  abdomen  and  lower  part  of  the  chest,  were  strongly  marked;  and 
but  little  less  so  over  the  forehead,  temples,  and  backs  of  the  hands.  For 
several  months  he  had  been  unable  to  walk  across  his  room  without  ex- 
treme feelings  of  exhaustion,  and  the  final  collapse  resulted  from  protract- 
ed diarrhoea  and  vomiting. 

A  post  mortem  examination  showed  the  body  not  much  emaciated;  the 
blood  in  the  heart  pale  and  only  partially  coagulated;  the  liver  and  spleen 
of  normal  size  and  color;  the  mucous  membrane  of  the  stomach  and  ilium 
congested,  softened  in  some  places,  with  abrasions;  but  no  other  morbid 
appearances  were  noticed  except  in  the  suprarenal  capsules.  Both  of 
these  were  enlarged  to  more  than  twice  their  natural  size.  One  of  them  I 
here  show  you  from  the  patholofe-ical  collection  in  the  college  museum. 
It  has  been  laid  open  by  an  incision  directly  through  the  center,  and  you 
see  it  composed  of  two  distinct  parts.  The  exterior  is  composed  of  gray 
fibrous  tissue,  with  spots  and  streaks  of  yellowish  color,  firm  in  texture, 
and  distended  into  the  form  of  a  sac,  enclosing  a  mass  of  caseous  matter, 
more  than  twenty-five  millimeters  (one  inch)  in  diameter,  and  about  the 
consistence  of  new  cheese,  except  a  thin  laj^er  on  its  circumference  next 
to  the  capsule  which  was  nearer  the  consistence  of  thick  cream.  The 
central  mass  appears  to  be  identical  in  all  repects  with  the  caseous  mat- 
ter found  in  scrofulous  glands,  while  the  gray  fibrous  tissue  of  the  capsule 
shows,  under  the  microscope,  fuciform,  lymjDhoid,  and  large  granular  or 
giant  cells,  in  considerable  numbers. 

The  other  capsule  was  similar  to  this,  both  in  size  and  texture.  This 
was  in  all  respects  a  typical  case  of  the  disease,  and  its  post  mortem 
appearances  well  illustrated  the  essential  pathological  changes  resulting 
from  it  in  the  great  majority  of  cases.  In  some,  however,  the  mesen- 
teric glands,  in  the  vicinity  of  the  suprarenal  capsules,  have  been  found 
enlarged,  with  partial  caseous  degeneration;  in  a  larger  number  either 
tubercular  or  caseous  deposits  have  been  found  in  the  lungs;  and  in  a 
very  few,  the  spleen  has  been  moderately  enlarged.  One  or  two  cases 
are  on  record,  in  which  the  marrow  of  the  bones  was  changed  as  in 
leucocythaemia. 

The  three  most  constant  and  essential  anatomical  changes  are,  the 
anaemic  condition  of  the  blood,  the  bronzed  color  of  the  skin,  and  the 
degeneration  of  the  suprarenal  capsules.  Yet  two  or  three  well  au- 
thenticated cases  have  been  reported,  in  which  all  the  constitutional  or 
general  symptoms,  and  the  characteristic  bronze  color  of  the  skin  were 
fully  developed,  but  in  which  the  post  mortem  examination  showed  the 
suprarenal  capsules,  entirely  free  from  any  appreciable  morbid  change. 
Much  difference  of  opinion  has  been  expressed  in  regard  to  the  nature 
of  the  disease  under  consideration.  Some  regard  the  suprarenal  cap- 
sules as  the  primary  seat  of  the  disease,  and  the  general  symptoms  as 
secondary.  Others,  among  whom  are  Virchow,  Green  how,  etc.,  claim  that 
all  the  symptoms  arise  from  irritation  of  the  sympathetic  nerves  and 
ganglia  in  the  vicinity  of  the  capsules.  I  think  that  all  the  facts  con- 
nected with  the  clinical  history  of  the  disease,  are  best  explained  by 
placing  it  in  the  same  category  with  leucocythaemia,  pseudo-leucocytha?- 
mia,  and  pernicious  anaemia;  and  regarding  the  failure  in  the  processes 
of  assimilation,  by  which  the  haemoglobin  and  corpuscular  elements  of 
the  blood  become  deficient  as  the  primary  and  essential  pathological 
condition,  while  the  changes   in    the  skin,  suprarenal  capsules,  etc.,  etc., 


278  CARCINOMA. 

are  secondary.  Much  the  same  view  has  been  expressed  by  Dr.  Wm. 
Pepper,  who  regards  the  disease  as  primarily  a  profound  impairment  oi' 
the  blood-forming  function.  Neither  from  my  past  clinical  experience, 
nor  from  the  kiiown  pathological  changes  which  take  place  in  the  blood  and 
tissues  during  the  progress  of  the  disease,  can  I  give  you  any  better  sugges- 
tions for  its  treatment  than  those  made  in  reference  to  the  management 
of  leucocythfemia  and  pernicious  anaemia.  They  are  all  summed  up  in 
the  use  of  such  means,  hygienic  and  medical,  as  are  best  calculated  to 
restore  the  function  of  hiematosis,  and  palliate  the  more  distressing- 
symptoms  as  they  arise.   • 


LECTURE    XXX. 

Carcinoma — Its  Local  Varieties,  Anatomical  Structures,  Modes  of  Development,  Diagnostic  Feat- 
ures Prognr)sis  and  Treatment :  Constitutional  .Syphilis — A.  brief  allusion  to  the  varieties  of  its 
manifestation,  and  the  most  reliable  methods  of  treatment. 

GENTLEMEN:  In  the  list  of  constitutional  diseases  I  enumerated  carci- 
noma, or  cancer,  and  in  doing  so,  I  alluded  to  its  acknowledged  hered- 
itary character  as  the  chief  evidence  that  it  was  derived  from  a  prior 
special  diatliesis.  1  am  aware  that  a  large  proportion  of  both  pathologists 
and  practical  surgeons,  at  the  present  time,  regard  all  the  varieties  of 
cancer  as  primarily  of  local  origin,  and  represent  the  general  failure,  or 
cachexia  as  secondary,  and  directly  dependent  on  the  diffusion  of  cancer  cells 
from  the  point  of  their  local  origin.  They  freely  admit  its  capability  of 
hereditary  transmission;  and  even  allege  this  as  its  chief  mode  of  propa- 
gation, leaving  us  to  infer,  from  their  expressions,  that  there  is  a  specific 
germ  transmitted  Avhich  finds  lodgment  in  the  new  being,  as  the  nucleus 
of  a  future  local  morbid  growth.  It  is  not  difficult  to  conceive  the  possi- 
bility of  having  the  germinal  cell  of  the  ovum,  or  the  spermatozofe  of  the 
semen,  impressed  with  the  same  deviation  from  the  natural  condition  of 
the  properties  inhering  in  each  atom  of  living  matter  belonging  to  the 
parent  in  which  such  germinal  cells  or  spermatozcae  was  originally  develop- 
ed; and  that  such  deviation  in  the  properties  constituting  the  formative 
forces  might  ultimately  so  increase  as  to  develop  such  changes  both  in  the 
production  and  arrangement  of  cells  and  tissue  elements,  as  to  constitute 
morbid  growths.  But  that  a  specific  cancer  germ  should  be  thus  trans- 
mitted, and  retained  through  a  period  of  forty  or  fifty  years,  and  then  be- 
come the  nucleus  of  a  local  cancerous  growth,  is  certainly  very  difficult 
to  comprehend.  To  my  mind,  the  generally  admitted  hereditary  character 
of  the  disease,  coupled  with  the  persistent  tendency  to  reproduction  after 
the  extirpation  of  the  local  tumors,  constitute  sufficient  evidence  that, 
however  obscure  it  may  be,  there  is  a  special  constitutional  condition  that 
predisposes  to  the  development  of  the  local  morbid  growths.  That  such 
diathesis  or  constitutional  tendency  is  not  characterized  by  any  apprecia- 
ble symptoms,  I  admit.  But  the  same  is  true  of  the  tuberculous,  gouty, 
and  rheumatic  diatheses;  yet  no  one  appears  to  doubt  the  existence  of 
such  diatheses  on  that  account. 

Causes. — Aside  from  hereditary  influences,   the  causes  of  carcinoma  are 


VARIETIES.  279 

but  little  understood.  My  own  observations  and  study  have  led  me  to  the 
conclusion  that  the  free  use  of  tobacco,  alcoholic  drinks,  and  meat,  have 
some  influence  in  favoring  the  development  and  progress  of  this  form  of 
disease.  I  think  a  careful  analysis  of  vital  statistics  will  show  that  the 
people  of  those  countries  in  which  these  several  agents  have  been  most 
freely  and  universally  used,  furnish  the  highest  ratio  of  deaths  from  the 
different  varieties  of  carcinoma.  Statistics  also  indicate  that  density  of 
population  exerts  a  predisposing  influence.  Still  we  have  very  little  accu- 
rate knowledge  concerning  the  causes  of  any  variety  of  cancerous  disease. 
Varieties. — The  local  developments  of  cancer,  present  such  differences 
in  their  appearance,  density  and  rapidity  of  growth,  as  to  constitute  several 
varieties.  Those  most  generally  recognized  are  the  scirrhus,  encephaloid 
and  colloid.  The  first  is  charcterized  b}?-  great  density  of  structure  and 
generally,  slowness  of  growth.  The  second  is  softer  to  the  touch,  more 
rapid  in  growth,  and  generally  attains  much  larger  size.  The  third  is  in- 
termediate both  in  density  of  structure  and  rapidity  of  development. 
These  several  varieties  are  not  made  up  of  essentially  different  structural 
elements  nor  do  they  depend  altogether  on  the  character  of  the  structure 
in  which  they  are  developed.  It  is  true  that  the  scirrhus,  or  hard  variety 
is  found  most  frequently  in  the  skin,  the  female  breast,  the  uterus,  the 
stomach,  and  the  lymphatic  glands  ;  the  encephaloid  in  the  liver,  kidneys, 
structures  of  the  eye  and  brain  ;  and  the  colloid  in  the  peritoneum,  mesen- 
tery, and  intestines.  When  any  of  the  varieties  of  cancer  originate  in  the 
epithelium  of  the  skin  or  mucous  membranes,  it  is  generally  called  an 
epithelioma.      When  in  the  structure  of  bone  it  is  called  an  osteo-sarcoma. 

Anatumical  Structure. — Soon  after  the  microscope  was  applied  to  the 
study  of  minute  ora:anic  structures,  both  healthy  and  morbid,  it  was 
thought  by  many  observers  that  cancerous  growths  contained  character- 
istic cells,  peculiar  to  themselves  and  sufficiently  distinctive  to  consti- 
tute a  reliable  diagnostic  feature.  Minute  descriptions  were  given  of  these 
supposed  peculiar  cells,  and  of  their  mode  of  multiplication  and  diffusion. 
And  you  still  find  in  all  your  books  expressions  used  in  relation  to  cancer 
cells.,  which  fairly  imply  some  peculiarity  in  their  character.  But  it  is  now 
universally  admitted  that  there  are  no  cells  or  other  organic  elements 
peculiar  to  cancerous  growths.  On  the  contrary,  they  all  consist  of  es- 
sentially two  structural  elements,  namely,  cells,  and  fibrous,  or  connective 
tissue.  The  cells  vary  in  size  and  shape,  but,  as  a  rule,  closely  resemble 
the  natural  epithelial  cells  of  the  tissue  in  which  the  cancerous  growth 
originates.  They  are  usually  larger  than  the  leucocytes  of  the  blood, 
and  contain  either  nuclei  or  granules.  The  fibrous  tissue,  which  consti- 
tutes the  matrix,  in  the  meshes  of  which  the  cells  are  collected,  presents 
no  characteristics  which  will  enable  you  to  distinguish  it  from  the  con- 
nective tissue  of  healthy  structure. 

The  principal  features  of  a  cancerous  structure,  which  distinguish  it 
from  other  structures,  are  not  any  peculiarity  in  the  form  or  appearance 
of  either  the  cells,  or  the  fibrous  structure,  but  in  the  relations  which  these 
two  tissue  elements  bear  to  each  other.  The  fibrous  structure  is  so  ar- 
ranged as  to  leave  interspaces  or  alveoli  of  varying  size  and  shape,  and  the 
cells,  instead  of  being  somewhat  equally  distributed  along  the  fibres,  are, 
for  the  most  part,  collected  into  clusters  in  these  alveoli.  This  arrange- 
ment is  characteristic  of  all  the  varieties  of  cancer,  and  gives  to  the  cut 
surface,  when  magnified,  the  appearance  of  clusters  of  cells,  varying  in  size 
and  number,  with  intervening  bands  of  fibrous  structure.  In  the  scir- 
rhus, or  hard  cancer,  the  fibrous  tissue  predominates,  and  the  alveoli  con- 
taining cells  are  small;  which  has  caused  this  variety  to  be  called  by  some 


280  CAECINOMA. 

observers,  fibro-carcinoma.  In  the  enceplialoid  or  soft  cancer,  the  fibrous 
tissue  is  less  abundant,  and  the  alveoli  or  interspaces  are  much  larger,  and  the 
cells  correspondingly  more  abundant.  Hence  it  has  been  called,  medul- 
lary-carcinoma. The  colloid  variety  also  contains  less  fibrous  tissue  than 
the  scirrhus,  but  the  alveoli  contain  a  less  number  of  cells  than  the  en- 
cephaloid,  the  deficiency  being  supplied  by  an  unorganized  gelatinous  ma- 
terial, which  has  caused  this  variety  to  be  called,  gelatiniform  carcinoma. 
There  is  also  in  all  the  forms,  a  modification  of  this  gelatinous  material, 
vphich  may  be  pressed  out  of  the  cut  surface  of  fresh  cancer  structure,  and  is 
often  called  caoicer-juice.  In  the  scirrhus  variety  the  quantity  of  this  fluid  is 
very  small.  All  cancerous  structures  contain  some  vessels  and  nerves,  and 
v^hen  the  integument  gives  way  over  the  prominent  part  of  the  softer  va- 
rieties, a  ver}'  rapid  and  highly  vascular  fungus  growth  is  developed,  which 
bleeds  on  the  slightest  touch.  In  former  times  such  cases  were  called 
"  fungus-haematodes."  In  the  progress  of  development  or  growth,  the 
cancerous  structure  exhibits  a  constant  tendency  to  invade  and  convert 
into  itself,  all  other  structures  with  which  it  may  be  in  contact.  It  does 
not  merely  push  them  aside  to  make  room  for  itself,  like  other  tumors, 
but  rather  absorbs  them  into  itself.  In  addition,  the  cells  appear  to 
follow  the  lymphatic  vessels  into  the  neighboring  lymphatic  glands,  causing 
in  them  secondary  cancerous  growths.  A  similar  extension  may  also  take 
place  along  the  blood  vessels,  causing  many  little  masses  or  nodules  to 
form  in  the  vicinity  of  the  original  growth,  more  especially  when  the 
cutaneous  surface  is  involved. 

Diagnosis. — From  what  I  have  already  said,  you  will  readily  infer  that 
the  chief  diagnostic  features  common  to  all  cancerous  tumors,  are  the  ag- 
gregation of  the  cells  in  clusters,  filling  the  alveoli  or  spaces  formed  by  the 
interlacing  of  the  fibrillated  structures;  the  indiscriminate  conversion  of 
adjacent  structures  into  a  part  of  itself ;  The  induction  of  secondary 
growths  in  the  neighboring  glandular  structures,  and  its  persistent  tend- 
ency to  deteriorate  the  general  health,  and  ultimately  to  destroy  the  life  of 
the  patient.  While  these  features  are  sufficient  to  enable  you  to  diagnos- 
ticate the  various  external  or  superficial  cancerous  growths,  they  are  not 
available,  except  to  a  limited  extent,  when  the  diseased  mass  is  developed 
in  the  parenchyma  of  internal  organs.  In  the  latter  cases  there  must  be 
added  a  careful  comparison  of  their  clinical  history  in  each  tissue  or  organ, 
with  that  of  other  local  affections  in  the  same  parts.  This  can  better  be 
done  in  connection  with  the  consideration  of  local  diseases  than  at  pres- 
ent. Yet  there  are  certain  clinical  phenomena,  pretty  uniformly  present 
in  the  several  stages  of  all  internal  cancerous  affections,  which  are  suffi- 
ciently distinctive  to  merit  your  attention: 

1st.  When  once  begun,  there  is  a  degree  of  uniformity  and  persistence 
in  the  symptoms  accompanying  the  local  development  of  a  cancerous 
disease,  that  does  not  characterize  either  functional  disturbances  or 
chronic  inflammations  in  the  same  parts. 

2nd.  The  pain  in  cancer  is  rarely  continuous  unless  from  direct  pressure 
of  the  tumor  on  surrounding  sensitive  parts,  but  is  lancinating,  of  short 
duration,  and  recurs  at  irregular  intervals.  There  is  also  less  tenderness 
to  pressure  or  percussion  than  in  chronic  inflammation. 

3d.  There  is  a  progressive  impoverishment  of  the  red  corpuscles  of 
the  blood,  causing  a  steadily  increasing  pale  or  sallow  color  of  the  surface, 
with  little  emaciation,  and  generally  no  increase  of  temperature  or 
frequency  of  pulse.  When  the  disease  is  located  in  the  stomach,  however, 
the  emaciation  becomes  more  marked,  especially  in  the  advanced  stage,  on 
account  of  the  inability  to  take  and  assimilate  food. 

4th.     At  some  stage  in  the  advancement  of  the  disease,  it  causes  sufficient 


PROGNOSIS.  281 

enlargement  of  the  structure  or  organ  in  which  it  is  located,  to  be  capable 
of  detection  by  palpation  and  percussion,  when  its  location,  size,  density, 
and  other  physical  qualities,  will  aid  in  rendering  the  diagnosis  certain. 

Prognosis. — The  tendency  of  all  true  cancerous  affections  is  to  steadily 
increase,  both  in  local  development  and  in  general  impairment  of  the 
health,  until  the  life  of  the  patient  is  destroyed.  The  rate  of  progress 
varies  much  in  the  different  varieties  of  carcinoma,  and  is  also  influ- 
enced, in  some  degree,  by  the  character  of  the  structure  involved.  As  a 
rule  the  scirrhus  variety  progresses  much  slower  than  the  encephaloid;  and 
the  more  vascular  the  tissue  in  which  the  local  growth  originates,  the  more 
rapid  is  its  progress.  Some  rare  cases  have  been  observed  in  which  the 
cancerous  structure  appeared  to  undergo  partial  fatty  degeneration  with 
some  diminution  of  size,  and  then  remain  stationary  for  several  years. 
But  it  may  be  said  properly,  that  there  is  no  tendency  to  a  spontaneous 
cure  by  complete  resolution  or  disappearance  of  the  cancerous  structure. 
Neither  does  there  appear  to  be  any  hygienic  or  medical  treatment  known 
that  is  capable  of  affecting  a  cure  with  any  degree  of  certainty.  I  have 
seen  a  considerable  number  of  cases  of  scirrhus  of  the  breast,  and  of  some 
other  parts,  relieved  entirely  of  pain  and  their  growth  much  retarded,  by 
confining  the  patients  to  a  milk  and  vegetable  diet,  and  excluding  meat, 
with  the  protracted  use  of  certain  medicines.  The  fact  that  cancerous 
growths  have  neither  a  tendency  to  spontaneous  cure,  nor  to  disappear 
under  medical  treatment,  has  caused  them  to  be  very  generally  placed  in 
the  hands  of  the  surgeon  for  extirpation;  and  not  a  few  go  to  pretended 
"  cancer  doctors,"  to  be  murdered  Oy  caustics  under  the  name  of  cancer 
salves  and  plasters,  or  to  be  occupied  a  few  months  in  drinking  clover  tea., 
or  some  other  equally  harmless  infusion. 

If  the  cancerous  tumor  is  so  located  that  it  can  be  safely  removed,  the 
surgeon  generally  proceeds  at  once  to  extirpate  it  as  completely  as  possi- 
ble, without  any  special  preparatory  or  subsequent  constitutional  treatment. 
The  result  is,  that,  except  in  the  mildest  form  of  cutaneous  epithelial 
cancers,  such  as  occur  most  frequently  on  the  lip,  the  disease  returns  in 
from  four  months  to  three  years,  and  causes  a  more  rapid  failure  of  the 
patient  than  before  the  operation.  Consequently,  so  far  as  permanent  re- 
sults have  been  obtained,  they  are  no  better  from  surgical  than  from  med- 
ical treatment. 

This  leads  us  directly  to  the  question  whether  there  is  any  treatment  that 
is  capable  of  either  mitigating  or  curing  cases  of  the  true  cancerous  forms 
of  disease?  My  own  clinical  observations  would  not  justify  me  in  giving 
an  unqualifiedly  negative  answer  to  this  question. 

Treatment. — And  yet  there  is  great  difficulty  in  arriving  at  just  and  reli- 
able conclusions  concerning  it.  This  arises  from  the  fact  that  nearly  all 
the  methods  of  treatment  adopted,  have  been  founded  on  the  idea  that 
cancers  originate  locally  from  some  specific  germ  or  cell,  the  multiplication 
of  which  not  only  causes  the  morbid  growths,  but  also  the  general  failure 
of  health  by  their  diffusion  in  the  blood.  The  logical  inference  from  this 
pathological  view,  is,  that  the  earlier  the  local  tumors  can  be  removed  the 
less  danger  will  there  be  of  either  constitutional  impairment  or  renewal  of 
the  local  growth. 

Hence,  the  chief  anxiety  of  the  surgeon  has  been  to  operate  early  and 
to  remove  all  the  visible  cancerous  tissue,  as  the  only  hope  of  cure.  And 
in  cases  where  surgical  procedures  were  not  admissible,  the  leading  thought 
has  been  to  find  some  sj^ecijic  that  would  be  capable  of  such  administra- 
tion as  to  destroy  the  supposed  cancer  cells  or  germs  in  the  system.  So 
prominent  was  this  idea  of  finding  some  specific  remedy  capable  of  curing 


282  CAIiCINOMA. 

or  destroying  the  cancer  germs,  that  more  than  a  quarter  of  a  century 
since,  the  late  Dr.  Daniel  Braiiiard,  of  this  city,  after  numerous  experi- 
ments thought  he  had  found  such  a  specific  in  the  lactate  of  iron,  a  solu- 
tion of  which  he  found  very  active  in  dissolving  pieces  of  cancerous 
tumors.  He  also  ascertained  by  careful  experiments  on  dogs,  that  a  weak 
solution  of  the  lactate  of  iron  could  be  safely  injected  into  the  veins  of 
the  living  animal. 

With  these  preliminary  facts  ascertained,  he  became  very  confident  that 
cancers  could  be  permanently  cured  by  removing  with  the  knife  all  the 
visible  cancerous  tumors,  and  then  destroying  the  cells  or  germs  remain- 
ing in  the  blood  by  the  intra-venous  injection  of  a  solution  of  lactate  of 
iron.  He  made  a  fair  trial  of  this  method  in,  at  least,  two  cases  that  came 
under  my  own  observation.  One  was  an  adult  male,  with  a  well  devel- 
oped encephaloid  tumor,  originating  in  the  eye-ball,  and  occupying  the 
whole  cavity  of  the  orbit.  He  removed  the  diseased  mass  very  perfectly 
by  the  usual  operation,  and  injected  a  solution  of  the  lactate  of  iron  into 
the  venous  blood  through  the  vein  in  the  arm,  which  is  usually  opened  in 
performing  venesection.  The  injection  was  repeated  two  or  three  times, 
at  intervals  of  from  four  to  six  days.  The  wound  in  the  orbit  granulated 
and  healed  up,  with  a  healthy  appearance,  and  the  case  was  reported,  and 
published  in  the  American  Journal  of  Medical  Sciences^  as  permanently 
cured  by  extirpation  and  intra-venous  injection  of  lactate  of  iron.  Un- 
fortunately, however,  before  the  ink  was  fairly  dry  on  the  jDages  of  the 
journal,  the  cavity  of  the  orbit  was  being  again  rapidly  filled  with  a  re- 
newal of  the  cancerous  growth,  and  in  about  eighteen  months  the  patient 
died  from  the  effects  of  the  disease. 

The  other  case  was  a  well  developed  scirrhus  in  the  breast  of  a  female 
aged  about  fifty  years.  The  whole  breast  was  removed  by  an  operation, 
and  the  solution  of  lactate  of  iron  injected  through  the  vein  in  the  arm, 
as  in  the  previous  case.  Before  the  end  of  the  first  week  after  the  opera- 
tion, symptoms  of  septicfemia  supervened,  and- the  patient  died. 

I  think  the  same  treatment  was  tried  in  two  cr  three  other  cases,  with- 
out encouraging  results,  and  was  abandoned.* 

The  very  recent  confident  assertions  of  a  Dr.  De  Clat  concerning  the 
curability  of  cancerous  and  other  malignant  diseases,  by  the  use  of  pure 
phenic  or  carbolic  acid,  are  founded  on  the  same  idea  of  specific  cancer 
cells  or  germs  and  specific  remedies  for  their  destruction.  And  it  is  safe 
to  say,  that  whoever  resorts  to  his  particular  rem.edies  and  methods  of 
using  them,  will  soon  demonstrate  their  entire  inefficiency.  Indeed,  it  is 
only  a  few  days  since,  that  I  was  called  to  see  a  lady  who  had  suffered 
severely  from  a  well  marked  scirrhus  tumor  in  the  pyloric  portion  of  the 
stomach.  I  learned  that  for  about  three  months  past,  she  had  faithfully 
used  the  exact  remedies  and  methods  of  treatment  recommended  by  Dr. 
De  Clat.  She  had  used  one  preparation  by  the  mouth,  another  by  hypo- 
dermic injection,  and  a  third  by  inhalation.  Yet  they  had  exerted  no  ap- 
parent efi^ect  on  the  progress  of  the  disease  ;  certainly  no  mitigating  in- 
fluence, for  she  had  steadily  failed  or  grown  worse  in  all  respects.  Jt  is 
now  generally  conceded  by  the  most  experienced  microscopists  and 
minute  anatomists,  that    no  peculiar  germs,  nor  specific    cells,  have    been 

*  A  fact  worthy  nf  nolice,  for  the  guidance  of  other  experimenters,  wa  ascertained  during  the 
trials  of  lactate  of  iron  in  solution  for  intra-venous  injection.  So  long  as  the  pera  ing  surgeon 
succeeded  in  introduiing  the  solution  wholly  into  the  current  of  venous  b  ood,  it  appeared  to 
produce  no  noticeab  e  disturbing  eft'ect.  But  twice  the  operator,  by  mistake,  injected  some  into  the 
areohir  tissue  outside  of  the  vessel,  and  once  without  misiake,  but  for  a  purpose,  he  injected  it  into 
the  popliteal  artery.  In  the  two  first  it  speedily  destroyed  every  vestige  of  the  areolar  tissue  with 
whi'h  it  came  in  contact;  and  in  the  last,  being  carried  with  the  arterial  i-lnod  directly  into  the 
capi.laries  of  the  leg  and  foot,  .t  rapidly  induced  in  them  an  inflammation  so  iuteuse  as  to  jeopard- 
ize the  patient's  life. 


TREATMENT.  283 

discovered  in  any  of  the  varieties  of  cancerous  structure.  On  the  contrary, 
the  cells  and  fibrous  tissue  composing  the  various  cancerous  growtiis,  are 
either  identical  with,  or  only  modifications  of  the  natural  epithelial  cells 
and  connective  tissue  of  the  part  in  which  the  cancer  is  located.  The 
peculiar  ago-regation  of  the  cells,  and  their  modification,  const  tuting  the 
cancer  structure,  is  doubtless  the  result  of  a  morbid  condition  of  the  2)rop- 
ertles  which  control  the  primary  forms  of  organization,  either  derived  from 
hereditary  influence  or  the  slow  and  persistent  action  of  such  causes  as 
are  capable  of  modifying  the  processes  of  assimilation  and  cell  evolu- 
tion. This  view  would  lead  us  to  expect  better  results  from  the  persistent 
adherence  to  proper  hygienic  regulations,  and  the  use  of  such  remedies  as 
are  capab'e  of  modifying  the  elementary  properties  of  the  tissues,  than 
Ironi  either  specific  medication  or  simple  surgical  extirpation,  or  both  com- 
bined. Tlie  direct  removal  of  an  existing  morbid  growth  or  tumor  by 
either  knife  or  caustic,  does  not  in  any  degree  change  either  the  quality 
of  the  blood  or  the  properties  that  govern  the  development  of  tissue  ele- 
ments and  their  aggregation  into  definite  structures.  And  if  these  remain 
unaltered,  there  is  every  reason  to  suppose  that  they  will  sooner  or  later 
lead  to  the  same  result,  namely,  the  renewal  of  the  morbid  growth  in  the 
same  or  some  other  place.  A  supposition  which  is  in  direct  consonance 
with  all  past  experience. 

The  rational  indications  then,  are,  to  put  the  patient  upoi]  such  diet  and 
mode  of  living,  aided  by  such  general  alterants,  as  will  be  best  calculated 
to  change  the  properties  governing  the  development  of  tissue  elements, 
and  especially  the  epithelial  cell  formations.  If,  by  such  management, 
the  cancerous  growth  ceases  to  be  painful  and  remains  stationary  in  size 
for  two  or  three  months,  and  is  so  situated  that  it  can  be  safely  removed, 
it  should  then  be  extirpated  as  completely  as  possible,  and  the  hygienic 
and  general  medical  treatment  continued  faithfully  for  one  or  two  years. 
By  thus  first  altering  the  quality  of  the  blood  and  the  properties  controll- 
ing tissue  growth,  then  extirpating  the  morbid  structure  already  developed, 
and  continuing  for  a  long  time  subsequently  the  same  modifying  influences 
as  at  first,  you  will  give  the  patient  the  best  possible  chance  for  a  perma- 
nent cure.  But  you  are  doubtless  ready  to  ask  whether  I  have  any  evi- 
dence that  the  progress  of  true  cancerous  diseases  can  be  materially 
influenced  either  by  hygienic  or  medical  treatment?  I  am  confident  that 
such  evidence  is  in  my  possession,  especially  in  relation  to  the  scirrhus  or 
hard  variety  of  cancers.  The  encephaloid  cases  appear  to  be  much  less 
under  the  control  of  any  measures  yet  devised.  At  an  early  period  I  saw 
the  opinion  expressed  by  some  one  worthy  of  credit  (perhaps  by  the  elder 
Dr.  Jackson,  of  Boston,  in  one  of  his  letters  to  a  young  physician),  that 
adherence  to  a  diet  of  milk,  farinaceous  articles,  vegetables  and  fruits,  ex- 
cluding meat,  would  much  retard  the  progress  of  malignant  tumors.  Act- 
ing in  part  upon  this  suggestion,  in  1848,  while  residing  in  New  York  City, 
I  took  charge  of  a  poor  woman  who  had  presented  herself  in  the  surgical 
clinic  of  Dr.  Wiilard  Parker,  and  had  been  dismissed  with  the  opinion  that 
surgical  interference  was  inadmissible,  as  both  breasts  were  nearly  de- 
stroyed by  open  scirrhus  cancers,  and  what  soft  parts  were  left,  were  closely 
adherent  to  tUe  ribs.  I  advised  her  to  adhere  rigidly  to  the  diet  just  men- 
tioned, use  tea  and  coffee  only  lightly,  and  nothing  of  fermented  or  dis- 
tilled drinks. 

I  gave  her  the  bichloride  of  mercury  in  doses  of  two  milligrams  (gr. 
1-32)  three  times  a  day,  generally  in  connection  with  some  simple  bitter 
infusion;  and  instructed  her  to  keep  herself  supplied  with  fresh  stramo- 
nium ointment  with  which  to  dress  the  open  cancerous  ulcers  morning  and 


284-  CARCINOMA. 

evening.  She  made  the  unguent  by  simmering  fresh  stramonium  leaves 
gathered  from  the  roadside,  with  lard.  The  patient  carried  out  my  nistruc- 
tions  faithfully  and  patiently  for  little  more  than  twelve  months,  during 
which  time  the  local  cancerous  disease  had  ceased  to  be  painful,  and  in- 
stead of  extending,  actually  showed  some  limited  places  of  cicatrization, 
and  her  general  health  was  improved.  I  then  removed  from  the  city  and 
know  not  what  became  of  the  case  afterward.  Since  that  time  I  have  had 
an  opportunity  to  note  the  effects  of  a  simple  milk  and  vegetable  diet, 
without  meat,  accompanied  by  good  air,  and  the  use  of  small  doses  of  either 
the  bichloride  of  mercury  or  the  arseniate  of  sodium  with  conium,  inter- 
nally, in  a  large  number  of  cases  of  carcinomatous  disease.  And  in  no  case  of 
the  hard  variety  of  cancer,  except  when  located  in  some  part;  of  the  stom- 
ach, have  I  known  the  treatment  fail  to  relieve  the  pain  and  arrest  the 
growth  in  less  thau  two  months;  and  the  gain  thus  made  was  usuall}'^  re- 
tained as  long  as  the  treatment  was  continued. 

But  in  no  case  was  I  able  to  obtain  more  than  a  slight  reduction  in  the 
size  of  the  local  cancerous  tumor.  And  such  is  the  anxiety  felt  by  most 
patients  so  long  as  they  know  the  tumor  remains,  and  so  frequent  the  in- 
terference of  friends  in  advising  this  specific  or  that  doctor,  as  certain  to 
cure,  that  only  a  very  small  proportion  of  the  whole  number  of  patients 
have  adhered  faithfully  to  the  prescribed  diet  and  medicines  more  than 
three  or  four  months  without  interruption.  And  even  in  those  cases, 
in  which,  after  one  or  two  months  of  preparatory  treatment,  the  tumor  has 
been  removed,  so  soon  as  the  wound  has  fairly  healed,  and  there  is  a  fair 
appearance  of  recovery,  the  great  majority  will  at  once  return  to  a  promis- 
cuous diet  and  abandon  further  treatment  as  unnecessary.  Among  my 
patients  I  have  found  a  few  exceptions  to  the  general  rule.  At  least 
twenty  years  since  an  intelligent  married  woman,  aged  thirty -eight  years, 
from  a  neighboring  state,  came  to  me  with  a  well  marked  scirrhus  cancer  in 
the  right  breast.  The  tumor  was  about  fifty  millimeters  (two  inches)  in 
diameter,  occupying  the  central  part  of  the  mammary  gland,  causing  re- 
traction of  the  nipple,  and  some  adherence  of  the  integument  to  the  hard 
mass.  It  was  but  little  sensitive  to  the  touch,  but  was  subject  to  occasion- 
al lancinating  pains,  and  had  been  gradually  increasing  in  size  since  it 
was  discovered,  about  eighteen  months  previous.  The  patient  was  thin 
in  flesh,  but  otherwise  in  apparent  good  health.  The  cancerous  affection 
was  hereditary  in  her  family,  both  her  mother  and  grandmother  having 
died  from  cancerous  disease.  She  had  come  expecting  to  have  the  tumor 
immediately  removed.  But  when  I  explained  to  her  that  a  removal  of  her 
breast  would  neither  change  the  quality  of  her  blood,  the  properties  of  her 
tissues,  nor  the  hereditary  family  tendency,  and  that  unless  these  could  be 
first  changed,  the  local  development  of  cancerous  tissue  would  be  very 
certain  to  follow  within  a  few  months,  she  readily  consented  to  postpone 
the  operation  for  a  preparatory  treatment  of  two  months.  She  adhered 
strictly  to  a  milk  and  vegetable  diet,  spent  much  time  in  the  open  air,  and 
took  one  of  the  following  pills  after  each  meal-time. 

5.    Sodii  Arseniatis  0.250  grams       gr.  iv 

Extracti  Conii  4.000       "  3i 

Mix,  divide  into  sixty  pills. 

At  the  end  of  the  two  months  she  returned,  in  apparent  good  health,  hav- 
ing had  no  twinges  of  pain  in  the  tumor  during  the  last  three  or  four 
weeks,  and  so  far  as  could  be  judged  by  careful  measurement,  no  increase 
in  the  size  of  the  tumor.     I  now  removed   the  entire   breast,  by  the  usual 


TREATMENT.  285 

operation,  leaving-  enough  of  the  integument  to.  enable  me  to  close  up  the 
wound  by  sutures.  The  part  was  covered  with  simple  dressings  without 
antiseptics  in  any  form.  The  same  diet  and  medicines  were  continued  as 
before  the  operation.  The  wound  healed  rapidly,  cicatrization  being  com- 
plete in  three  weeks,  when  she  returned  to  her  home,  where  she  could  en- 
joy good  air  and  all  the  comforts  of  life.  She  continued  under  my  direc- 
tion, however,  through  correspondence  with  her  husband,  for  two  years. 
During  all  the  first  year  she  continued  to  take  the  pills  of  arseniate  of 
sodium  and  extract  of  conium;  omitting  them  only  three  times,  for  four 
or  five  days  at  a  time.  During  the  second  year  she  omitted  the  pills  every 
third  month,  and  subsequently  omitted  them  entirely.  At  no  time,  how- 
ever, did  she  return  to  the  use  of  meat  as  an  article  of  diet.  At  the  end 
of  three  years  and  six  months,  she  visited  me  in  good  health;  and  at  two 
subsequent  times  when  visiting  this  city  she  called  at  my  office;  the  last 
time  about  thirteen  years  after  the  extirpation  of  the  breast.  She  was 
still  in  good  health,  and  a  careful  examination  could  detect  no  appearance 
of  cancerous  development  in  any  part  of  the  system.  She  was  enjoying 
her  milk  and  vegetable  diet  as  usual,  with  no  apparent  disposition  to 
abandon  it.  Since  that  time  I  have  neither  seen  nor  heard  from  her.  I 
am  satisfied  that  the  same  management,  executed  with  the  same  faithful- 
ness and  perseverance,  would  result  in  the  permanent  cure  of  a  very  large 
proportion  of  all  the  cases  of  scirrhusor  hard  cancers,  so  located  that  they 
could  be  extirpated  at  the  proper  time.  And  even  in  the  cases  where  the 
cancerous  growth  cannot  be  extirpated,  its  progress  may  be  greatly  re- 
tarded and  the  life  of  the  patient  much  prolonged.  In  proof  of  this,  I 
could  cite  several  cases  of  well  marked  cancer  of  the  uterus  and  its  append- 
ages. In  cancer  located  in  any  part  of  the  stomach  or  oesophagus,  I  have 
found  a  milk  diet,  and  the  use  of  the  following  formula  to  afford  more  re- 
lief than  I  could  obtain  in  any  other  way. 

]^      Acidi  Carbolici  0.50  grams   gr.  viii 

Glycerine  15.00  c.  c.      3iv 

Tincturas  Gelsemini  15.00    "         3iv 

Tincturge  Opii  Camphoratas  60.00    "         §ii 

Aquae  60.00    «         |ii 

Mix.  Give  four  cubic  centimeters  (fl.  Z'l),  just  before  each  regular  meal 
time,  and  at  bed  time.  In  the  early  stage  of  the  disease,  I  have  some- 
times added  two  minims  of  the  liquor  potassii  arsenici  (Fowler's  solution) 
to  each  dose,  with  apparent  benefit.  Dr.  Bartholow  decidedly  recom- 
mends, in  the  same  class  of  cases,  small  doses  of  an  equal  mixture  of  pure 
carbolic  acid  and  iodine.*  In  the  more  rapidly  developed  encephaloid 
growths  in  the  liver,  kidneys,  structures  of  the  eye,  etc.,  I  have  seen  hut 
little  influence  exerted  by  diet  or  medicine,  and  in  no  instance  have  I 
known  a  case  of  that  variety  to  be  permanently  relieved  by  surgical  oper- 
ations. In  the  present  state  of  our  knowledge,  the  services  of  either  phy- 
sician or  surgeoa  are  limited,  in  such  cases,  to  the  judicious  use  of  such 
diet,  and  anodyne  medicines  as  will  best  palliate  the  suffering  of  the  patient, 
and  thereby  render  the  brief  period  he  has  to  live  as  comfortable  as  possi- 
ble. 

For  further  details  in  regard  to  the  local  development  of  cancerous 
diseases,  and  the  surgical  procedures  for  their  relief,  including  the  very 
recent  operations  for  extirpation  of  cancers  of  the  stomach  and  intestines, 
[  must  refer  you  to  the  more  recent  valuable  works  on  surgery. 

*See  Practice  of  Medicine,  by  Roberts  Bartholow,  M.  D.,  etc.,  etc.,  p.  48. 


286  CONSTITUTIONAL   SYPHILIS. 


CONSTITUTIONAL    SYPHILIS. 

Syphilis  in  all  its  forms  and  stages,  is  so  fully  presented  to  the  profes- 
sion, both  in  special  treatises  and  in  general  works  on  surgery,  in  addition 
to  being  in  special  courses  of  instruction  in  the  medical  schools,  that  I 
might  be  justified  in  omitting  all  allusion  to  the  subject  in  the  present 
course.  Yet  there  are  two  or  three  conclusions  to  which  1  have  been, 
forced  by  my  own  clinical  observations,  that  I  deem  of  sufficient  impor- 
tance to  occupy  your  attention  during  the  remainder  of  the  present  hour. 
Syphilis  in  all  its  forms  is  the  result  of  the  action  of  a  specific  virus  gen- 
erally introduced  into  the  human  system  by  inoculation.  Such  inocula- 
tion usually  takes  place  during  impure  sexual  connection,  but  may  be.  the 
result  of  accident,  as  when  introduced  into  wounds  on  the  fingers  while 
dressing  syphilitic  sores,  washing  clothing  impregnated  with  the.  virus;  or 
in  any  other  way  bringing  the  matter  in  contact  with  an  abraded  or 
sensitive  surface. 

The  first  eifect  of  inoculation  is  the  formation  of  a  sore  at  the  point  of 
contact,  from  which,  if  not  speedily  destroyed,  the  poison  is  carried  by  the 
lymphatics  to  the  nearest  lymphatic  glands,  causing  them  to  become  in- 
flamed and  swollen.  The  sore  at  the  place  of  inoculation  and  the  inflamma- 
tion of  the  adjacent  glands  constitute  what  is  called  primary  syphilis. 
Whatever  subsequent  manifestations  of  disease  occur,  are  the  result  of 
the  introduction  of  the  poison  into  the  blood,  and  are  called  constitutional. 
Most  writers  divide  the  latter  into  secondary  and  tertiary  fornix  of  disease; 
but  the  distinction  is  for  the  most  part  arbitrary  and  without  practical  utility. 
The  primary  sores  difi'er  somewhat  in  diff"erent  cases.  In  some,  the  sore 
is  small  with  smooth  edges  and  a  hard  base,  and  is  called  the  hard  or  true 
Hunterian  chancre.  In  others,  it  is  larger  in  circumference,  without  hard- 
ness at  its  base,  and  with  rather  irregular  excavated  edges,  and  is  called 
the  soft  chancre  or  chancroid. 

In  stdl  other  cases  more  rarely  met  with,  the  sore  is  large,  irregular, 
rapidly  spreading,  and  accompanied  by  much  tumefaction  of  the  surround- 
ing areolar  tissue,  and  is  called  the  phagedenic  chancre.  The  first  of  these 
sores  does  not  generally  appear  until  from  five  to  fifteen  days  after  the  inocu- 
lation, spreads  but  little,  and  generally  soon  heals  up.  But  the  poison  from 
it  is  very  liable  to  reach  the  neighboring  lymphatic  glands,  causing  them 
to  become  swollen,  tender,  and  hard,  and  remain  so  for  two  or  three 
weeks,  and  then  undergo  resolution  without  suppurating.  But  their  dis- 
appearance is  almost  always  followed,  in  due  time,  by  some  form  of  con- 
stitutional disease. 

The  second  variety  appears  within  from  one  to  five  days  after  inoc- 
ulation or  contact  with  the  poison,  soon  extends  its  poison  to  the  lymphat- 
ic glands,  causing  more  active  inflammation,  swelling  and  pain,  and  very 
generally  ends  in  suppuration,  forming  al)scesses,  which  are  often  slow  to 
heal,  but  which  are  notso  constantly  followed  by  constitutional  or  second- 
ary manifestations.  Indeed,  many  of  the  modern  specialists  in  this  de- 
partment, claim  that  the  soft  chancre  originates  from  a  specifically  difi'er- 
ent  poison  from  that  which  produces  the  hard  variety,  and  is  never  followed 
by  constitutional  infection.  The  phagedenic  chancre  is  only  a  severe 
form  of  the  soft  variety,  accompanied  by  more  diffuse  inflammation,  sup- 
puration, and  sometimes  even  extensive  sloughing. 

Now,  gentlemen,  while  I  freely  admit  the  accuracy  of  the  descriptions  of 
all  these  varieties  of  primary  syphilitic  sores,  and  their  relative  tendencies 
to  infect  the  neighboring  glands,  and  at  a  later  period  to  induce  a  succes- 


MANIFESTATIONS.  287 

sion  of  constitutional  symptoms,  one  of  the  important  conclusions  I  wish 
to  o-ive  you  is,  that  it  is  entirely  unsafe  to  rely  upon  the  doctrine  that  any 
one  of  these  syphilitic  sores,  wliether  it  be  chancre  or  chancroid,  will  not 
be  fo  lowed  by  constitutional  symptoms  at  some  subsequent  period  of 
time. 

In  other  words,  if  a  patient  comes  to  you  with  the  most  perfect  speci- 
men of  a  soft  chancre,  and  it  is  speedily  followed  by  abundantly  suppur- 
ating' buboes  or  lymphatic  glands,  you  cannot  safely  promise  him  that 
there  will  positively  be  no  svibsequent  constitutional  or  secondary  symp- 
toms resulting  from  the  infection.  Fori  have  repeatedly  seen  almost  ev- 
ery variety  of  secondary  and  tertiary  manifestation,  in  patients  whose  pri- 
mary sores  were  entirely  Iree  from  induration,  and  whose  groins  were  well 
scared  from  the  original  suppurated  glands. 

Another  conclusion  based  on  direct  clinical  observation,  is  that  you  can 
never  rely  upon  destroying  a  primary  syphilitic  sore  so  early  and  com- 
])letely  as  to  certainly  prevent  the  poison  from  entering  the  blood  and  in- 
ducing constitutional  eifects. 

That  true  chancres  are  sometimes  thus  completely  destroyed  and  never 
followed  by  any  secondary  effects  I  freely  admit.  But  in  other  cases 
when  the  primary  point  of  inoculation  has  been  attacked  equally  early,  and 
to  all  appearance  with  equal  effect,  the  subsequent  history  has  shown 
abundant  evidences  of  constitutional  infection.  There  is,  therefore,  no 
i-eliable  index  by  which  we  may  know  whether  any  given  patient  is  safe 
from  futiire  trouble,  until  the  lapse  of  time  demonstrates  it. 

The  principal  secondary  or  constitutional  manifestations  of  syphilitic 
disease  are  cutaneous  eruptions;  specific  inflammations  and  ulcerations  of 
the  mucous  membrane  of  the  fauces,  nostrils  and  mouth;  inflammation  of 
the  periosteum,  especially  that  covering  the  bones  of  the  nose  and  palate, 
the  long  bones  of  the  extremities,  and  those  of  the  cranium;  and  struct- 
ural degeneration,  usually  called  syphiloma,  in  the  parenchyma  of  internal 
organs,  more  especially  the  liver,  kidneys,  lungs  and  brain  with  its  append- 
ages. For  full  descriptions  of  all  these  I  must  refer  you  to  the  lectures 
on  surgery  and  dermatology,  or  to  special  works  on  syphilitic  diseases. 
I  will  only  state  that  they  are  all  the  effects  of  a  specific  virus,  primarily 
introduced  into  the  system  from  without,  and  may  vary  .much,  bath  in  the 
order  of  their  manifestation,  and  in  the  length  of  time  from  the  primary 
introduction. 

Long  intervals  may  occur,  even  amounting  to  ten  or  twenty  years,  dur- 
ing which  patients  once  having  had  syphilis,  may  appear  perfectly  well, 
and  yet  become  sorely  afflicted  with  periosteal  nodes  or  syphiloma  of  the 
nervous  centers,  etc.  Consequently  you  can  never  assume  to  know  cer- 
tainly, whether  in  any  given  case,  the  patient  is  perfectly  and  permanent- 
ly cured  or  not. 

Clinical  facts  also  show  that  a  wife  may  contract  constitutional  syphilis 
from  the  bearing  of  children  congenitally  affected  with  the  disease  from 
the  father.  This,  with  the  preceding  statement,  will  remind  yo,u  that 
physicians  are  liable  to  meet  with  secondary  or  remote  manifestations  of 
the  disease  at  times,  and  in  families  where  they  least  expect  them.  It  is 
not  rare  that  a  young  married  woman,  belongnig  to  a  domestic  circle  that 
no  one  would  suspect,  after  one  or  more  abortions  or  premature  deliveries,  be- 
gins herself  to  fail  in  health,  and  soon  presents  unmistakable  symptoms  of 
some  form  of  constitutional  syphilis.  Or  the  child  may  be  born  at  full  term, 
and  in  a  few  days  its  skin  is  found  speckled  with  copper  colored  spots,  or  its 
mouth  and  nostrils  occupied  with  the  characteristic  erythema.  On  the 
other  hand  I  have  seen  both  m^n  and  woman,  in  the  advanced  period  of 


288  CONSTITUTIONAL    SYPHILIS. 

life,  after  having  reared  families  of  apparently  healthy  children,  and  lived 
as  exemjDlary  and  leading  members  of  society  for  twenty-five  or  thirty 
years,  become  seriously  afflicted  with  cephalalgia,  derangements  of  vision, 
unsteadiness  of  gait,  in  one  instance  hemiplegia,  and  in  another  epilepsy,  in 
which  a  careful  examination  showed  well  marked  pericranial  nodes  and 
corresponding  thickening  of  the  dura-mater,  with  pressure  upon  the  cere- 
bral surface;  and  all  of  which  were  relieved  by  well  directed  anti-syphilitic 
treatment.  In  one  lady,  at  least  fifty  years  of  age,  and  mother  of  a  family 
of  grown-up  children,  the  functions  of  the  brain  became  so  seriously  dis- 
turbed that  her  attending  physician,  who  from  the  circumstnnces  of  the 
family,  had  not  so  much  as  thought  of  a  possible  syphilitic  influence,  was 
very  confident  that  she  had  effusion  into  the  lateral  ventricles  of  the  brain. 
Seeing  the  patient  in  consultation,  and  passing  my  hand  over  the  forehead 
and  top  of  the  head  to  note  the  temperature,  I  discovered  two  well  devel- 
oped nodes  over  the  upper  part  of  the  f.  ontal  and  one  over  the  parietal 
bones. 

After  retiring  to  a  private  room  for  consultation,  I  asked  the  family 
physican  if  he  knew  anything  in  regard  to  syphilitic  diseases  in  the  early  life 
of  either  the  patient  or  her  husband,  and  whether  it  was  not  possible  that 
the  present  condition  of  his  patient  resulted  from  slow  alterations  of  the 
structures  inside  of  the  cranium  corresponding  with  the  thiikeningsof  the 
pericranial  membrane  visible  externally.  But  finding  him  quite  inclined  to 
resent  even  the  suggestion,  and  not  wishing  to  Lave  the  family  disturbed  by 
any  questions  which  might  raise  unpleasant  suspicions  1  dropped  the  sub- 
ject, and  without  further  questioning  of  his  diagnosis,  easily  pursuaded 
him  to  put  his  patient  upon  the  use  of  a  prescription  containing  iodide  of 
sodium,  bichloride  of  mercury  and  conium;  claiming  that  its  alterative 
action  avouM  be  more  likely  to  induce  absorption  of  the  supposed  serous 
effusion  than  any  other  remedies  I  could  suggest.  The  result  was,  that 
in  a  few  days  the  patient  began  perceptibly  to  improve,  which  encour- 
aged a  continuance  of  the  medicine  ;  and  under  its  influence,  in  three 
months,  all  her  cerebral  symptoms  as  well  as  the  nodes  on  the  cranium  had 
disappeared,  and  the  patient  was  able  to  ride  out  and  resume  some  charge 
of  her  household.  It  will  be  well  for  you  to  be  ever  on  the  alert  for  these 
remote  and  trouljlesome  syphilitic  affections,  but  when  you  meet  them 
in  families,  affecting  innocent  parties,  sometimes  from  hereditary  influence, 
other  times,  as  I  have  already"  intimated,  from  a  husband  either  directly, 
or  indirectly  through  placental  connection  with  a  diseased  foetus,  it  is  not 
necessary  to  create  domestic  discord  and  destroy  the  happiness  of  a  whole 
life,  by  such  inquiries  as  will  at  once  suggest  the  real  nature  of  the  case. 
On  the  contrary,  simply  explain  to  the  wife  or  mother  that  there  is  some 
chronic  derangement  of  the  nutritive  processes,  which  will  need  careful 
treatment  for  some  time,  and  proceed  at  once  with  the  most  reliable  rem- 
edies for  what  you  suppose  to  be  the  real  disease. 

If  the  nature  of  the  case  is  such  as  to  indicate  that  the  constitutional 
condition  of  the  husband  is  still  impure,  inform  him  privately  of  his  con- 
dition, and  insist  that  he  shall  faithfully  use  the  necessary  means  for  cor- 
recting his  own  morbid  condition.  By  such  a  course,  the  judicious  and 
skillful  phj'sician  can  obviate  an  immense  amount  of  moral,  social,  and 
physical  evil,  during  his  professional  career.  My  views  of  the  treatment 
of  syphilis  may  be  briefly  stated  in  the  following  propositions: 

_  First.  If  I  meet  a  primary  sore,  during  the  first  three  days  after  it  becomer 
visible  1  immediately  cauterize  it  freely  either  with  strong  nitric  acid  or 
liquid  carbolic  acid,  with  the  hope  of  destroying  all  the  virus  before  it  has 
left  the  sore,  or  entered  either  the  lymphatics  or  the  blood.     Subsequently 


TREATMENT.  289 

I  have  it  dressed  morning  and  evening  with  carbolated  cosmoline  or  iodo- 
form until  it  is  healed.  If  the  sore  or  chancre  is  more  than  three  days  old, 
the  cauterization  may  as  well  be  omitted,  and  the  iodoform  or  carbolated 
dressing  applied  from  the  beginning;  for  there  is  little  or  no  probability 
that  absorption  of  the  virus  can  be  prevented,  and  there  is  generally  no 
difficulty  in  healing  the  sore. 

Second.  As  there  is  no  absolute  certainty  that  absorption  of  the  virus 
will  be  prevented  in  any  given  case,  I  am  in  the  habit  of  commencing  at 
once,  in  all  cases,  the  internal  administration  of  mercury,  or  the  prepara- 
tions of  iodine,  or  both,  as  the  most  reliable  means  for  neutralizing  or  ex- 
pelling so  much  of  the  poison  as  may  have  been  taken  up.  If  the  patient 
is  young  and  vigorous,  I  give  one  of  the  following  pills  three  or  four  times 
a  day: 

5.   Hydrargyri  Chloridi  Mitis  1 .5  grams         gr.  xxiv 

Extracti  Conii  1.5     "  gr.  xxiv 

Mix,  divide  into  xx  pills. 

If  the  patient  is  already  aneeraic  or  debilitated,  I  prefer  giving  four 
cubic  centimeters  (fl  3i)  of  the  following  formula,  before  each  meal  and 
at  bed  time: 

I^  Hydrargyri  Chloridi  Coros.       0.1  gram         gr.  iss 
Extracti  Conii  Fluidi  15.0  c.  c  3iv 

Tinctur^e  Cinchonae  Comp.    160.0  c.  c.  |v 

Mix.  Put  each  dose  with  sweetened  water  when  given.  If  the  bowels  do 
not  move  regularly  each  day  I  prompt  them  by  the  mildest  class  of  laxa- 
tives, and  confine  the  patient  to  a  mild  plain  diet,  without  any  alcoholic 
drinks  either  fermented  or  distilled.  If  the  gums  and  teeth  do  not  become 
tender  to  pressure,  and  no  swellings  appear  in  the  groins  or  neighboring- 
lymphatic  glands,  I  allow  one  or  the  other  of  these  prescriptions  to  be 
continued  until  the  primary  sore  is  entirely  healed,  and  then  discontinue 
them  on  the  presumption  that  none  of  the  specific  poison  had  been  ab- 
sorbed, and  further  treatment  is  unnecessary. 

Third.  If,  however,  in  spite  of  the  foregoing  treatment,  or  from  the 
delay  of  the  patient  before  presenting  himself,  the  lymphatic  glands  have 
become  inflamed  and  swollen,  whether  they  present  any  appearance  of 
suppurating  or  not,  I  commence  directly  the  administration  of  the  iodide 
of  sodium, bichloride  of  mercury,  and  conium,  in  accordance  with  the  fol- 
lowing formula: 

^     Hydrargyri  Chloridi  Coros.  0.10  grams  gr.  iss 

Sodii  lodidi  15.00      "  3iv 

Extracti  ConiiFluidi  15.00  c.  c,  3iv 

Elixer  Simplicis  145.000 "  "  fivss. 

Mix.  Give  four  cubic  centimeters  (li.  3i)  in  a  little  additional  water 
before  each  meal  time  and  at  bed  time. 

If  the  swollen  glands  are  very  tender  and  present  indications  of  commenc- 
ing suppuration,  I  apply  emolient  poultices  until  the  abscesses  are  sufficiently 
matured,  and  then  open  them  freely,  deeming  it  important  to  give  the 
pus  an  early  and  free  outlet.  They  are  then  washed  out  and  dressed  with 
antiseptic  applications  morning  and  evening  until  they  become  healed. 
If  the  affected  glands  are  not  large  or  tender  and  give  no  indication  of 
19 


290  COXSTITUTIOXAL    SYPHILIS. 

suppurating,  I  dress  them  with  mercurial  ointment  or  a  liniment  of  two 
parts  of  camphorated  soap  liniment  and  one  of  tincture  of  iodine,  until 
they  disappear.  If  the  affection  of  the  glands  disappears  either  by  reso- 
lution, or  by  suppuration  and  subsequent  cicatrization,  I  continue  the 
administration  of  the  iodide  and  mercurial  each  morning  and  eveninof  for 
three  or  four  weeks,  when,  if  no  secondary  symptoms  appear,  all  medicines 
are  discontinued.  But  the  patient  is  warned  to  immediately  apply  for  fur- 
ther treatment,  should  constitutional  symptoms  of  any  kind  make  their  ap- 
pearance. 

Fourth.  For  all  the  forms  of  constitutional  syphilitic  disease,  whether  in 
the  skin,  the  membranes  of  the  mouth,  fauces  and  nostrils;  the  periosteum, 
bones,  or  parenchyma  of  internal  organs;  I  have  found  the  combination  of 
iodide  of  sodium,  bichloride  of  mercury  and  conium,  to  come  nearer  to  a 
reliable  specific,  than  any  or  all  other  remedies  that  have  been  suggested. 
For  manv  cases,  the  formula  I  gave  you  a  few  minutes  since,  is  the  best; 
but  if  the  patient  is  already  more  or  less  debilitated,  it  is  better  to  substi- 
tute the  compound  tincture  of  cinchona  in  the  place  of  the  simple  elixer. 
I  generally  commence  giving  four  cubic  centimeters  (  fl  "i)  in  a  table- 
spoonful  of  sweetened  water  four  times  per  day,  for  adults,  and  proportion- 
ately less  for  children.  I  allow  a  diet,  embracing  a  fair  variety  of  good 
plain  food,  but  prefer  the  entire  avoidance  of  alcoholic  drinks  and  tobacco. 
In  old  aofemic  cases,  and  in  generally  depraved  conditions  of  the  system,  I 
give  in  addition  to  the  alteratives  and  good  food,  such  additional  tonics 
•and  nutrients  as  extract  of  malt  and  cod-liver  oil;  citrate  of  iron  and  qui- 
nine; or  iron,  quinine  and  strychnia;  giving  them  usually  after  meals.  I 
do  not  remember  ever  meeting  a  case,  in  which  the  iodide  of  sodium  and 
Ij'chloride  of  mercury,  given  as  I  have  suggested,  did  not  relieve  the  pains 
of  svphilitic  nodes  in  four  or  five  days,  with  a  subsequent  reduction  of  the 
swelling.  Neither  have  I  ever  met  with  syphilitic  ulcerations  in  the  nos- 
trils, mouth,  or  elsewhere,  that  did  not  heal  under  their  influence,  unless 
hindered  by  the  presence  of  decayed  bone.  You  may  be  ready  to  ask  why 
not  give  the  biniodide  of  mercury  ready  formed,  as  the  iodide  of  sodium 
and  bichloride  are  supposed  to  form  the  biniodide  when  combined  in  solu- 
tion. I  answer,  that  if  the  combination  is  formed,  there  is  left  an  efficient 
excess  of  the  iodide  of  sodium  in  the  formula,  and  that  an  abundant  clin- 
ical experience  has  shown  the  two  to  be  much  more  efficient  than  either 
one  of  the  salts  of  iodine  or  mercury  are  alone.  The  combination  given  in 
the  formula  can  be  taken,  by  the  great  majority  of  patients,  longer  without 
aflfecting  the  gums  or  mouth,  than  either  the  proto  or  the  biniodide  of 
mercury,  and  with  less  impairment  of  the  digestive  and  nutritive  functions 
than  the  large  doses  of  the  iodide  of  potassium,  which  are  so  generally  rec- 
ommended. Like  all  other  active  drugs,  however,  its  effects  should  be 
carefully  noted  in  each  case,  and  the  mercurial  part  of  the  prescription 
omitted  whenever  the  gums  or  the  breath  show  the  mercurial  impression; 
but  may  be  cautiously  resumed  when  these  symptoms  have  disappeared. 
Strict  attention  should  be  given  to  hygienic  and  sanitary  regulations;  and 
patients  should  not  be  allowed  to  continue  a  perpetual  use  of  drugs,  when 
there  are  no  real  appearances  of  disease,  merely  because  they  fear  some 
form  of  trouble  may  come.  With  these  brief  and  somewhat  dogmatic 
statements  I  must  leave  the  subject. 


KHEUMATISM.  291 


LECTUEE    XXXI. 

Rheumatism— Its  Varieties,   Causes,  Symptoms,   Diagnosis,  Special  Pathologj',  Treatment,    and 
Prophylaxis. 

GENTLEMEN :  I  shall  occupy  your  attention  durinfr  the  present  hour  with 
the  consideration  of"  one  of  the  most  common  and  most  troublesome  dis- 
eases that  you  will  encounter  in  the  field  of  general  practice.  I  allude  to 
rheumatism,  which  in  its  general  application,  includes  a  considerable  vari- 
ety of  painful  and  tedious  affections.  When  cases  present  active  general 
fever,  associated  with  the  local  inflammation  and  swelling,  they  are  called 
acute  rheumatism  or  rheumatic  fever.  When  they  present  considerable 
local  inflammation  and  swelling  with  but  little  general  fever,  they  are 
often  classed  as  sub-acute  rheumatism.  Cases  presenting  local  pains, 
stiffness,  and  impairments  of  motion,  persisting  through  considerable  pe- 
riods of  time,  but  without  fever,  are  called  chronic.  Cases  are  also,  by 
many,  grouped  and  named  from  the  structures  proininently  involved;  as, 
myalgia,  when  located  in  the  muscles;  neuralgic  rheumatism,  when  affect- 
ing the  nerves  or  their  sheaths;  and  other  cases  are  named  from  the  disease 
with  which  they  may  be  associated,  as  syphilitic,  gonorrhoeal,  and  gouty. 
This  variety  of  grouping  of  cases  and  application  of  names,  does  not  indi- 
cate any  specific  differences  in  the  nature  of  the  rheumatic  affections,  but 
simply  differences  in  activity,  location,  or  coincident  morbid  conditions. 
For  accuracy  of  description  and  certainty  of  diagnosis,  it  is  quite  suffi- 
cient to  arrange  all  cases  in  one  or  the  other  of  two  classes  called  acute  and 
chronic  rheumatism. 

Etiology. — The  causes  of  rheumatism,  in  all  its  grades  and  forms,  must 
be  divided  into  predisposing  and  exciting.  The  first  embrace  all  those  in- 
fluences that  are  capable  of  increasing  the  excitability  of  the  tissues  on  the 
one  hand,  and  of  retarding  the  cutaneous  eliminations  on  the  other. 

The  most  important  of  these  are  habitual  exposure  to  frequent  and  se- 
vere atmospheric  changes  coupled  with  dampness,  and  protracted  mental 
or  physical  labor.  The  influence  of  these  causes  in  favoring  the  accumu- 
lation of  an  excess  of  lactic  acid  and  lactates  in  the  blood  and  secretions, 
and  the  localities  in  our  country  where  they  are  most  active,  I  explained 
sufficiently  in  a  preceding  lecture  while  commenting  on  the  general  eti- 
ology and  pathology  of  the  class  of  constitutional  diseases.*  Under  the 
same  head  must  be  placed  hereditary  influences  which  were  also  explained 
in  the  preceding  lecture.  The  chief  exciting  or  direct  cause  of  the  local 
phenomena  of  rheumatism  is  an  excess  of  such  acid  material  in  the  system 
as  is  capable  of  inducing  a  specific  grade  of  inflammation  in  some  one  or 
more  of  the  fibrous  tissues  of  the  body.  I  say  acid  material,  because  in 
all  the  more  acute  forms  of  the  disease,  the  blood  and  the  several  secre- 
tions have  almost  uniformly  been  found  to  contain  more  than  the  natural 
evidences  of  acidity,  and  the  efficient  neutralization  of  this  by  remedies 
has  generally  afforded  relief.  While  careful  and  extensive  analytical  inves- 
tigations by  different  parties,  have  not  shown  conclusively  the  particular 
acid  or  acids  present  in  excess,  they  have  rendered  it  highly  probable  that  it 
is  chiefly  lactic  acid  and  its  salts.  Whatever  may  be  the  particular  mate- 
ries  morbi  that  constitutes  the  direct  active  agent  in  the  production  of 
rheumatic  inflammation,  its  impression  on  the  living  tissues  once  made, 
leaves  them  ever  afterward  more  susceptible  to  its  influence  than  before. 

*  See  pages  252-3-4  of  this  work. 


292  RHEUMATISM. 

This  susceptibility  is  not  merely  local,  thereby  determining  eacli  new 
attack  of  inflammation  to  appear  in  the  same  articulations,  but  is  so  general 
tliat  each  successive  outbreak  is  as  likely  to  invade  new  structures  or 
places  as  the  old  ones.  This  fact  alone  proves  the  constitutional  or  gen- 
eral character  of  the  disease.  Statistics  show  that  all  the  fonns  of  rheu- 
matism are  most  prevalent  between  the  ages  of  fifteen  and  thirty  years, 
yet  they  are  sometimes  met  with  at  all  periods  from  the  first  to  the  last 
year  of  human  life.  The  acute  and  subacute  grades  are  most  prevalent  in 
youth  and  the  early  part  of  adult  life,  while  the  chronic  forms  are  more 
frequently  associated  with  old  age.  The  disease  attacks  a  larger  propor- 
tion of  males  than  females;  and  is  more  prevalent  among  those  engaged  in 
physical  labor  than  other  classes,  which  is  doubtless  owing  to  their  greater 
degree  of  exposure  to  the  predisposing  causes  of  the  disease. 

Clinical  Ilistory  or  ISymptoms  of  Acute  Articular  JRheumatism. — The 
acute  form  of  rheumatism,  or  rheumatic  fever,  varies  much  in  its  severity,  ra- 
pidity of  progress,  and  duration.  The  great  majority  of  cases  of  average  se- 
verity commence  suddenly  or  with  but  little  premonitory  waining.  The  pa- 
tient often  retires  at  night  with  only  a  little  stiffness  or  slight  feeling  of  sore- 
ness in  his  back.  In  some  cases,  this  is  so  slight  as  to  escape  the  patient's  no- 
tice; while  in  others  it  is  quite  marked,  either  in  the  back  or  in  sojne  of  the 
articulations.  But  he  usually  awakes  before  midnight  with  a  severe  ach- 
ing or  gnawing  pain  in  some  part  of  the  spine,  or  wherever  the  stiffness 
had  been  felt  the  previous  evening.  In  attempting  to  change  his  position, 
he  finds  the  pain  greatly  increased  by  every  movement.  Feeling  fever- 
ish, restless  and  unable  to  leave  his  bed  without  intense  suffering,  he 
sends  for  his  physican  in  the  morning.  The  doctor,  on  his  arrival,  finds 
his  patient  with  some  redness  or  flush  of  the  face;  heat  and  dryness 
of  the  skin;  a  full  and  frequent  pulse,  generally  between  90  and  100 
per  minute;  tongue  covered  with  a  thin  white  coat;  urine  scanty  and 
high  colored;  bowels  inactive;  temperature  in  the  axilla  from  38.3" 
to  39'^C  (101°  to  102.5°  F.);  with  great  restlessness  from  constant  pains 
aggravated  by  motion.  In  other  words  he  finds  his  patient  presenting  all 
the  symptoms  of  an  active  irritative  fever,  to  which  are  added  the  severe 
and  constant  local  pains  coupled  with  restlessness  and  yet  inability  to 
move  without  great  increase  of  suffering,  which  is  characteristic  of  acute 
rheumatism.  In  the  most  acute  and  severe  form  of  the  disease,  the  pain 
generally  attacks  the  whole  length  of  the  spine  at  once,  and  in  twenty- 
four  hours  it  extends  to  the  shoulders  and  hips;  the  next  day  it  includes 
the  elbows  and  knees,  and  by  the  end  of  the  third  or  fourth  day,  it  will  have 
extended  to  the  wrists,  ankles,  and  small  joints  of  the  fingers  and  toes, 
thereby  involving  almost  every  articulation  in  the  body  and  extremities. 
All  the  articulations  attacked  quickly  become  swollen,  excessively  tender 
to  the  touch,  with  constant  aching  pain  much  increased  by  the  slightest 
motion.  The  swelling  is  generally  diffused  more  or  less  over  the  whole 
joint,  but  is  most  prominent  over  the  course  of  the  ligaments,  diminishes 
gradually  in  both  directions  from  the  articular  junctions,  having  no  ab- 
rupt margins  or  terminations,  and  presenting  little  or  no  redness  on  the 
surface.  In  the  later  stage  of  severe  cases,  the  areolar  tissue  in  the  vi- 
cinity of  the  inflamed  parts  is  often  found  infiltrate!  with  serum  so  as  io 
pit  more  or  less  from  pressure;  and  in  some,  the  synovial  membrane  is 
sufficiently  involved  to  cause  serous  effusion  into  the  sac,  which  will  make 
the  most  prominent  part  of  the  swelling  between  the  ligaments  crossing  the 
joint,  where  there  is  the  least  resistance  to  the  distension  of  the  membrane. 
In  the  very  severe  cases  I  have  been  describing  the  disease  generally  reaches 
its  acme,  or  highest  stage  of  activity  during  the  fourth  or  fifth  days;   when 


SYMPTOMS.  ZvjS 

the  temperature  is  between  40°  and  41°  C.  (104°  and  106°  F.);  the  pulse 
full,  and  varying  in  frequency  from  100  to  120  per  minute;  general  scant- 
iness of  secretion,  especially  of  the  urine,  which  is  redder  than  natural  and 
strongly  acid  in  reaction  with  litmus,  and  the  patient  tortured  with  gnaw- 
ing pains  throughout  the  trunk  and  extremities,  yet  utterly  helpless  from 
the  increase  of  pain  on  every  attempt  to  move.  Having  arrived  at  this 
stage  of  development,  the  natural  tendency  of  the  disease,  when  unmodi- 
fied by  treatment,  is  to  remain  nearly  stationary  for  three  or  four  days,  or 
until  about  the  middle  of  the  second  week  from  the  commencement  of  the 
attack.  Of  course  during  these  days  the  loss  of  appetite,  continued  suffer- 
ing, and  want  of  sleep,  cause  correspondingly  increased  weakness,  with 
increased  frequency  and  diminished  force  of  the  pulse;  and  sometimes, 
more  especially  during  the  night,  some  degree  of  delirium.  During  the 
last  half  of  the  second  and  the  first  half  of  the  third  weeks,  the  constant 
hard  aching  pains  gradually  disappear,  leaving  only  soreness  and  pain  on 
motion,  with  some  swelling;  the  temperature  gradually  declines;  the  pulse 
becomes  slower;  the  urine  more  abundant  and  often  deposits  on  standin<3^ 
in  the  vessel,  a  red  sediment;  the  skin  becomes  moist,  and  the  patient  takes 
short  intervals  of  quiet  sleep.  These  changes  are  pretty  sure  indications 
of  a  more  rapid  decline  in  ail  the  general  and  local  symptoms  durmg  the  last 
half  of  the  third  week,  and  the  establishment  of  convalescence  as  the  pa- 
tient enters  the  fourth  week  of  his  confinement.  In  some  few  instances  there 
has  occurred  during  the  last  half  of  the  second  week  a  more  copious  dis- 
charge of  urine,  containing  a  large  excess  of  saline  and  excretory  constit- 
uents, with  moderate  spontaneous  looseness  of  the  bowels  and  moisture  of 
the  skin,  followed  by  a  rapid  decline  in  all  the  general  and  local  symp- 
toms of  disease,  and  an  early  establishment  of  convalescence.  On  the 
other  hand,  a  larger  number  of  cases  are  met  with,  in  which,  after  the 
middle  of  the  second  week  the  temperature  remains  high;  the  urine  scanty, 
and  though  the  skin  becomes  moist,  the  perspiration,  even  when  quite 
free,  has  a  sour  disagreeable  odor;  the  pulse  becomes  weaker  and  more 
frequent;  the  skin  on  the  neck,  upper  part  of  the  chest  and  axilla,  cov- 
ered with  sudamina;  and  by  the  end  of  the  third  week  the  wrists,  back  of 
the  hands  and  feet  are  more  or  less  oedematous,  and  the  patient  feels  a 
great  sense  of  exhaustion.  Su^h  cases  usually  prove  very  tedious,  the  full 
convalescence  being  postponed  until  the  end  of  the  fourth,  fifth  or  even 
sixth  week.  iVnd  even  then,  in  some  cases,  one  or  more  of  the  articula- 
tions remain  swollen,  stiff,  and  sore  for  an  indefinite  period,  the  local  in- 
flammation having  assumed  a  chronic  form. 

It  is  not  often  that  acute  rheumatic  inflammation  attacks  internal  or- 
gans or  structures,  except  the  heart  and  its  appendages. 

Inflammation  of  the  interior  lining  of  the  left  cavities  of  the  heart  and 
of  the  aorta,  constituting  rheumatic  endocarditis,  supervenes  during  the 
progress  of  a  considerable  percentage  of  the  cases  of  acute  rheumatism. 
Inflammation  of  the  pericardium  is  next  in  the  order  of  frequency;  while 
acute  rheumatic  inflammation  of  the  membranes  of  the  brain,  the  fibrous 
structure  of  the  lungs,  and  the  muscular  coat  of  the  stomach  and  intes- 
tines occurs  very  rarely. 

The  fact  that  endocardial  and  pericardial  inflammations  frequently  su- 
pervene as  complications  of  acute  rheumatic  fever,  should  cause  you  to 
make  direct  examination  of  the  condition  of  those  organs  everyday  during 
your  attendance  upon  this  class  of  patients.  They  may  supervene  at  any 
stage  of  the  general  disease,  but  in  the  large  majority  of  cases  their  pres- 
ence is  first  manifested  during  the  second  week  of  its  progress.  Their 
presence  is  readily  detected  by  the  more   excited  and  fuller  pulse;  pain 


294  SUBACUTE     KHEUMATISM. 

and  oppression  in  the  cardiac  resfion,  and  especially  by  the  characteristic 
bellows  murmur  from  the  endocardium,  and  friction  sounds  from  ttie  peri- 
cardium. The  occurrence  of  either  or  both  of  these  complications  during 
the  progress  of  a  case  of  rheumatism,  adds  much  to  its  gravity,  and  gen- 
erally increases  much  the  duration  of  the  patient's  sickness,  though  seldom 
causing  a  directly  fatal  result. 

From  the  description  I  have  given  you  of  the  more  active  grades  ol 
acute  rheumatism  you  will  infer  that  the  disease,  though  varying  much  in 
ii-s  severity  and  duration,  generally  tends  toward  recovery  in  from  two  to 
six  weeks, 

baoacate  Rhewmatism. — In  a  large  proportion  of  the  rheumatic  at- 
tacks met  with  in  general  practice,  the  symptoms  commence  less  abruptly 
and  the  febrile  phenomena  are  much  less  severe  throughout  their  course. 
After  feeling  some  stiffness  and  soreness,  either  in  the  upper  part  of  the 
dorsal  or  in  the  lumbar  part  of  the  spine  for  one,  two  or  three  days,  the 
patient  finds  it  difficult  to  get  out  of  bed  on  account  of  an  increase  of  such 
stift'ness,  accompanied  by  continuous  dull  pain  and   a  moderate  fever. 

The  local  pain  usually  increases  moderately  for  about  three  days,  when 
it  quickly  declines.  But  simultaneously  with  such  decline,  if  it  had  been 
in  the  lower  part  of  the  back  and  hips,  it  commences  in  the  knees  and 
steadily  increases  with  some  swelling  and  tenderness,  for  three  days,  when 
it  moves  to  the  ankles,  and  after  about  the  same  length  of  time,  it  moves  to 
the  smaller  joints  of  the  feet  and  toes.  If  the  attack  has  commenced  in  the 
neck  and  shoulders,  it  will  tarry  the  same  length  of  time,  presenting  the  same 
symptoms,  and  then  move  successively  to  the  elbows,  wrists^  and  smaller 
joints  of  the  hands  and  fingers.  Occasionally  a  case  occurs  in  which  the 
local  inflammation  attacks  parallel  articulations  in  both  upper  and  lower 
extremities  simultaneously.  While  in  a  large  majority  of  the  sulmcute 
cases  the  local  symptoms  commence  in  some  part  of  the  spine  and  move 
from  one  series  of  articulations  to  another,  in  the  direction  of  the  feet  and 
hands,  I  have  seen  cases  in  which  this  order  was  reversed,  the  smaller 
joints  being  attacked  first,  and  the  larger  ones  in  successive  order  until 
the  spinal  column  was  reached.  In  a  large  majority  of  cases  the  local  inflam- 
mation moves  bilaterally;  that  is,  it  attacks  corresponding  articulations  on 
both  sides  at  the  same  time.  This  is  not  always  the  case,  however,  for  I 
have  seen  many  of  the  milder  grade,  in  which  the  disease  attacked  in  suc- 
cession all  the  joints  of  one  arm  or  one  leg,  and  then  those  of  the  other. 
But  it  is  exceeding  rare  that  true  rheumatic  inflammation  limits  its  attack 
to  a  single  articulation,  either  in  the  trunk  of  the  body  or  extremities. 

It  is  generally  the  subacute  grade  of  rheumatism  that  sometimes  at- 
tacks the  muscles  or  the  fascia  surrounding  them,  and  their  tendinous 
attachments,  technically  called  myalgia. 

The  muscular  structures  most  frequently  involved  are  those  of  the  loins, 
shoulders,  diaphragm,  intercostals,  and  the  muscular  coat  of  the  intestines. 
It  is  the  same  grade  of  the  disease  that  so  frequently  involves  the  spinal 
nerves  at  their  exit  from  the  spinal  column,  particularly  the  roots  of  the 
sciatic  and  the  intercostals,  causing  severe  neuralgic  pains  throughout  the 
whole  distribution  of  those  nerves.  It  is  also  the  subacute  form  of  rheu- 
matism that  is  apt  to  attack  patients  suffering  from  gonorrhoea,  and  it  is 
then  called  gonorrhoeal  rheumatism. 

In  this  connection  it  is  limited  to  no  class  of  structures,  but  is  most 
frequently  met  with  in  the  wrists  and  ankles  and  the  smaller  joints  of  the 
extremities,  where  it  often  persists  for  a  longtime,  and  in  some  cases  per- 
manently impairs  the  usefulness  of  the  parts  either  by  inducing  adhesions 
of  the  tendons  to  their  sheaths,  causing  a  form    of  false   anchylosis,  or  by 


CHKONIC     RHEUMATISM.  295 

such  a  degree  of  softeiiing  of  the  lioraments  and  .fibrous  structures,  as  make 
the  joints  loose,  flabby,  and  too  weak  for  use.  As  rheumatic  gout  is  a 
mingling  of  some  of  the  phenomena  of  both  gout  and  rheumatism,  I 
shall  defer  any  special  description  of  it  until  the  plienomena  of  gout  have 
been  under  consideration. 

Chronic  llJiemnatism. — Chronic  rheumatism  may  be  a  sequel  of  the 
acute  or  subacute  varieties  or  it  may  oiiginate  in  a  chronic  form  without 
having  been  preceded  by  any  more  active  stage.  AVhen  it  follows  a  more 
acute  attack,  some  of  the  articulations  that  were  primarily  affected,  re- 
main more  or  less  stiff,  and  the  ligaments  sufficiently  thickened  to  make 
the  parts  appear  slightly  swollen.  The  stiffness  and  soreness  is  most 
marked  on  first  rising  in  the  morning,  or  in  commencing  motion  after  a 
period  of  rest,  but  diminishes  while  the  exercise  is  continued,  so  that 
many  who  are  hardly  able  to  dress  themselves  in  the  morning,  after  get- 
ting started,  do  a  fair  day's  work  every  day.  They  are  exceedingly 
sensitive  to  atmospheric  changes,  being  generally  comfortable  during 
warm  and  dry  weather,  but  suffering  much  increase  of  lameness  and  pain, 
especially  during  the  night,  with  every  recurrence  of  cold  and  damp. 
They  are  also  very  liable  to  a  renewal  of  more  acute  attacks,  especially 
during  the  variable  weather  of  spring  and  autumn.  Cases  of  rheumatism 
that  are  chronic,  nh  initio^  are  chiefly  met  with  among  the  laboring  classes 
of  both  sexes.  Washing  and  scrubbing  women,  and  those  men  who  are 
engaged  in  such  manual  labor  as  exposes  them  much  to  cold  and  wet, 
furnish  a  large  portion  of  all  the  cases  of  strictly  chronic  rheumatism. 
The  disease  may  commence  in  the  muscular  and  ligamentous  structures 
in  any  part  of  the  body  or  extremities,  but  is  much  the  most  frequent  in 
the  lower  part  of  the  back  and  hips,  in  the  shoulders,  in  the  wrists  and 
smaller  joints  of  the  hands,  and  in  the  ankles.  It  usually  commences 
with  dull  aching  pains  during  the  night,  followed  by  some  sense  of  stiff- 
ness and  soreness  in  the  morning,  which  mostly  disappears  after  a  little 
exercise,  but  returns  in  the  same  manner  when  night  comes.  At  first 
the  symptoms  continue  only  a  few  days  at  a  time,  which  is  generally  dur- 
ing wet  and  cold  weather,  or  after  unusually  severe  exercise,  and  disap- 
pear while  it  is  mild  and  dry.  Each  succeeding  year,  however,  the 
periods  of  suffering  become  more  protracted  and  severe;  and  the  patient 
finally  becomes  a  more  delicate  indicator  of  the  electric  and  hygrometric 
conditions  of  the  atmosphere  than  any  instruments  hitlierto  devised.  The 
ligaments  and  fibrous  structure  of  the  articulations  most  affected,  become 
gradually  thickened  or  hypertophied  and  hardened,  causing  the  joints  to 
appear  enlarged  as  well  as  stiff,  and  much  of  the  time,  painful. 

This  is  particularly  true  concerning  the  wrists  and  the  smaller  joints  of 
the  hands  and  fingers,  which  sometimes  become  so  stiff  that  they  can  be 
neither  fully  flexed  nor  extended,  and  consequently  their  usefulness  is 
very  much  impaired.  And  yet,  most  of  these  patients  are  exem'pt  from  all 
general  febrile  symptoms,  retaining  a  fair  appetite,  a  good  degree  of  nutri- 
tion, and  a  general  feeling  of  health. 

Sometimes  they  are  troubled  with  constipation,  sour  eructations,  acid 
urine,  and  some  degree  of  general  muscular  atrophy.  The  latter,  by 
shortening  the  muscles,  causes  more  flexure  of  the  joints  and  more  deform- 
ity of  the  extremities.  I  have  seen  several  old  cases  of  this  kind,  in  which 
the  patients  could  neither  get  a  hand  to  their  head?,  feed  themselves,  nor 
walk.  Purely  chronic  rheumatism  seldom  invades  the  internal  organs  and 
structures  of  the  body,  and  consequently  manifests  but  little  tendency  to 
shorten  the  duration  ©f  life.  If  there  are  any  exceptions  to  this  rule,  they 
relate  chiefly  to  the  fibrous  tissues  of  the  bronchial  tubes,  the  uterus,  and 
the  bladder. 


296  CHROJsric   rheumatism. 

I  have  long  been  satisfied  that  many  of  the  habitually  recurring  cases  of 
chronic  capillary  bronchitis,  and  of  a  similar  grade  of  morbid  action  in  the 
connective  tissue  of  the  lungs  leading  to  what  has,  by  some,  been  called 
fibroid  phthisis,  are  strictly  rheumatic  in  their  nature.  The  same  is  true  of 
the  fibrous  structure  of  the  uterus  in  many  of  the  cases  of  dysmenorrhoea 
aud  habitual  aching  in  the  back  and  hips;  and  of  the  bladder  in  some  of  the 
cases  called  cystitis  and  irritable  bladder.  But  the  special  features  of  all 
such  cases  are  more  conveniently  considered  in  connection  with  the  local 
affections  of  those  organs. 

Diagnosis. — The  symptoms  and  progress  of  acute  and  subacute  rheu- 
matism are,  in  several  respects,  so  peculiar  as  to  leave  very  little  liability 
to  error  in  regard  to  diagnosis.  The  movable  or  migratory  character  of 
the  local  inflammation,  the  involvement  of  corresponding  articulations  on 
each  side  at  the  same  time,  the  absence  of  all  tendency  to  suppuration,  and 
the  character  of  the  accompanjnng  fever,  are  suflBcient  to  distinguish  all 
ordinary  cases  from  other  affections.  The  diseases  most  likely  to  be  con- 
founded with  rheumatism,  are  acute  and  chronic  synovitis,  periostitis, 
gout,  and  some  cases  of  pyaemia.  If  you  remember  that  the  two  first  are 
fixed,  not  movable  from  one  part  to  another,  and  generally  accompanied 
by  some  degree  of  serous  effusion  into  the  synovial  sac,  that  periostitis 
commences  on  the  shaft  of  the  bones  between  the  articular  extremities, 
and  that  both  gout  and  pygemia  have  characteristic  antecedent  histories, 
you  will  readily  avoid  mistaking  either  of  these  for  any  grade  of  rheuma- 
tism. There  is  more  danger  of  mistaking  rheumatic  inflammation  of  the 
diaphragm  and  intercostal  muscles  for  pleurisy  or  hepatitis,  or  that  of  the 
muscular  coat  of  the  intestines  for  peritonitis.  The  more  dull  and  con- 
tinuous character  of  the  pain,  and  the  absence  of  either  pleuritic  friction 
or  diminished  resonance  above  the  diaphragm,  and  equally,  absence  of  the 
physical  signs  of  enlargement  of  either  liver  or  spleen  below,  will  remove 
all  doubts  in  regard  to  rheumatism  in  the  lower  part  of  the  chest  and 
diaphragm.  While  in  the  abdomen,  the  co-existence  of  dull  pain,  much 
increased  by  peristaltic  motion  of  the  bowels,  only  moderate  tenderness  to 
pressure,  moderate  general  fever,  constipation,  scantiness  and  increased 
acidity  of  the  urine,  and  the  persistence  of  these  from  day  to  day  with 
but  little  distension  of  the  abdomen,  and  no  effusion  into  the  peritoneal 
sac,  differs  so  much  from  the  more  acute  pain,  quicker  pulse,  higher  tem- 
perature, greater  tenderness  and  earlier  abdominal  distension  of  peritoni- 
tis, that  the  one  should  not  be  mistaken  for  the  other  by  any  of  you. 

The  diagnosis  between  chronic  rheumatism  and  neuralgia  rests  mainly 
on  the  fact  that  the  pain  in  the  first  is  dull  and  aching,  and  located 
chieflj'  in  the  muscular  and  ligamentous  structures;  while  that  of  neuralgia 
is  sharp,  intermitting,  and  located  in  the  course  of  some  one  or  more 
nerves.  The  first  is  most  stiff  and  painful  at  the  beginning  of  motion, 
and  often  disappears  during  its  continuance,  while  the  lattei  is  either  un- 
affected by  motion,  or  it  increases  with  the  continuance  of  the  movements 
in  the  part  which  is  the  seat  of  pain. 

Prognosis. — The  prognosis  in  all  forms  and  stages  of  rheumatism  is 
favorable,  so  far  as  relates  to  the  continuance  of  life.  In  some  of  the  most 
acute  attacks,  unmodified  by  treatment,  the  long  continuance  of  extreme 
pyrexia,  or  very  high  temperature,  causes  great  prostration,  and  doubtless 
in  some  rare  instances,  terminates  fatally,  without  the  extension  of  the 
local  inflammation  to  important  internal  orgtins.  But  no  such  case  has 
come  directly  under  my  own  observation.  ^Yhen  the  attacks  become 
complicated  with  acute  rheumatic  inflammation  of  the  cerebral,  pulmonary, 
or  cardiac  structures,  there  is  more  danger,  and  fatal  results  are  much 
more  frequent. 


TEEATMENT.  297 

Yet,  far  the  larger  proportion  even  of  these  complicated  cases  recover  from 
the  acute  stage  of  the  disease,  but  with  thickened  and  hardened  cardiac 
valves,  pericardial  adhesions  or  sclerosis  of  the  connective  tissue  of  the 
lungs,  which,  in  the  remote  changes  they  induce,  ultimately  lead  to  a 
material  shortening  of  the  period  of  life. 

Special  Pathologi),  and  Pathological  Anatomy. — In  the  lecture  on  the 
general  pathology  of  the  class  of  constitutional  diseases,  I  stated  that  the 
essential  pathology  of  rheumatism  consisted  in  an  increase  or  exaltation  of 
the  elementary  properties  of  the  tissues;  an  increase  of  the  plasticity  of 
the  blood,  resulting  from  the  accumulation  of  certain  acid  products  (prob- 
ably lactates)  in  the  system;  with  a  strong  tendency  to  develop  local 
sthenic  or  plastic  inflammation  in  the  fibrous  structures  of  the  body  and 
extremities.  That  these  views  are  correct,  both  in  regard  to  the  general 
rheumatic  diathesis  and  the  special  characters  of  the  local  inflammations 
accompanying  it,  is  rendered  more  evident  by  the  nature  uf  the  structural 
changes  that  are  found  to  have  taken  place  in  the  inflamed  tissues.  There  is 
literally  no  tendency  in  rheumatic  inflammation  to  purulent  degeneration  of 
the  exudative  material  or  to  the  establishment  of  the  suppurative  process. 
Ou  the  contrary  the  exudative  material  rapidly  acquires  a  low  grade 
of  organization,  increasing  the  bulk  and  density  of  the  inflamed 
structures,  and  in  many  instances  becomes  so  fully  identified  with  the  nat- 
ural structure  as  to  disintegrate  and  disappear  very  slowly  after  convales- 
cence; and  in  some  cases,  even  remaining  permanent,  as  in  the  thickened 
and  indurated  cardiac  valves,  the  hypertrophied  ligaments  over  the  affect- 
ed articulations,  and  the  firm  adhesions  in  the  pericardium,  sheaths  of  the 
tendons,  synovial  membranes,  etc.  In  no  other  form  of  disease  do  we 
find  inflammation  presenting  a  character  so  persistently  plastic  as  in  rheu- 
matism. 

Aside  from  the  evidences  of  increased  acidity  in  the  blood  and  secretions, 
the  most  notable  changes  in  the  first  named  fluid  are  the  great  increase 
of  fibrin,  and  moderate  decrease  in  the  red  corpuscles,  albumen,  and  sol- 
uble salts.  These  changes  are  most  notable  in  the  more  severe  grades  of 
the  acute  form  of  rheumatism,  while  in  the  subacute  and  chronic  forms 
they  are  very  slight. 

Treatment. — In  the  treatment  of  acute  rheumatic  fever  and  inflammation, 
the  practitioner  has  four  distinct  indications  to  be  fulfilled,  or  well  defined 
purposes  to  be  accomplished. 

1st.  To  neutralize  the  excess  of  acidity  which  is  supposed  to  constitute 
the  immediate  cause  of  the  febrile  and  inflammatory  actions, 

2nd.  To  promote  the  eliminations,  more  especially  from  the  skin  and 
kidneys  for  the  purpose  of  preventing  further  accumulation,  in  the  system, 
of  the  same  offending  material. 

3rd.  To  alleviate  the  suffering  of  the  patient  by  such  sedative  and  ano- 
dyne remedies  as  will  lessen  the  morbid  excitement  in  the  nervous  and  vas- 
cular structures. 

4th,  To  so  far  lessen  the  plasticity  of  the  exudative  material  that  it  will 
undergo  early  disintegration  and  removal  from  the  tissues  ;  thereby  pre- 
venting those  hypertrophies  and  indurations  which  are  so  prone  to  result 
in  permanent  cardiac  changes,  and  such  stiffness  as  to  permanently  im- 
pair the  usefulness  of  many  of  the  articulations. 

The  first  and  second  of  these  indications  are  founded  on  the  idea  that 
the  disease  depends  upon  the  presence  of  a  material  cause,  and  have  for 
their  object  its  destruction  or  removal,  so  far,  at  least,  as  to  suspend  its 
further  influence  in  the  system. 

The  third  and  fourth    relate  to  the  modification  or  removal  of  the  morbid 


298  EHEUMATISM. 

processes  already  established.  The  means  for  fulfilling  these  several  in- 
dications may  be  numerous  and  varied  in  tiieir  nature;  but  the  indications 
themselves,  being  founded  upon  the  assumption  of  an  efficient  cause  and 
the  nature  of  the  morbid  actions  it  induces,  will  always  remain  the   same. 

Although  each  of  the  indications  named  presents  a  well  defined  purpose 
which  should  be  clearly  comprehended  by  the  practitioner,  yet,  as  often 
happens  in  the  treatment  of  acute  diseases,  especially  in  the  early  stage, 
the  same  remedies  that  efficiently  fulfill  the  indications  for  the  removal  of 
the  exciting  cause  or  causes,  also  fulfill,  at  the  same  time,  all  the  others. 

That  is,  an  early  removal  of  the  efficient  cause,  is  directly  followed  by 
a  disappearance  of  its  effects.  This  is  not  always  the  case,  however;  for 
when  inflammatory  action  has  continued  until  more  or  less  exudation  has 
taken  place,  and  the  blood  has  become  impregnated  with  an  excess  of 
fibrin  and  other  products  of  tissue  changes,  it  will  often  continue  through 
its  remaining  stages  after  the  further  action  of  the  exciting  cause  has  en- 
tirely ceased.  In  acute  and  subacute  rheumatism  the  first  object  is  to 
impregnate  the  blood  and  tissues  with  such  quantity  of  alkaline  salts  as 
will  fully  neutralize  the  excess  of  acid  material,  and  render  the  urinary 
secretion  either  neutral  or  alkaline  in  its  reaction.  For  this  purpose  alone 
we  have  no  better  remedies  than  the  carbonates  and  bicarbonates  of  sodium 
and  potassium,  given  dissolved  in  water,  in  as  large  and  frequently  re- 
peated doses  as  the  stomach  will  tolerate  until  the  desired  saturation  is 
obtained.  From  one  to  three  grams  (gr.  xv  to  gr.  xlv)  given  every 
one  or  two  hours  will  generall}'  produce  the  desired  effect  in  neutralizing 
the  acidity  in  from  one  to  three  days;  after  which  the  same  doses  may  be 
continued  at  longer  intervals.  This  same  saturation  of  the  blood  with 
alkaline  salts,  constitutes  one  of  the  most  efficient  means  for  lessening  the 
plasticity  of  the  exudation  taking  place  in  the  inflamed  structures;  and 
consequently  helps  to  fulfill  the  fourth  indication  that  I  named  to  you. 
To  promote  the  action  of  the  skin,  kidneys,  and  glandular  structures  gen- 
erally, and  at  the  same  time  lessen  the  suffering  of  the  patient,  it  was 
formerly  the  practice  to  give  a  combination  of  the  compound  powder  of 
ipecacuanha  and  opium  with  nitrate  of  potassium  and  small  doses  of  calo- 
mel, every  four  or  six  hours  until  the  intensity  of  the  disease  abated. 
During  the  last  few  years  it  has  been  ascertained,  both  by  experiments  on 
animals  and  by  abundant  clinical  observation,  that  the  salicylic  acid,  in 
efficient  doses,  produces  a  strong  sedative  effect  on  the  sensory  and  ex- 
cito-motory  nervous  system  and  lessens  the  temperatur,e  as  an  antipyretic. 
These  properties  give  it  the  power  to  speedily  relieve  the  intense  suffering 
and  high  temperature  of  acute  articular  rheumatism;  and  when  combined 
with  a  carbonate  or  bicarbonate  of  sodium,  its  administration  fulfills  all 
the  indications  presented  in  the  early  stage  of  the  more  acute  and  severe 
grades  of  rheumatic  disease.  You  may  combine  it  with  the  alkaline  salt 
extempore,  or  better  perhaps  use  the  officinal  salicylate  of  sodium,  of 
which  from  six  to  ten  decigrams  (gr.  x.  to  gr  xv),  may  be  given,  in  dilute  so- 
lution in  water,  every  one  or  two  hours  until  the  pain  and  fever  abate; 
then  double  the  interval  between  the  doses  and  continue  it  until  all  pain 
and  fever  have  ceased.  I  have  seen  many  cases  during  the  last  four  or  five 
years,  both  in  hospital  and  private  practice,  in  which  the  salicylate  of  sodi- 
um thus  administered,  produced  entire  relief  from  pain  and  fever  in  from 
one  to  three  days.  Then  by  lengthening  the  interval  between  the  doses 
just  sufficient  to  perpetuate  the  influence  gained  for  three  or  four  days 
more,  with  a  laxative  when  needed,  and  from  three  to  five  decigrams  of  qui- 
nine three  times  a  day,  convalescence  has  been  well  established,  in  from 
five  to  seven  days  from   the   commencement  of  the  attack.     It  is  only  in 


TKEATMENT.  299 

+he  acute  form  of  the  disease  accompiinied  by  an  active  grade  of  fever, 
that  I  have  found  the  salicyhite  to  act  so  jiromptly  beneficial.  And  even 
in  these,  if,  from  neg-lect  or  otherwise,  the  disease  has  already  progressed 
to  the  middle  or  latter  part  of  the  second  week  and  presents  a  small  fi  e- 
quent  pulse,  a  skin  bathed  in  a  sour  perspiration;  scanty  urine;  and  a  de- 
cided sense  of  weakness,  I  have  found  the  salicylate  too  strongly  sedative; 
and  have  obtained  much  better  results  from  sub-nitrate  of  bismuth,  bi- 
carbonate of  soda,  and  quinine;  the  two  first,  in  doses  of  six  decigrams 
(gr.  x)  and  the  last,  two  decigrams  (gr.  iii),  given  every  three  hours  until 
relief  is  obtained.  At  the  same  time  I  have  derived  additional  benefit 
by  giving  fair  doses  of  the  tincture  of  digitalis  to  lessen  the  cardiac  irrita- 
bility and  promote  the  action  of  the  kidneys.  It  is  in  this  same  condition 
of  debility  with  unhealthy  perspiration,  that  the  tincture  of  chloride  of 
iron  has  been  found  beneficial. 

If  either  endocardial  or  pericardial  symptoms  supervene  in  any  stage  of 
acute  rheumatic  attacks,  I  continue  vigorously  the  same  remedies  for  the 
general  rheumatic  disease,  as  in  other  cases,  but  give  in  addition  alterative 
doses  of  calomel  every  four  hours  until  there  is  a  slight  mercurial  odor  in 
the  breath,  and  such  doses  of  the  tincture  of  veratrum  viride  as  will  aid  in 
controlling  the  excess  of  cardiac  excitement.  If  effusion  takes  place  into 
the  pericardium,  or  the  endocardial  bellows  sounds  continue  after  the  cli- 
max of  the  fever  has  passed,  a  blister  over  the  cardiac  region  will  do 
much  good;  and  a  continuance  of  fair  doses  of  the  iodide  of  potassium 
in  conjunction  with  digitalis  for  a  considerable  time  after  the  slight  mercu- 
lial  impression  has  been  induced,  will  add  to  the  probability  of  preventing 
any  permanent  induration  or  thickening  of  the  cardiac  valves,  which  is  a 
matter  of  great  importance  in  all  these  cases. 

In  the  various  grades  of  subacute  rheumatism,  the  several  indications 
for  treatment  are  the  same  as  in  the  acute,  and  the  remedies  to  be  used 
substantially  the  same,  but  they  need  not  be  used  with  the  same  degree 
of  activity. 

When  either  the  acute  or  subacute  grades  of  rheumatism  prove  unu- 
sually persistent,  and  notwithstanding  the  thorough  use  of  alkaline  salts,  sal- 
icylate sodium,  quinine  and  anodynes  with  light  mercurial  rdteratives,  some 
of  the  articulations  remain  swollen,  tender  to  pressure  and  motion,  with 
an  irritable  pulse,  restless  nights,  rather  scanty  and  high-colored  urine, 
though  not  much  fever  or  elevation  of  temperature,  you  may  know  that 
the  disease  is  strongly  disposed  to  assume  a  chronic  form.  Many  such 
cases  will  get  almost  convalescent,  and  then  be  renewed  moderately,  with 
every  noticeable  change  in  the  atmospheric  conditions.  In  such  cases  I 
have  found  certain  vegetable  remedies  of  much  value,  more  particularly 
the  cimicifuga  racemosa,  phytolacca  decandra,  and  the  senecio  aureus. 
They  may  be  conveniently  used  either  in  the  form  of  tincture  or  fluid  ex- 
tract. ]  have  used  them  chiefly  in  the  latter  form,  and  in  combination 
with  stramonium  and  some  saline  diuretic. 

The  following  is  a  convenient  formula: 

^      Potassii  Acetatis 

Extracti  Phytolaccas  Dec.  Fluidi 
Tincturae  Stramonii 
Elixer  Simplicis 

Mix,  and  give  four  cubic  centimeters  (fl  3i)  every  six  hours,  in  a  little 
additional  water.  The  cimicifuga  or  the  senecio  may  be  substituted  for 
the  Phytolacca  in  the  same  proportion  to  the  other  ingredients.  When 
the  case  requires  a  constant  prompting  of  the  action  of  the  kidneys,  bow- 


15.  grams 

3iv 

60.  c.  c. 

!ii 

15.     " 

3iv 

45.     " 

?iss 

300  KHEUMATISil. 

els  and  secretory  structures  generally,  T  think  the  phytolacca  decandra  the 
most  efficient.  But  if  the  bowels  and  secretions  are  free,  and  the  fibrous 
tissues,  including  the  cardiac  structures,  are  especially  irritable,  the 
cimicifuga  or  the  senecio  aureus  are  preferable. 

To  get  the  full  beneficial  eifects  of  either  of  these  remedies,  their  use 
must  be  continued  several  ^Yeeks.  In  cases  having  any  of  the  elements  of 
gout,  either  hereditary  or  acquired,  I  have  found  much  benefit  from  the 
administration  of  colchicum. 

The  wine  of  colchicum  root  maybe  added  in  proper  proportion  to  the  for- 
mula just  given,  or  it  may  be  given  separately  in  doses  of  one  cubic  centi- 
meter (min.  xv)  three  or  four  times  per  day.  In  cases  involving  either 
syphilitic  orgonorrhoeal  influences,  the  iodide  of  potassium  may  be  substi- 
tuted in  the  place  of  the  acetate  with  much  advantage. 

The  successful  management  of  cases  of  purely  chronic  rheumatism,  is  a 
matter  of  great  difficulty.  This  is  owing  in  part  to  the  fajt  that  a  very 
large  proiDortion  of  such  cases  occur  among  the  laboring  classes,  and  in  in- 
dividuals who  can  neither  afford  to  separate  themselves  from  further  expos- 
ure to  the  predisposing  and  exciting  c  suses  of  the  disease,  nor  be  induced 
to  adopt  such  measures,  habitually,  as  would  best  protect  them  from  the 
effects  of  such  further  exposures.  Consequently  they  generally  call  for  the 
aid  of  the  physician  only  when  they  are  suffering  some  exacerbation  of 
their  sym]3toms,  and  cease  to  heed  his  directions  as  soon  as  such  special 
exacerbation  has  passed.  When  you  are  called  to  prescribe  for  these 
chronic  cases  on  account  of  some  fresh  increase  of  the  symptoms,  I  know 
of  no  remedies  for  internal  use  that  will  be  more  likely  to  relieve 
them  than  such  as  I  have  just  mentioned  for  cases  that  are  passing 
from  a  more  acute  to  the  chronic  form.  If  the  fresh  aggravation  of 
symptoms  has  been  sufficiently  severe  to  make  the  patient  feverish,  with 
coated  tongue  and  dry  skin,  it  will  often  render  relief  more  certain  if  in 
addition  to  other  remedies,  you  give  the  first  night  five  or  six  decigrams 
(gr.  viii  or  x)  of  Dover's  powder  with  two  decigrams  (gr.  iii)  of  calomel, 
and  follow  with  a  saline  laxative  in  the  morning.  For  permanent  relief 
from  chronic  rheumatism,  we  must  aim  to  maintain,  continuously,  a 
healthy  and  natural  action  of  all  those  organs  and  structures  concerned  in 
the  work  of  eliminating  the  products  of  tissue  changes  and  other  waste 
and  foreign  material  from  the  blood.  The  means  for  doing  this  are  chief- 
Iv  hygienic  rather  than  medicinal.  To  lessen  the  effects  of  sudden  and 
severe  atmospheric  changes,  underclothes  of  flannel  or  other  non-conduct- 
ors of  heat  and  electricity  must  be  habitually  worn  next  to  the  skin; 
damp  and  uncomfortably  cold  rooms  must  be  avoided  both  during  the  day 
and  the  night;  both  physical  and  mental  exercise  should  be  as  uniform  as 
possible,  avoiding  the  extremes  of  close  confinement  on  the  one  hand, 
and  of  excessive  or  protracted  exercise  on  the  other;  the  diet  should  be 
plain,  nutritious,  sufficient  in  quantity  and  variety  to  furnish  all  the  ele- 
ments necessary  for  healthy  nutrition  and  taken  at  the  regular  meal  times; 
and  the  drinks  should  be  such  as  do  not,  either  retard  molecular  changes 
in  the  blond  and  tissues,  or  lessen  important  excretory  functions.  Good 
water,  milk  in  any  form,  and  weak  tea  and  coffee  may  be  allowed  in  any 
quantity  the  patient  may  desire.  Strong  tea  and  coffee  used  freely,  in- 
creases the  excitability  of  the  nervous  system  and  lessens  the  appetite  for 
nutritious  food,  and  had  better  be  avoided.  And  all  forms  of  alcoholic 
drinks,  whether  fermented  or  distilled,  lessen  molecular  changes  and  the 
elimination  of  excretory  material,  and  consequently  favor  the  accumula- 
tion of  such  material  in  the  blood  and  tissues.  Their  effects,  therefore, 
are  positively  detrimental  in  the  rheumatic  as  vv^ell  as  in  the  gouty  diathe- 


TREATMENT.  301 

sis.  Tn  addition  to  all  those  hyo^ienic  measures,  a  v/arm  alkaline  bath  mav 
be  taken  once  or  twice  per  week,  especially  in  such  cases  as  present  an 
unusually  dry  skin.  From  240  to  3liO  g-rams  (fviii  to  ^^ii)  of  carbonate  of 
sodium  may  be  put  into  an  ordinary  bath  tub  of  comfortably  warm  water, 
in  which  the  patient  may  remain   immersed  from  five  to  eight  minutes. 

On  rising  from  the  bath  the  water  should  be  wiped  off  with  towels,  and 
the  whole  surface  briskly  but  lightly  rubbed  with  dry,  soft  flannel,  which 
brings  a  very  pleasant  g-low  of  electric  warmth  to  the  surface,  and  greatly 
promotes  the  healthy  function  of  the  skin.  The  best  and  safest  time  for 
the  bath  is  just  before  retiring  to  bed  for  the  night.  In  some  cases  of 
long  standing,  in  which  the  bowels  are  habitually  costive,  and  the  diges- 
tion of  food  somewhat  impaired,  I  have  found  the  following  pills  capable 
of  affording  much  relief  from  the  constipation,  and  at  the  same  time,  of 
lessening  the  rheumatic  pains  and  soreness: 

5-  Ferri  Sulphatis  3.0  grams,  gr.  xlv 

Extracti  Colchici  Acetici  1.5       "         "  xxii 

Extracti  Cannabis  Indica3  1.0       "         "  xv 

Extracti  Stramonii  0.6       "         "  x 

Pulervis  Aloes  0.6      "         "  x 

Mix;  divide  into  xlv  pills,  of  which  one  maybe  given  before  each  meal- 
time until  the  bowels  become  regularly  moved  once  a  day.  Then  the 
one  before  dinner  may  be  omitted,  and  generally  one  week  later,  another 
may  be  omitted,  leaving-  but  one  pill  every  night,  which  often  proves  suf- 
ficient to  keep  the  digestive  organs  and  alimentary  canal  in  a  strictly 
regular  and  healthy  condition,  and  the  patient  comparatively  comfortable. 
In  another  class  of  cases,  you  will  find  not  only  habitual  constipation  and 
flatulency,  but  also  considerable  spanaraia  or  impoverishment  of  the 
blood,  with  cold  extremities. 

In  such,  thirteen  centigrams  (gr.  ii)  of  gum  guaiac  may  be  added  to 
each  of  the  pills  just  mentioned,  in  the  place  of  the  extract  of  colchicum. 
I  might  detail  to  you  a  gr.-at  variety  of  additional  remedies  that  have  been 
used  with  more  or  less  benefit  in  different  forms  and  stages  of  rheumatism; 
but  if  I  have  enabled  you  to  see  clearly  the  objects  to  be  accomplished,  a 
proper  knowledge  of  your  materia  medica  will  furnish  you  an  ample 
number  of  remedial  agents  from  which  to  choose.  Consequently,  I  will 
detain  you  for  only  one  further  suggestion.  In  all  cases  where  the  cir- 
cumstances of  the  patient  will  permit,  a  permanent  change  from  a  resi- 
dence in  a  cold,  damp  and  variable  climate,  to  one  that  is  mild  and  dry, 
will  be  the  surest  mode  of  obtaining  permanent  relief.  Of  course,  even 
this  will  not  restore  those  old  cases  of  chronic  deformity  from  hypertrophy 
and  induration  of  ligaments,  tendinous  adhesions,  and  atrophied  muscles; 
but  those  in  which  the  morbid  changes  are  less  structural,  or  more  recent, 
great  benefit  may  be  derived  from  the  change.  So,  where  the  rheumatic 
diathesis  is  strong,  temporarily  residing  in  a  mild  and  dry  climate  during 
the  most  wet  and  variable  parts  of  each  year,  will  often  enable  the  indi- 
vidual to  avoid  attacks  from  which  he  would  otherwise  suffer.  Mineral 
waters  containing  a  large  proportion  of  the  alkaline  carbonates,  may  also 
be  used  with  advantage  in  many  cases,  both  for  drinking  and  warm 
bathino". 


302  GOUT. 


LECTURE  XXXII. 

Gout— Its  History,  Causes,  Symptoms,  Morbid  Anatomy,  Diagnosis,  Prognosis,  Treatment  and 
Prophylaxis. 

GENTLEMEN:  The  disease  to  which  I  shall  invite  your  attention  dur- 
ing the  present  hour,  is  not  one  that  you  will  meet  often  in  the  ordi- 
nary field  of  practice  outside  of  the  older  cities  of  our  country.  Podagra, 
arthritis,  or  gout,  as  the  disease  has  been  called  by  different  writers,  is  pre- 
eminently an  affection  originatinof  in  the  midst  of  civilization  and  luxury. 
It  was  recognized  and  accurately  described  by  the  earlier  medical  writers, 
though  not  always  differentiated  from  rheumatism  with  which  it  has  some 
symptoms  in  common.  The  word  gout,  and  all  the  other  names  applied  to 
the  disease,  relate  to  an  affection  accompanied  by  deposits  in  or  about  the 
joints,  and  consequently  is  suggestive  of  a  mere  local  disease.  But  like 
rheumatism,  it  always  involves  more  or  less  alteration  of  the  properties  of 
the  tissues  generally,  in  such  a  way  as  to  give  the  individual  a  constant 
and  strong  tendency  to  develop  certain  local  morbid  phenomena  on  the 
occurrence  of  any  exciting  cause.  When  this  alteration  in  the  properties 
of  the  tissues  or  general  constitutional  condition  is  once  established,  it  is 
seldom  entirely  removed,  and  is  readily  transmitted  to  the  offspring. 

Causes. — Both  th^  predisposing  and  exciting  causes  of  gout  are  well 
understood.  The  former  consist  chiefly  of  hereditary  influence,  the  habit- 
ual use  of  rich  food,  fermented  alcoholic  drinks,  and  very  little  outdoor 
exercise.  The  coincidence  of  the  three  last  influences  without  the  first, 
if  continued  for  several  years,  is  sufficient  to  develop  the  disease  in  any 
of  its  active  forms.  But  they  will  induce  the  same  result  much  earlier 
and  more  readily  if  the  hereditary  predisposition  aleady  exists. 

The  free  use  of  meats  and  other  nutritious  articles  of  food,  requires  for 
their  proper  disposition  in  the  human  system,  a  conicident  full  supply  of 
oxygen  to  the  blood  as  it  passes  through  the  lungs,  and  an  active  state  of 
all  the  excretory  or  eliminative  functions.  You  are  all  familiar  with  the 
physiological  fact  that  all  eliminations  are  increased  by  physical  exercise 
and  diminished  by  rest.  And  no  fact  is  better  established  than  that  the 
presence  of  a  small  quantity  of  alcohol  in  the  blood,  such  as  is  supplied 
by  a  moderate  daily  use  of  beers  and  wines,  decidedly  diminishes  both 
the  oxygenation  and  decarbonization  of  the  blood  as  it  passes  the  air  cells 
of  the  lungs.  It  is  plain,  therefore,  that  if  the  supply  of  new  material 
through  the  digestive  organs  continues  abundant  while  the  supply  of  ox- 
ygen through  the  lungs  and  the  activity  of  the  excretory  processes  are 
both  diminished  by  a  daily  moderate  supply  of  alcohol  from  fermented 
drinks  and  too  little  physical  exercise,  we  shall  necessarily  have  retained 
in  the  blooJ  and  tissues  an  excess  of  materials  that  should  have  been  fur- 
ther oxidizad  and  eliminated.  The  habitual  presence  of  this  excess  of 
materials,  so  alters  the  properties  governing  the  molecular  movements,  as 
to  result  in  the  final  establishment  of  a  morbid  constitutional  condition 
or  diathesis,  and  the  development  from  time  to  time  of  the  active  local 
phenomena  of  gout. 

From  the  investigations  of  Dr.  Garrod  and  others,  it  appears  well  as- 
certained that  the  prolonged  operation  of  the  causes  I  have  just  detailed 
finally  results  in  the  accumulation,  in  the  serum  of  the  blood,  of  a  large 
excess  of  uric  acid  and  urate  of  sodium,  which  become  the  direct  exciting 
causes  of  the  local  development  of  acute  and  chronic  gout.  When  a  well 
marked  gouty  diathesis  has  been  inherited,  the  individual  may  suffer  from 


CAUSES.  303 

the  neuralgic  and  other  chronic  forms  of  gout,  without  any  personal  errors 
of  diet  or  modes  of  living;  and  even  acute  attacks  may  be  produced  in 
such  by  sedentary  habits  and  free  indulgence  at  the  table,  without  any 
use  of  alcoholic  drinks. 

But  I  doubt  whether  the  disease  is  ever  j)roduced,  de  novo^  in  persons 
having  no  previous  hereditary  tendencv,  without  the  habitual  use  of  some 
variety  of  alcoholic  drink. 

As  you  will  infer  from  what  I  have  said  concerning  the  predisposing 
causes  of  gout,  the  active  forms  of  the  disease  seldom  occur  until  near  the 
middle  period  of  adult  age.  It  is  also  much  more  frequently  met  with  in 
males  than  females.  The  disease  prevails  most  in  countries  and  commu- 
nities where  the  social  habits  of  the  people  lead  to  the  daily  moderate  use 
of  wines  and  malt  liquors,  with  comparatively  little  of  the  distilled  spirits. 
The  free  use  of  the  stronger  liquors,  as  whisky,  brandy,  rum  and  gin,  leads 
more  directly  to  functional  and  structural  diseases  of  the  stomach,  liver 
and  kidneys,  and  seldom  develops  the  gouty  diathesis.  But  the  efficiency 
of  the  fermented  drinks,  in  producing  the  disease,  appears  to  be  in  direct 
proportion  to  the  percentage  of  alcohol  they  contain.  For  a  very  inter- 
esting illustration  of  the  effects  of  social  and  hygienic  habits  on  the  pro- 
duction of  diseases,  including  all  the  varieties  of  gout,  I  refer  you  to  the 
chapter  in  one  of  the  volumes  of  "  Medical  Inquiries  and  Observations," 
by  Dr.  Benj.  Rush,  in  which  he  compares  the  social  customs  and  diseases 
pievalent  in  Philadelphia  during  the  ten  years  preceding  the  commence- 
ment of  the  War  for  Independence  in  1775,  with  those  qf  the  ten  years 
following  the  close  of  that  war  in   1782. 

Where  the  diathesis  or  constitutional  condition  already  exists,  an  acute 
attack  or  paroxysm  of  local  gouty  irritation  may  be  induced  by  a  variety 
of  temporary  exciting  causes,  as  severe  and  protracted  mental  application 
or  anxiety;  undue  physical  exercise,  or  exposure  to  cold  and  wet;  and  ex- 
cesses in  eating  and  drinking.  Working  in  contact  with  lead  is  thought 
to  favor  the  development  of  the  disease.  It  is  more  prevalent  in  the  tem- 
perate than  in  either  the  tropical  or  the  more  extreme  cold  climates.  It  is 
much  more  prevalent  in  the  older  cities  in  the  eastern  part  of  our  country 
than  in  those  of  the  western.  The  difference,  however,  is  owing  much 
more  to  the  differences  in  the  social  habits  of  the  various  communities  and 
nations  than  to  any  influence  of  climate  or  topography.  During  an  active 
practice  of  more  than  thirty  years  in  this  city  1  have  seen  but  very  few 
cases  of  gout,  except  in  persons  who  had  a  plain  hereditary  predisposition, 
or  had  brought  the  disease  with  them  from  some  older  community. 

Clinical  History  or  Symptoms. — The  cases  of  gout,  as  they  are  met  with 
by  the  physician,  may  be  grouped  for  convenience  of  description  under 
the  familiar  names  of  acute  and  chronic.  An  attack  of  acute  or  transient 
gout  is  generally  sudden,  and  often  without  warning,  although  in  many 
cases  the  patient  has  been  suffering  for  the  two  or  three  preceding  days 
from  indigestion,  flatulence,  mental  depression  or  irritability  of  temper, 
etc.  And  sometimes  an  attack  comes  as  the  direct  I'esult  of  one  or  two 
days  or  evenings  of  excessive  debauchery.  The  acute  symptoms  usually 
commence  during  the  middle  or  last  part  of  the  night,  and  consist  of  a 
severe  pain  in  some  one  of  the  joints,  most  frequently  in  the  proximal 
joint  of  one  of  the  large  toes,  coincident)}'  with  first,  slight  chilliness,  and 
subsequent  quick  development  of  general  fever.  The  skin  becomes  hot 
and  dry;  face  a  little  flushed;  tongue  often  covered  with  a  white  fur; 
some  thirst;  pulse  from  100  to  110  per  minute  and  generally  full;  urine 


304  CHEONIC    GOUT. 

scanty,  high-colored,  and  deficient  in  uiic  acid;  and  general  restless- 
ness. But  the  symptom  that  overshadows  all  others  and  occupies 
the  entire  attention  of  the  patient,  is  the  intense  aching,  gnawing 
pain  in  the  toe,  or  whatever  part  is  attacked  with  the  intlammation.  The 
articulation  affected  quickly  becomes  swollen,  red  upon  the  surface  and 
most  acutely  sensitive  to  the  touch  and  to  the  slightest  motion.  In  the 
more  acute  and  severe  cases  to  which  1  am  now  alluding,  both  the  local 
pain  and  general  fever  reach  their  highest  intensity,  in  from  two  to  four 
hours.  After  remaining  nearly  stationary  for  one  or  two  hours  more,  they 
begin  to  decline.  The  patient  becomes  less  restless,  and  sometimes  has 
short  intervals  of  sleep;  and  in  from  two  to  four  hours  more  his  fever  and 
severe  pains  have  disappeared,  leaving  him  feeling  weak  and  weary,  with 
a  continuance  of  the  swelling,  redness,  and  tenderness  of  the  toe,  but  with 
little  continuous  pain.  From  this  description  you  will  see  that  an  ordina- 
ry paroxysm  may  last  from  six  to  twelve  or  eighteen  hours.  On  its  sub- 
sidence the  skin  may  become  moist,  the  urinary  secretion  abundant,  fol- 
lowed by  a  rapid  diminution  of  both  swelling  and  tenderness,  and  in  two 
or  three    days  the  patient  appears  as  well  as  usual. 

In  a  large  proportion  of  cases,  however,  the  subsidence  of  the  active 
sympt^oms  proves  only  a  remission  which  continues  until  the  middle  of 
the  follo\Ving  night,  when  another  exacerbation  begins,  and  presents  the 
same  symptoms,  both  local  and  general,  as  in  the  first.  The  paroxysms  may 
continue  thus  to  return  every  night,  for  a  week  or  even  longer,  and  in  the 
meantime  the  local  inflammation  may  have  extended  to  all  the  articula- 
tions of  the  toes  and  sometimes  to  the  ankle,  or  even  to  the  articulations  of 
the  fingers  and  hands.  In  such  protracted  attacks,  the  patient  becomes 
much  more  debilitated,  the  swelling  and  tenderness  of  the  inflamed  ar- 
ticulations, subside  slower  and  less  perfectly,  with  much  more  tendency 
to  pass  into  the  chronic  form.  Yet  many  of  these  more  severe  and  pro- 
tracted attacks  are  recovered  from  so  perfectly  that  in  two  or  three  weeks 
the  patient  feels  more  buoyant  and  in  better  health  than  for  sometime  be- 
fore the  attack.  But  the  susceptibility  of  the  system  to  the  disease  in- 
creases with  every  new  paroxysm,  until  such  patients  as  have  suffered 
several  attacks,  become  subject  to  their  recurrence  from  the  slightest 
causes. 

In  some  cases  the  attacks  are  characterized  by  the  same  local  pains,  swell- 
ing, redness  and  extreme  tenderness  that  I  have  described,  but  with  much 
less  general  fever.  These  have  been  classed  by  some  writers  as  subacute 
gout.  In  some  cases  of  both  acute  and  subacute  attacks,  the  inflamma- 
tion, after  progressing  a  short  time  in  the  usual  articulations,  suddenly  re- 
cedes, and  is  immediately  manifested  in  some  one  of  the  internal  organs, 
as  the  stomach,  lungs,  heart  or  brain;  and  with  the  rapid  development  of 
all  the  usual  symptoms  of  acute  inflammation  of  the  organ  attacked. 
Such  cases  are  called  retrocedent^  or  misplaced  gout,  and  are  very  danger- 
ous to  the  life  of  the  patient.  Happily,  they  are  not  of  very  frequent  oc- 
currence. 

Chronic  Gout. — The  greater  number  of  cases  of  chronic  gout  are  the 
sequelae  of  acute  attacks,  and  their  local  manifestations  are  of  an  inflamma- 
tory character.  But  more  rarely  cases  are  met  with  in  persons  of  both 
sexes,  which  are  characterized  by  periods  of  extreme  pain  without  accom- 
panying inflammation,  and  without  having  been  preceded  by  any  acute 
inflammatory  attacks.  These  cases  are  usually  classed  as  neuralgic  gout, 
and  are  probably  met  with  only  in  persons  having  a  strong  hereditary  pre- 
disposition. When  after  repeated  attacks  of  acute  arthritic  inflammation, 
the  affected  articulations  remain  constantly  more  or  less  swollen,  purplish- 


SYMPTOMS.  305 

red,  tender  to  pressure,  stiifened,  and  painful  when  motion  is  attempted, 
but  without  general  fever,  the  disease  is  said  to  have  assumed  a  chronic 
form;  and  may  continue  thus  during  the  remainder  of  the  patient's  life. 
Such  cases  are  subject  to  frequent  temporary  periods  of  increased  activity 
with  marked  aggravation  of  the  suffering  of  the  patient;  sometimes  from 
atmospheric  changes,  but  more  frequently  from  excesses  in  mental  or 
physical  labor  and  errors  in  diet  and  drink.  Unless  great  care  is  exercised 
in  avoiding  all  the  causes  that  tend  to  increase  the  disease,  the  tendency 
of  chronic  cases  is.  to  gradually  increase,  both  in  the  local  developments 
and  in  the  general  impairment  of  health.  The  affected  articulations  be- 
come slowly  increased  in  size,  the  tissues  more  indurated,  and  the  joints 
less  movable.  This  is  owing  in  part  to  the  sclerosis,  or  hypertrophy  of  the 
inflamed  fibrous  tissue  composing  the  ligaments,  synovial  membranes, 
and  connective  tissues  belonging  to  the  affected  articulations,  and  partly 
to  the  deposit  of  urate  of  sodium,  calcium,  etc.,  both  into  the  cavity  of  the 
joints  and  into  the  surrounding  tissues.  In  some  cases  of  long  duration, 
these  deposits  become  so  large  as  to  cause,  by  their  pressure,  the  absorp- 
tion of  the  soft  parts  covering  them  and  the  protrusion  of  naked  inorganic 
crusts  at  the  most  prominent  part  of  the  articulations. 

While  such  external  local  changes  are  taking  place  from  year  to  year, 
there  are  progressive  internal  changes  of  no  less  importance,  that  should 
receive  your  attention.  In  most  cases  the  functions  of  digestion  and 
assimilation  become  more  impaired,  as  indicated  by  gaseous  eructations, 
frequent  turns  of  gastric  acidity,  and  alternations  of  constipation  and  diar- 
rhoea, with  progressive  impoverishment  of  the  red  corpuscles  of  the  blood. 
The  urine  becomes  habitually  scanty,  and  sometimes  albuminous;  the  feet 
and  ankles  begin  to  show  some  oedematous  infiltration  while  dependent 
during  the  day;  a  little  exertion  causes  shortness  of  breath,  palpitations, 
and  sometimes  faintness;  and  finally  general  dropsy  supervenes,  and  the 
patient  approaches  near  to  the  end  of  life.  The  final  result  may  be 
reached  in  various  ways.  In  some  cases  the  general  dropsical  infiltrations 
simply  continue  to  increase,  with  corresponding  diminution  of  the  urinarv 
secretion;  the  mind  becomes  dull  and  somnolent;  the  breathing  heavy 
and  slow;  pulse  soft,  irregular  or  intermitting;  the  whole  exterior  of  face, 
body,  and  extremities  much  bloated  from  the  dropsical  infiltrations;  finally, 
muscular  twitchings,  cold  extremities,  suppression  of  urine,  irregular  and 
stertorous  respiration,  entire  coma  and  death  supervene.  In  some  cases, 
either  from  fatty  degeneration  or  overwhelming  pericardial  effusion,  death 
takes  place  more  suddenly  from  failure  of  the  heart's  action.  Or  from  a 
similar  fatty  degeneration  of  the  coats  of  the  arteries  of  the  brain,  some 
weakened  vessel  gives  way,  allowing  hgemorrhagic  exudation  or  extravasa- 
tion into  the  texture  of  the  brain,  and  death  by  apoplexy  or  paralysis.  In 
still  other  cases  respiration  is  overwhelmed  either  by  pulmonary  oedema  or 
pleuritic  effusion.  Such  is  a  very  brief  description  of  the  general  course 
and  terminations  of  chronic  arthritic  gout,  when  it  proceeds  to  its  own 
legitimate  results.  But  patients  subject  to  chronic  gout,  are  more  or  less 
prone  to  intercurrent  attacks  of  acute  inflammation  of  important  organs 
which  often  prove  fatal  before  the  gouty  disease  has  reached  the  ultimate 
changes  I  have  just  described. 

Pneumonia,  pleurisy,  endo-  and  pericarditis,  gastro-enteritis,  and  acute 
and  chronic  nephritis  are  among  the  most  common  intercurrent  inflamma- 
tory affections  to  which  gouty  patients  are  subject. 

The  neuralgic  form  of  chronic  gout  is  less  uniform  in  its  characteristics, 
and  more  difficult  to  distinguish  from  other  forms  of  neuralgia.  It  is  usual- 
ly characterized  by  the  sudden  attack  of  very  severe  pain  in  some  partlcu- 
20 


306  GOL'T. 

lar  part,  without  any  premonition  or  warning,  its  unremitting  continuance 
from  one  to  six  or  eight  hours  without  general  febrile  disturbance,  and 
leaving  the  part  without  swelling  or  other  visible  changes.  In  some  cases 
the  patient  endures  but  a  single  paroxysm  of  the  pain;  and  in  others  it 
recurs  at  intervals  of  a  few  hours  for  several  days  in  succession. 

The  locations  most  frequently  the  seat  of  pain,  are  the  same  as  those 
most  frequently  attacked  by  inflammation  in  the  acute  form  of  the  disease, 
namely  ttie  articulations  of  the  toes  and  feet,  those  of  the  hands,  and  the 
stomach.  One  of  the  best  characterized  cases  that  has  come  under  my 
observation,  was  that  of  a  well-educated  lady  of  most  correct  habits  of 
life,  but  whose  ancestors,  through  two  or  three  generations,  had  suffered 
severely  from  gout.  For  several  years  she  had  been  attacked  two  or  three 
times  a  year,  with  the  most  excruciating  pain  in  the  proximal  joint  of  the 
great  toe.  It  usually  came  suddenly,  without  warning,  and  so  severe  as 
to  render  her  entirely  helpless  while  it  lasted,  which  was  usually  six  or 
eio-ht  hours,  unless  sooner  relieved  by  remedies.  The  first  occasion  of  my 
seeino-  her,  she  had  been  attacked  with  the  pain  while  on  the  street,  and 
had  been  obliged  to  have  a  carriage  called  to  take  her  home.  I  recollect 
only  three  cases  in  which  the  epigastrium  was  the  seat  of  pain.  Two  were 
males,  and  one  a  female  of  sedentary  habits;  and  all  belonged  to  families 
in  which  the  hereditary  gouty  diathesis  was  strongly  marked. 

Morbid  Anatomy. — Tlie  changes  that  take  place  in  the  fluids  and  solids 
of  the  body  in  connection  with  gout,  have  been  investigated  with  much 
care.  The  earliest  and  most  marked  change  in  the  blood  is  the  decided 
increase  of  uric  acid  and  uric  acid  salts,  particularly  the  urate 
of  sodium.  The  existence  of  this  excess  of  uric  acid  as  a  character- 
istic condition  of  the  blood  in  acute  gout  was  perhaps  first  suggested 
bv  Murray  Forbes,  but  not  fully  proved  until  the  more  valuable 
investigations  of  D  ■.  Garrod,  published  in  1854.  As  the  disease  progresses, 
the  red  corpuscles  and  the  albumen  both  fall  below  the  natural  proportion, 
■while  the  fibrin  is  increased.  For  a  few  days  before,  and  during  the  early 
:stage  of,  an  attack  of  gout,  the  urine  has  been  found  to  contain  less  than 
its  natural  proportion  of  uric  acid,  and  in  some  instances  an  increase  of  the 
phosphoric.  In  the  structures  constituting  the  seat  of  the  local  inflamma- 
tions in  all  stages  of  gout,  there  has  constantly  been  found  more  or  less 
depositio!!  of  urate  of  sodium,  both  in  the  form  of  acicular  crystals  and 
of  granules.  In  recent  cases  these  deposits  appear  in  white  lines  or  layers 
on  the  articular  surfaces,  and  in  the  ligamentous  and  other  tissues  sur- 
rounding the  affected  joints.  In  older  cases  they  accumulate  in  thicker 
layers  or  masses  called  tophi  or  concretions;  and  in  such  they  are  also 
found  in  many  other  parts  of  the  body,  more  especially  in  the  tubules  of 
-the  kidneys,  the  sheaths  of  tendons  and  nerves,  and  in  the  membranes  of 
the  spinal  cord.  When  the  tophi  or  concretions  in  and  about  the  joints 
become  large,  they  usually  contain,  besides  the  urate  of  sodium,  urates  of 
mao-nesium  and  calcium,  with  more  or  less  of  the  carbonate  and  phosphate 
of  calcium. 

In  many  cases  of  long  standing,  the  structure  of  the  kidneys  not  only 
contains  the  uric  acid  deposits,  but  it  has  undergone  more  or  less  granular 
deo-eneration  and  atrophy,  givmg  it  the  appearance  of  the  small  granular 
ikidney  of  Bright's  disease,  and  constituting  the  gouty  kidney.,  of  Dr. 
Todd.  Waxv  degeneration  of  the  renal  structure  has  also  been  observed 
in  some  cases;  and  in  some,  fatty  and  atheromatous  changes  have  been 
found  in  the  heart  and  in  the  coats  of  many  of  the  arteries.  The  special 
pathology  of  acute  and  chronic  gout  is  sufficiently  indicated  in  the  com- 
ments I  have  made  on  the  causes,  and  morbid  anatomy  of  the  disease. 


DIAGNOSIS.  307 

Diagnosis. — The  only  diseases  with  which  gout  is  liable  to  be  con- 
founded are  rheumatism,  neuralgia,  and  rheumatoid  arthritis. 

The  difficulty  chiefly  relates  to  the  earlier  attacks  of  acute  articular 
g-out.  Ifyoukeepin  mind  the  facts  that  this  variety  of  gout  seldom 
occurs  before  thirty  years  of  age,  that  it  almost  always  attacks  the  small 
articulations  of  the  extremities  and  very  generally,  first  the  proximal  or 
metatarso-phalangeal  joint  of  the  great  toe;  that  the  pain  is  much  more  in- 
tense and  aggravating,  compared  \yith  the  general  febrile  disturbance; 
that  the  tenderness  is  more  acute  and  the  redness  deeper;  and  finally, 
tliat  the  patient's  habits  of  life  and  perhaps  hereditary  predisposition,  have 
been  entirely  different  from  those  favoring  the  develop,ment  of  rheuma- 
tism, you  will  find  but  little  difficulty  in  arriving  at  a  correct  diagnosis  at 
once.  If  there  remain  doubts,  however,  you  can  obtain  eight  or  ten  cubic 
centimeters  (fl  3ii  or  3iiss)  of  the  serum  of  the  blood,  either  by  scarifying 
and  cupping,  or  by  a  blister,  and  apply  to  it  any  of  the  well-known  tests 
for  detecting  uric  acid  or  urate  of  sodium,  the  presence  of  which  would 
confirm  the  diagnosis  of  gout.  In  chronic  cases  of  articular  gout,  the 
simple  clinical  history  of  each  case,  with  due  attention  to  the  present 
condition  of  the  affected  articulations,  will  be  sufficient  to  establish  a 
proper  diagnosis.  In  neuralgic  gout  the  diagnosis  must  be  determined 
mainly  by  the  intensity  and  location  of  the  pain,  the  time  and 
manner  of  its  recurrence,  and  the  hereditary  tendencies  of  the  patient.  Its 
diflferentiRtion  from  rheumatoid  arthritis  will  be  more  appropriate  after  I 
have  described  that  form  of  disease. 

Prognosis. — Except  in  the  cases  of  retrocedent  gout,  in  which  some 
important  internal  organ  has  become  the  seat  of  the  gouty  inflammation, 
there  is  but  little  danger  of  a  fatal  result  during  the  acute  stao-e  of  the  dis- 
ease. Yet  the  gouty  diathesis  is  seldom  wholly  removed  by  any  method 
of  treatment  that  has  been  devised;  and  when  the  local  inflammations  have 
recurred  many  times,  they  are  almost  certain  to  induce  a  sufficient  degree 
of  structural  changes  in  the  kidneys  and  other  important  organs,  to  materi- 
ally shorten  the  duration  of  life. 

Treatment . — A  proper  knowledge  of  the  causes  and  pathology  of  gout 
will  suggest  three  distinct  and  important  objects  to  be  accomplished  in 
its  treatment;  namely,  the  removal  of  the  special  exciting  cause,  supposed 
to  be  an  excess  of  uric  acid  and  urates,  from  the  system;  the  alleviation  oc 
the  intense  suffering;  and  the  prevention  of  the  re-accumulation  of  the 
exciting  cause  for  the  purpose  of  avoiding  a  relapse  or  a  new  attack. 
The  first  of  these  objects  may  be  accomplished  by  remedies  that  either 
neutralize  the  action  of  the  uric  acid  and  urate  of  sodium  bv  forming  new- 
compounds  with  them,  which  are  either  harmless  or  more  readily  elimi- 
nated through  the  natural  channels  of  excretion,  or  by  such  as  rapidly  di- 
minish their  formation  on  the  one  hand,  and  increase  their  elimination  by 
causing  increased  action  of  the  skin  and  kidneys  on  the  other.  The  par- 
ticular remedies  that  have  been  found  by  clinical  experience  to  act  most 
efficiently  in  the  first  direction,  are  the  bicarbonate  of  potassium,  carbonate, 
bromide  and  citrate  of  lithium,  and  phosphate  of  ammonium;  while  of  those 
that  act  in  the  second  direction,  colchicum  stands  pre-eminent,  having 
maintained  its  reputation  undiminished  from  the  earliest  records  of  medi- 
cine in  Greece  and  Rome  to  the  present  time.  Recently  jaborandi,  from 
its  known  efficacy  in  producing  copious  diaphoresis,  has  been  used  in  some 
cases  and  with  decided  advantage.  To  fulfill  the  second  indication,  by 
temporarily  mitigating  the  intensity  of  the  pain,  the  preparations  of  opi- 
um, especially  when  given  in  connection  with  colchicum,  are  by  far  the 
most  effioientth.it  we  can  use.     Soriii  effect  miy  be  produced  by  the  use 


308  GOUT. 

of  chloroform,  hyoscyamus.  belladonna,  and  aconite;  but  they  are  mnch 
less  reliable  than  the  opiates.  The  same  may  be  said  of  the  chloral  hy- 
drate and  the  bromides. 

In  the  limited  number  of  cases  to  which  I  have  been  called  during  the 
active  paroxysms  of  acute  or  subacute  gout,  I  have  given  promptly  a 
combination  of  the  wine  of  coichicum  root,  two  parts,  and  the  acetated 
tincture  of  opium  one  part,  in  doses  of  two  or  three  cubic  centimeters, 
(min.  XXX  or  xlv)  repeated,  at  first,  in  one  or  two  hours  until  the  pain  and 
fever  abated  and  then  at  longer  intervals  until  the  paroxysm  had  wholly 
subsided.  In  none  of  the  cases  coming  under  my  own  observation,  has  this 
combination  failed  to  afford  speedy  and  satisfactory  relief  from  all  the 
more  active  symptoms.  There  are  cases,  however,  in  which  the  opiates 
are  promptly  rejected  by  the  stomach,  or  soon  create  much  nausea  and  de- 
pression. In  such  cases  I  would  substitute  the  bromide  of  liihium  in  the 
place  of  the  opiate,  in  combination  with  coichicum.  One  of  the  benefits 
of  combining  an  opiate  with  the  coichicum,  in  addition  to  its  effeot  in  re- 
lieving pain,  is  the  lessening  of  the  tendency  of  full  doses  of  the  latter  to 
operate  harshly  on  the  bowels  before  its  specific  effects  are  obtained  in 
checking  the  production  of  uric  acid  and  promoting  its  elimination. 
When  it  is  found  that  the  acute  paroxysm  has  supervened  while  the  bow- 
els were  constipated  or  inactive,  the  tongue  coated,  and  skin  hot  and  dry, 
much  benefit  may  be  derived  by  giving  at  once  five  decigrams  (gr.  vLH) 
of  calomel  and  following  it  in  ti  ree  or  four  hours  by  sufficient  Rochelle 
salts  to  cause  two  or  three  free  evacuations  from  the  bowels.  This,  how- 
ever, should  not  prevent  or  delay  the  use  of  the  coichicum  and  opiate  as 
already  described. 

Recently  some  cases  have  been  reported,  in  which  liberal  doses  of  the 
salicylates  have  been  given,  and  ajjparently  with  prompt  and  satisfactory 
relief.  If  given  in  this  disease,  the  salicylate  of  potassium  is  preferable 
to  that  of  sodium,  as  the  latter  already  exists  in  excess  in  combination 
with  the  uric  acid,  both  in  the  bio  'd  and  the  inflamed  tissues.  When  the 
acute  paroxysm  has  been  fairly  relieved  and  the  patient  restored  to  a  com- 
paratively comfortable  condition,  then,  the  means  for  fulfilling  the  third 
indication  should  be  resorted  to  without  unnecessary  delay,  in  the  hope  of 
preventing  the  re-accumulation  of  the  uric  acid  and  urates  in  sufficient 
quantity  to  produce  another  paroxysm.  This  cannot  be  accomplished  by 
any  kind  or  amount  of  medication  alone.  Moderate  doses  of  the  wine  of 
coichicum  may  be  continued  three  times  a  day,  either  by  itself  or  com- 
bined with  the  bromide  or  citrate  of  lithium,  until  the  change  in  the  diet, 
drinks,  and  exercise  of  the  patient  has  had  time  to  re-establish  a  healthy 
condition  of  the  nutritive  and  excretory  functions  of  the  whole  system. 
Particular  attention  should  be  given  to  the  condition  of  the  digestive  or- 
gans, both  in  regard  to  the  functions  of  the  stomach  and  the  regular  evac- 
uation of  the  bowels.  If  the  food  lies  heavy,  feeling  like  a  load  or  weight 
in  the  stomach  and  the  bowels  are  costive,  you  may  know  that  there  is 
both  deficiency  in  the  gastric  secretions  and  in  the  peristaltic  motion  of 
the  bowels.  Some  combination  of  a  tonic  and  laxative  will  be  needed  for 
correcting  these  deficiencies.  Perhaps  none  can  be  made  better  adapted 
to  this  purpose  than  the  following: 

I^      Extracti  Hj^oscyami  2.0  grams  gr.  xxx. 

Ferri  Sulphatis"'  2.0       "  "       " 

Extracti  Colocynthidis  2.0       "  "       " 

"  Nucis    VomicjE  0.6       "  "      x. 

Pilulge  Hydrargyri  0.6       «  «      " 


TilEATMENT.  309 

Mix,  Divide  into  tliirty  pills,  one  oT  which  may  be  taken  each  night,  or 
each  night  and  morning-,  as  found  necessary  to  secure  one  reg-ular  evacu- 
ation each  day.  But  wiiatever  may  be  the  kind  oi"  medicine  administered, 
no  permanent  relief  will  be  obtained  unless  a  judicious  and  persistent  reg- 
ulation of  the  diet,  drinks,  and  exercise  of  the  patient  accompanies  and 
follows  it.  The  diet  should  consist  chieily  of  milk,  farinaceous  articles, 
vegetables  and  fruit,  with  meat  only  sparingly.  Tea  and  coffee  may  be 
used  moderately,  but  alcoholic  drinks  of  every  kind,  whether  fermented 
or  distilled,  should  be  entirely  excluded  from  use.  You  will  see  it  stated 
l)y  authors  of  deservedly  high  reputation  that  the  loeaker  wines  and  small 
quantities  of  gin  may  be  allowed,  especially  to  patients  who  have  long 
been  habituated  to  their  use,  or  have  become  much  debilitated.  With 
all  proper  deference  to  the  opinions  of  others,  I  must  caution  you  against 
such  statements  as  conveying  an  important  error.  They  are  founded  on 
the  idea  that  alcohol  in  small  quantities  in  the  forms  mentioned,  helps  to 
sustain  the  strength  and  nutrition  of  patients  already  habituated  to  their 
use  and  debilitated  by  attacks  of  gout  or  other  forms  of  disease.  From 
many  years  of  observation  and  direct  professional  management  of  patients 
accustomed  to  the  use  of  alcoholic  drinks  both  in  hospital  and  private  prac- 
tice, I  am  satisfied  that  no  form  of  those  drinks  can  be  made  to  act  as  a 
tonic  or  as  a  promoter  of  healthy  nutrition.  I  have  never  known  a  pa- 
tient injured,  or  a  life  endangered,  by  stopping  their  use  too  suddenly,  or 
abstaining  from  them  too  persistently.  But  I  have  known  very  many  to  be 
injured  and  finally  lost,  by  persisting  in  the  effort  to  use  them  moJerately. 
And  the  sooner  a  patient,  predisposed  to  attacks  of  gout,  omits  entirely  the 
use  of  all  fermented  or  distilled  drinks,  the  more  readily  will  he  make 
genuine  progress  in  removing  such  predisposition,  and  in  securing  perma- 
nent exemption  from  new  attacks. 

Another  item  of  great  importance  in  the  management  of  these  cases,  is 
the  proper  regulation  of  the  patient's  exercise,  both  mental  and  physical. 
Whenever  the  patient  is  sufficiently  free  from  acute  symptoms  to  get  out 
of  the  house,  it  is  desirable  that  the  mind  should  be  occupied  if  possible  bv  a 
few  hours  of  daily  attention  to  some  light,  cheerful  business,  that  will  serve 
to  divert  attention  from  himself  and  promote  habitual  action  of  the  men- 
tal faculties.  But  all  business  involving  protracted  and  severe  mental  ap- 
plication, anxiety  or  depression,  should  be  avoided,  so  far  as  circumstances 
will  permit.  A  certain  amount  of  physical  exercise  in  the  open  air  is 
oi  paramount  importance.  Riding,  either  in  an  open  carriage  or  on  horseback, 
walking  when  the  joints  will  permit,  or  even  engaging  lightly  in  physical 
sports,  should  be  resorted  to  daily,  with  as  much  regularity  as  in  eating  or 
sleeping.  When  these  regulations  cannot  be  secured  at  home,  the  patient 
should  be  encouraged  to  travel  in  mild  climates,  or  visit  and  use  those 
mineral  springs,  either  in  this  country  or  in  Europe,  the  waters  of  wdiich 
promote  habitually  increased  elimination  of  effete  matter  through  the 
urinary  and  cutaneous  stiuctures. 

The  remedies,  hygienic  and  medical,  that  1  have  mentioned  as  best  cal- 
culated to  prevent  a  repetition  of  acute  attacks,  are  equally  applicable  in 
the  treatment  of  all  grades  of  chronic  gout.  When  the  latter  form  of  the 
disease  has  been  of  long  standing  and  the  blood  is  much  impoverished  of 
its  red  corpuscles,  with  perhaps  some  oedema  of  the  lower  extremities,  a 
moderate  dose  of  citrate  of  iron  and  quinine  taken  after  each  meal-time, 
mav  be  found  beneficial,  as  an  aid  to  other  remedies. 

When  general  dropsy  has  supervened  accompanied  by  scanty  arid  albu- 
niinous  urine,  it  very  generally  indicates  such  a  degree  of  structural  change 
in  the  kidneys  as    to  render  the  prognosis  altogether  unfavorable.     Palli- 


BIO  AETHRITIS    DEFOEMAN-S. 

ation  of  symptoms  and  a  rational  effort  to  render  the  patient  as  comforta- 
ble as  possible,  will  constitute  the  chief  objects  of  treatment  in  such  cases. 
When  acute  gout  is  misplaced  or  retrocedent,  attacking  important  internal 
organs,  it  must  be  treated  on  the  same  principles,  and,  so  far  as  the  func- 
tions of  the  organ  attacked  will  permit,  by  the  same  remedies,  as  in  ordi- 
nary acute  cases. 

You  will  occasionally  meet  with  cases  presenting  an  intermixture  of  the 
symptoms  of  gout  and  rheumatism;  or  with  cases  of  rheumatism  engrafted 
upon  an  inherited  gouty  constitution.  Nearly  all  such  cases  can  be  most 
readily  relieved  by  the  judicious  use  of  the  salicylate  of  sodium,  combined 
with  the  wine  of  colchicum,  or  by  a  combination  of  the  bromide  of  lithium 
with  the  alkaline  carbonates,  in  conjunction  with  warm  alkaline  baths,  and 
the  same  hygienic  regulations  as  in  similar  grades  of  unmixed  gout. 

ARTHRITIS  DEFORMANS. 

This  may  be  as  convenient  a  time  as  will  be  likely  to  occur  for  saying  a 
few  words  in  relation  to  a  disease  called  by  some  writers  arthritis  deform- 
ans, and  by  others  rheumatoid  arthritis;  although  it  is  doubtful  whether  it 
has  any  of  the  elements  of  gout  in  its  nature.  It  occurs  more  frequently 
in  women  than  in  men,  and  chiefly  in  subjects  who  have  been  much  ex- 
posed to  physical  hardship  and  mental  cares  or  anxiety.  It  seldom 
occurs  in  childhood  or  youth,  but  is  most  frequent  from  the  middle  period 
of  adult  life  to  old  age.  It  usually  attacks  first  the  larger  joints,  as  the 
hip,  knee,  shoulder,  and  elbow,  and  extends  subsequently  to  the  smaller 
joints  of  the  hands  and  feet.  It  does  not  attack  many  articulations  at  the 
same  time,  but  commences  in  parallel  joints  on  each  side  and  extends 
symmetrically  from  one  pair  of  joints  to  another  progressively,  until  in  some 
cases  it  has  involved  nearly  all  the  articulations  in  both  body  and  extrem- 
ities, and  rendered  the  patients  utterly  helpless.  The  joints,  when  first 
attacked,  present  much  the  appearance  of  subacute  rheumatism,  being 
moderately  swollen,  tender,  painful,  especially  on  attempting  motion,  but 
with  little  or  no  general  fever.  In  the  early  stage  effusion  of  serum  some- 
times takes  place  into  the  synovial  membrane,  uicreasing  for  a  time  the 
size  and  shape  of  the  joints.  This  subsequently  disappears  and  the  syno- 
vial membranes  generally  become  unnaturally  dry  and  the  joints  stiff,  or 
creaking  from  friction  on  motion.  The  pain  is  dull,  aching  in  character, 
and  increased  by  attempts  to  move  the  affected  parts.  Slowly  those  parts 
of  the  cartilages  covering  the  articular  surfaces  of  the  bones  that  are  sub- 
ject to  direct  pressure,  become  absorbed;  sometimes  to  such  an  extent  as 
to  leave  the  surfaces  of  the  bones  naked  in  contact  with  each  other.  At 
the  same  time  the  edges  of  the  cartilages  become  thickened  irregularly, 
presenting  hard  nodules.  The  same  thickening  and  induration  take  place 
in  portions  of  the  synovial  membranes,  periosteum  and  ligaments,  making 
the  joints  appear  large  and  irregular  in  shape.  Occasionally  a  hard 
nodule  will  be  formed  in  the  mere  projecting  fringe  that  often  appears  on 
the  edges  of  the  articular  cartilages,  and  will  become  detached  and  form 
a  loose  or  floating  cartilage  in  the  joint.  All  these  changes  appear  to 
consist  of  an  increase  or  proliferation  of  the  natural  histological  elements 
of  the  cartilaginous  and  fibrous  tissues.  In  some  cases  phosphate  of  calcium 
or  bony  matter  has  been  found  in  the  more  prominent  nodules,  but  never 
the  urates  or  chalky  materials  conui-on  to  gout.  Neither  has  there  been 
found  an  excess  of  uric  acid  or  urates  in  the  blood  of  this  class  of  pa- 
tients. The  changes  I  have  described  often  cause  much  deformity 
especially    in     old    people.     The    fingers    and    toes    not    only    become 


TREATMENT.  311 

stiff,  but  turned  in  various  directions,  the  former  chiefly  toward  the 
ulnar,  and  the  latter  toward  the  fibular  side  of  the  extremities. 
In  a  large  proportion  of  the  cases  the  muscles  undergo  more  or  lesa 
atrophy,  and  the  patients  become  pale  and  thin,  though  retaining  a  good 
appetite  and  fair  digestion.  Indeed  there  appears  to  be  little  or  no  tend- 
ency in  this  class  of  cases,  to  disease  of  either  the  cardiac,  pulmonary, 
or  digestive  organs;  and  we  consequently  find  the  patients  with  the  func- 
tions of  all  these  organs  well  performed,  who  have  been  entirely  helpless 
for  vears,  from  the  progressive  and  persistent  morbid  changes  in  the  or- 
gans of  locomotion.  It  is  only  a  few  days  since  I  saw  in  ihe  north  part 
of  the  city,  a  woman  about  fifty  years  of  age,  mother  of  a  large  family, 
who  had  lain  in  the  condition  just  described  between  five  and  six  years. 
Not  one  of  her  limbs  could  be  straightened  or  moved  sufficient!}'  to  get 
the  bottom  of  a  foot  to  the  floor  or  a  hand  to  her  head. 

The  special  pathology  of  this  class  of  cases  is  not  well  understood. 
That  it  is  essentially  different  from  either  rheumatism  or  gout,  is  evident, 
both  from  their  clinical  history,  and  the  nature  of  the  structural  changes 
developed  during  their  progress.  That  the  disease  consists  of  a  morbid 
increase  of  that  property  of  the  structures  involved,  which  I  have  called 
susceptibility  or  irritability  with  a  perversion  of  the  affinity  governing 
the  movement  of  atoms,  the  symptoms  and  structural  changes  plainly  show. 
But  whether  this  alteration  of  the  properties  of  the  tissues  results  from 
the  presence  of  some  retained  morbid  material,  as  in  rheumatism  and  gout, 
or  from  alterations  in  the  supply  of  blood,  through  disturbance  of  the 
vasomotor  or  trophic-nerve  function,  cannot  be  definitely  determined 
without  further  investigation.  Many  years  since,  Dr.  J.  K.  Mitchell,  of 
Philadelphia,  claimed  that  the  primary  seat  of  morbid  action  in  articular 
vheumatism,  and  other  affections  of  the  joints,  was  in  the  spinal  cord. 
And  several  of  the  eminent  neurologists  of  the  present  time  confidently 
claim  that  arthritis  deformans,  as  well  as  progressive  muscular  atrophy,  is 
the  result  of  disease  in  what  they  term  the  trophic  nerve  tract  or  center  in 
the  lateral  columns  of  the  spinal  cord. 

Treatment . — Whatever  may  be  the  theories  we  adopt  in  regard  to  the 
essential  pathology  of  the  disease  under  consideration,  it  is  certain  that 
the  remedies  which  have  been  found  most  efficacious  in  the  treatment  of 
rheumatism  and  gout,  have  no  influence  in  controlling  its  progress.  The 
cases  that  have  come  under  my  own  observation,  have  been  most  bene- 
fited by  much  rest  in  a  horizontal  position;  the  application,  for  ten  or  fif- 
teen minutes  each  day,  of  gentle  currents  of  electricity,  accompanied  hi 
light  friction  over  the  diseased  articulations  and  the  muscles  connected 
with  them;  the  use  of  a  fair  variety  of  plain  nutritious  food,  allowing  tea 
and  coffee  only  moderately,  and  entirely  prohibiting  alcoholic  drinks  both 
fermented  and  distilled,  and  tobacco;  and  the  administration  of  a  combi- 
nation of  iodide  of  calcium,  oxide  of  calcium,  and  stramonium,  as  in  the 
following  formula: 

5,     Syrupi  Calcii  lodidi  130.0  c.  c.         |iv 

Svrupi  Calcii  Oxydi  60.0    "  fii  , 

Tincturae  Stramonii  15.0    "  |ss 

Mix.  Shake  the  vial,  and  give  to  an  adult  four  cubic  centimeters  (fl  3i) 
each  morning,  noon,  tea-time,  and  bed-time,  in  a  tablespoonful  of  water. 
Mv  observatTons  have  led  me  to  think  that  if  the  disease  should  be  cor- 
rectly diagnosticated  in  its  early  stage,  and  the  plan  of  treatment  I  have 
suo-o-ested,  adopted  and  faithfully  executed   for  two    or    three    months,  a 


312  AETHEITIS    DEFORM AXS. 

large  proportion  of  the  pat'ents  would  recover.  Unfortunately,  how- 
ever, a  larp;e  proportion  of  the  cases  are  either  neglected  or  treated  as 
chronic  rheumatism,  until  the  structural  changes  have  become  too  extensive 
to  admit  of  repair  or  recovery. 

I  have  now  completed  the  consideration  of  all  those  diseases  which  I 
had  classed  under  the  head  of  constitutional  affections,  so  far  as  they  come 
under  the  care  of  the  physician,  andvpill  be  ready  at  the  next  lecture  hour, 
to  enter  upon  the  consideration  of  the  great  class  of  locals  as  distinguish- 
ed from  acute  and  chronic  general  diseases. 


LOCAL   DISEASES. 
LECTURE    XXXIII. 

General  Remarks— Inflammation— Its  Nature,  Varieties,  Anatomical  Changes  or  ResuKs,  and  the 
Principles  involved  in  its  Treatment. 

GENTLEMEN  :  Having  in  the  preceding  lecture  completed  the  con- 
sideration of  the  first  great  class  of  human  maladies,  embracing  the 
acute  and  chronic  general  diseases,  I  now  invite  your  attention  to  the  sec- 
and  class,  which  embraces  all  the  remaining  forms  of  disease  under  the 
name  of  local  aifections.  The  definition  of  the  words  general  and  local  as 
applied  to  the  designation  of  different  forms  of  disease  and  the  distinctive 
features  of  each  class  thus  designated,  were  sufficiently  considered  in  the 
sixth  lecture  of  the  present  course.*  In  the  same  lecture,  1  grouped  all 
the  local  affections  into  four  divisions  or  sub-classes,  calling  them  respect- 
ively inflammations,  fluxes,  neuroses,  and  miscellaneous  or  unclassifiable 
cases.  I  shall  now  proceed  to  consider  each  of  these  sub-classes  in  the 
order  in  which  they  were  named.  The  diseases  included  in  the  first  sub- 
class, called  phlegmasia,  or  local  inflammations,  are  among  the  most  fre- 
quent and  important  affections  that  come  under  the  care  of  the  physician. 
The  subject  of  inflammation,  like  that  of  fever,  has  occupied  thi'  attention 
of  the  profession  from  the  earliest  periods  of  medical  history;  and  upon 
these  two  forms  of  morbid  action  have  been  based  all  the  so-called,  great 
systems  of  medical  philosophy  of  past  generations.  Until  a  recent  period 
of  time  all  attempts  to  define  inflammation,  consisted  in  a  simple  enumera- 
tion of  the  more  prominent  symptoms  presented  during  the  active  stage 
of  the  disease,  name  y  heat,  redness,  swelling,  and  pain.  It  is  true  that 
when  a  part  or  a  structure  is  hot,  redder  than  natural,  swollen,  and  pain- 
ful, it  is  inflamed.  But  these  several  phenomena  do  not  constitute  the 
disease.  They  are  simply  results  or  symptoms  by  which  the  presence  of 
the  disease  is  made  known.  And  there  is  not  one  of  them  that  may  not 
be  absent  in  some  particular  case. 

Essential patlxology. — If  we  apply  the  same  analytical  method  to  the 
study  of  the  morbid  condition  called  inflammation,  that  we  adopted  in  re- 
Intion  to  the  essential  pathology  of  fevers,  we  will  find  it  to  involve  four 
elements  or  factors,  two  of  which  are  essential  and  uniform  and  the  other 
two  variable.  The  four  elements  that  constitute  factors  in  every  inflam- 
matory process,  are,  the  properties  of  the  tissue  involved,  which  I  have 
sailed  susceptihility  and  vital  affinity  and  the  quantity  and  quality  oi  the 
blood.  The  susceptibility  or  irritability  is  always  exalted  and  the  quan- 
tity of  blood  increased  in  every  case  of  inflammation.  If  the  susceptibil- 
ity of  the  structure  is  exalted  without  any  accumulation  of  blood  it  con- 
stitutes simple  irritation.  When  there  is  accumulation  of  blood  in  the 
vessels  of  the  part,  without  any  increase  or  exaltation  of  the  susceptibility 

*See  Lecture  VI,  pp.  48-52  of  this  volume. 

(313) 


314  INFLAMMATION". 

of  the  texture,  it  constitutes  simple  congestion.  "When  the  two  co-exist 
in  the  same  structure  they  constitute  the  first  and  essential  step  in  the 
inflammatory  process.  I  call  them  the  constant  elements,  because  they 
are  not  only  always  present,  but  always  altered  from  their  natural  condi- 
tion in  the  same  direction,  though  not  uniformly  in  the  same  degree.  The 
vital  affinity  inherent  in  all  living  matter  and  the  quality  of  the  blood, 
are  factors  present  also  in  every  case:  but  the  first  may  Le  increased  above 
or  diminished  below  its  natural  standard,  or  it  may  be  perverted  in  a  di- 
rection diifering  from  either  simple  increase  or  diminution  of  activity, 
while  the  second  may  have  its  plastic  elements  increased,  (hyperplastic) 
diminished,  (aplastic)  or  it  may  contain  foreign  constituents,  either  gener- 
ated in  the  system  or  imbibed  from  without,  rendering  it  toxaemic.  There- 
fore I  call  the  vital  affinity  or  property  that  regulates  the  movement  of 
organic  atoms,  and  the  quality  of  the  blood,  variable  elements  of  the  in- 
flammatory process. 

And  a  further  study  will  show,  that  it  is  the  variations  in  these  elements 
or  facto:s,  which  cause  the  diversities  in  symptoms,  progress,  and  results, 
so  constantly  met  with  in  different  cases  of  inflammation.  When  th  ; 
properties  of  a  structure  have  been  disturbed  and  blood  has  accumulated 
in  its  vessels,  constituting  the  first  step  in  the  morbid  process  called  in- 
flammation, these  conditions  never  remain  stationary.  If  the  morbid  ex- 
citability and  the  fullness  of  blood  can  be  at  once  relieved,  the  morbid 
process  is  arrested  and  the  structure  restored  to  its  natural  or  healthy 
condition.  In  other  words  the  inflammatory  process  is  rendered  abortive 
or  is  cut  short  in  its  incipiency.  If  such  a  result  is  not  obtained,  further 
changes  take  place  which  have  been  carefully  studied  with  the  aid  of  the 
microscope,  both  in  the  living  tissues  and  after  their  death.  Under  the 
microscope,  both  the  blood  and  the  vessels  which  contain  it  are  seen  rap- 
idly undergoing  important  histological  changes. 

At  first  the  arteries  dilate,  then  the  veins,  and  to  a  less  degree  the  capil- 
laries. Coincidently  the  flow  of  the  blood-current  is  increased,  but  after 
a  somewhat  variable  time  it  becomes  slower  than  normal,  and  in  some 
cases  even  stasis  takes  place  in  the  capillaries.  As  it  slackens  its  speed  the 
white  corpuscles  begin  to  cling  and  gather  along  the  walls  of  the  veins 
and  capillaries,  the  red  blood  still  flowiiig  through  the  center.  The  white 
corpuscles  then  begin  to  migrate.  By  their  amoeboid  movements,  or  the 
increas'-'d  affinity  of  the  tissue,  they  push  through  the  intercellular  cement 
of  the  lining  endothelium.  Outside  the  vessel  they  become  actively 
amoeboid  and  change  their  position  through  the  surrounding  tissue.  At 
the  same  time,  as  a  rule,  a  few,  though  exceptionally  very  many,  red 
corpuscles  also  pass  from  the  vessels.  The  fluid-portion  of  the  blood  aleo 
filters  out.  These  changes  constitute  the  process  of  exudation.  The 
exudate,  thus  formed,  resembles  blood  plasma,  but  contains  somewhat  less 
albumon.  The  migrated  white  blood  corpuscles  are  undistinguishable 
from  pus  cells.  Whether  they  are  the  sole  origin  of  these  cells  or  whether 
all  tissue-cells  proliferate  and  produce  the  pus  cell,  is  not  as  yet  definitely 
settled  by  histologists. 

The  subsequent  steps  in  the  inflammatory  process,  and  the  changes  in- 
volved in  it,  will  depL'nd  entirely  upon  certain  other  coincident  con- 
ditions. 

If  there  is  an  accumulation  of  healthy,  plastic  blood,  an  increased  sus- 
ceptibility, and  free  play  of  vital  affinity,  as  occurs  in  the  ordinary  sthenic 
or  active  form  of  inflammation,  a  plastic  exudation  is  produced.  The 
liquor  sanguinis,  which  permeates  the  tissue,  is  of  such  quality,  that  in- 
fluenced   by  active  vital  affinity,  it  speedily    undergoes  solidification  and 


PATHOLOGY. 


115 


more  or  less  complete  organization.  As  the  interstitial  spaces  are  filled 
with  this  solidified  and  oi-ganized  exudate,  two  things  are  caused:  an  in- 
crease of  bulk  or  swelling,  and  an  increase  of  density  or  hardening  of  the 
tissue.  Of  course,  the  increase  of  blood  causes  an  increase  of  redness; 
and  the  active  play  of  vital  affinity,  the  rapid  exvidatiou  and  its  organiz-i- 
tion,  develops  a  rise  in  temperature;  the  coincident  irritation  and  the 
pressure  of  th '  exudate  cause  pain;  and  tlius  by  successive  steps  you 
have  rapidly  developed  all  the  syniptontis  of  phlegmonous  or  active  sthenic 
inflammation,  symptoms  which  are  crystalized  in  the  classic  words:  tumor, 
ru'oor,  calor,  dolor. 

But  there  are  other  conditions  which  may  modify  this  result.  Suppose, 
instead  of  the  coincidence  of  active,  vital  affinity  and  a  healthy  plastic 
condition  of  the  accumulated  blood,  the  vital  affinity  is  lowered  and  the 
blood  aplastic:  Wiiat  will  be  the  result?  Exudation  will  take  place,  and, 
p  rhap-,  more  rapidly  than  in  the  other  case,  as  the  walls  of  the  capillaries 
and  arterioles,  uninfluenced  or  but  slightly  influenced  by  vital  affinity, 
readily  relax,  become  distended,  and  yield  to  the  pressure  of  the  accumu- 
lated blood.  Tiie  liquor  sanguinis,  which  permeates  the  surrounding  tis- 
sue, owing  to  its  aplastic  condition  and  general  lack  of  vital  force,  remains 
unorganized,  or  organizRS  very  slowly.  The  tumefaction,  which  takes 
place,  is  not,  therefore,  accompanied  by  induration,  but  the  tissue,  thouo-h 
swelled  and  red,  is  only  moderately  increased  in  density,  and  ultimately 
tends  to  soften  and  disintegrate,  or  undergo  diffuse  suppuration.  Good 
examples  of  this  variety  are  seen  in  the  local  asthenic  inflammations  that 
accompany  typhoid  and  other  low  grades  of  general  fever. 

A  third  condition  of  the  blood  that  may  cause  important  modifications 
of  the  inflammatory  process,  arises  from  the  presence  in  it  of  some  one  or 
more  foreign  substances  having  properties  which  are  capable  of  either 
interfering  with  the  ordinary  molecular  movements  and  combinations,  or 
of  altering  the  vasomotor  influence  over  the  action  of  the  vessels  of  the 
part  in  a  way  different  from  simple  increase  or  diminution.  To  this  class 
of  agents  belong  all  the  specific  contagiuras  and  infections.  Their  presence 
in  the  blood  of  a  part  excites  or  exalts  the  susceptibility,  and  perverts  or 
changes  from  its  natural  direction  the  affinity  that  controls  the  movements 
of  organic  atoms,  by  which  new  and  specific  combinations  are  formed. 
The  inflammations  accompanying  the  eruptive  fevers,  erysipelas,  gout, 
etc.,  are  familiar  examples  of  this  variety.  From  this  elementary  or 
analytical  study,  you  will  see  that  all  cases  of  inflammation  may  be  in- 
cluded under  three  heads,  which,  for  want  of  better  terras,  I  call  sthenic, 
asthenic,  and  specific. 

The  elements  or  factors  involved  in  each,  and  their  uifFerences,  will  be 
seen  by  the  following  table  which  I  place  on  the  blackboard: 


Sthenic. 


VARIETIES      OF 

J  Asthenic  . 

INFLAMMATION.    | 


Specific 


f  Susceptibility  of  structure  exalted, 
j   Quantity  of  blood  increased, 
j   Vital  aiBnity  increased. 
[  Quality  of  blood  plastic. 

{Susceptibility  of  structure  exalted. 
Quantity  of  blood  increased. 
Vital  affinity  diminished. 
Quality  of  blood  aplastic. 

f  Susceptibility  of  structure  exalted. 

I    Quantity  of  blood  increased. 

j    Vital  affinity  perverted. 

l^  QuaUty  of  blood  toxaemic  orfoisoned. 


316  INFLAMMATION. 

You  readily  psrcelve  that  the  differences  between  the  sthenic  and  as- 
thenic depend  upon  the  variations  in  the  vital  affinity  of  the  textui-e  an  i 
the  natural  plastic  elements  of  the  blood;  while  the  peculiarities  of  the 
specific  inflammations  are  owing  to  the  presence  in  the  blood  of  a  foreign 
toxfemic  or  poisonous  agent.  The  two  first  admit  of  cases  varying  much 
in  the  degree  of  alteration  in  the  elements  involved  until  those  called 
plastic  or  sthenic,  and  the  aplastic  or  asthenic,  meet  so  nearly  on  the  di- 
viding line  that  the  practitioner  may  properly  hesitate  in  deciding  un- 
der which  head  a  given  case  before  him  should  be  placed. 

MesuUs  or  Terminations  of  Inflammation. — The  inflammatory  process, 
■when  it  progresses  beyond  the  first  stage  of  its  existence,  may  terminate 
by  resolution,  by  formation  of  new  tissue,  by  suppuration,  and  by  gan- 
grene. As  I  have  already  explained,  the  first  stage  of  inflammation  con- 
sists of  simple  morbid  excitability  of  the  structure  and  accumulati  n  of 
blood  in  its  vessels;  and  the  second  embraces  the  period  during  which 
more  or  less  of  the  constituents  of  the  blood  are  passing  through  the  walls 
of  the  capillaries  into  the  interstitial  spaces,  and  is  often  called  the  stage 
of  exudation.  The  first  is  usually  very  brief,  occupying  from  six  to  twen- 
ty-four hours.  The  second  more  generally  continues  from  two  to  five 
days;  and  is  followed  by  the  third  or  stage  of  decline,  during  which  the 
results  of  the  inflammatory  process  are  developed,  either  in  resolution, 
the  permanent  organization  of  new  or  false  tissue,  the  formation  of  pus 
(suppuration),  or  the  death  of  the  part  (gangrene).  These  diverse  results 
which  are  liable  to  be  developed  during  the  third  stage,  depend  entirely 
upon  the  quantity  and  quality  of  the  exudation  material  and  the  condi- 
tion of  the  vital  affinitv  of  the  structure  involved.  If  the  amount  of  the 
exudate,  whether  plastic  or  aplastic,  is  moderate,  and  the  affinity  or  prop- 
erty regulating  the  movement  and  combination  of  organic  atoms  or  mole- 
cules not  much  below  the  natural  slandard  of  activity,  it  generally  begins 
to  undergo  disintegration  and  removal  by  re-absorption  as  soon  as  the  ex- 
udative process  is  arrested,  and  in  a  few  days  the  whole  is  removed,  leav- 
ing the  original  structure  in  its  natural  condition.  This  constitutes  the 
termination  by  resolution. 

If  the  amount  of  the  exudate  is  moaerate  and  decidedly  plastic  with  an 
active  state  of  vital  affinity,  as  in  acute  rheumatic  and  other  sthenic 
grades  of  inflammation,  it  not  only  undergoes  rapid  solidification,  but  its 
molecules  are  arranged  into  cells,  nuclei,  and  granules,  which  become  more 
or  less  assimilated  in  lorm  and  function  to  the  normal  tissue  in  which  the 
exudation  occurs.  The  structur  ;  thus  becomes  hypertrophied  and  often 
permanently  much  embarrassed  in  the  performance  of  its  function.  The 
thickened  and  indurated  valves  following  endocarditis;  the  sclerosis  of 
the  connective  tissue  of  the  lungs,  resulting  in  some  cases  from  pneumo- 
nia; and  parallel  changes  in  the  parenchyma  of  the  liver,  spleen  and  oth- 
er organs,  resulting  from  attacks  of  active  inflammation,  are  all  familiar 
examples  of  inflammation  terminating  in  the  formation  of  new  tissue. 
When  the  serous  membranes  are  the  seat  of  the  same  grade  of  inflamma- 
tion, the  blood  plasma,  c  ntaining  the  plastic  materials,  exudes  upon  the 
surface  of  the  membrane,  the  endothelial  cells  of  which  are  pressed  apart 
or  detached,  and  a  deposit  of  fibrin,  holding  in  its  meshes  white  cor- 
puscles and  granular  matter,  accumulates.  At  the  same  time  the  connect- 
ive tissue  cells  of  the  surface  enlarge  and  become  more  or  less  imbedded 
in  the  layer  of  exudate.  These  cell  structures  multiply,  a  new  basement 
substance  is  formed,  in  which  new  blood  vessels  appear,  while  the  fibrin 
and  serous  fluid  are  removed  by  absorption,  and  a  layer  of  complete  con- 
nective tissue  is  left  in  the  form  of  a  false  or  new  mem  rane  closely  iden- 
tified with  the  surface  of  the  natural  one. 


RESULTS    OF    INFLAMMATIOX.  317 

Or  if  two  inflamed  surfaces  are  in  contact,  the  layer  of  new  connective 
tissue  becomes  a  permanent  bond  of  union  between  them,  as  you  see 
often  in  the  pleuritic,  pericardial  and  other  membranous  adhesions  follow- 
ing attacks  cf  the  more  sthenic  grades  of  inflammation.  When  tha  grade 
of  inflammation  is  asthenic,  the  exudation  takes  place,  either  into  the 
parenchyma  of  organs  or  upon  the  surface  of  membranes,  in  the  same 
manner  as  just  described,  and  the  exudate  generally  partially  solidifies, 
presenting  many  of  the  characteristics  of  new  tissue  or  membrane,  as  you 
may  see  in  the  exudations  of  diphtheria.  But  its  organization  is  never 
complete,  and  it  soon  disintegrates  and  disappears,  often  accompanied  by 
softening  or  ulceration  of  the  inflamed  structure. 

Suppuration  or  the  formation  of  pus,  may  result  from  any  grade  or 
variety  of  inflammation,  and  will  occur  whenever  the  exudation  in  any 
given  case  is  sufficiently  copious  to  crowd  either  the  white  corpuscles  of 
the  blood  or  the  proliferating  connective  tissue  cells  beyond  the  influence 
of  the  properties  inherent  in  the  Hying  organized  structure.  In  the  most 
active  sthenic  grade  of  inflammation  where  the  blood  is  plastic,  and  both 
])roperties  of  structure  exalted,  giving  to  the  exudate  a  strong  tend- 
ency to  organization,  you  can  readily  conceive  that  in  the  central  parts 
of  the  inflamed  portion  of  structure  where  many  of  the  capillaries  are 
completely  blocked  up  by  the  accumulated  corpuscular  elements,  the 
amount  of  exudation  might  so  distend  some  of  the  interstitial  spaces  as  to 
leave  more  or  less  of  the  leucocytes  and  other  cell  elements  beyond  the 
vitalizing  influence  of  the  living  fibres  bounding  such  interstitial  spaces. 
The  ceils  and  corpuscles  thus  placed,  immediately  commence  undergoing 
degeneration,  and  generally  assume  the  form  of  pus  corpuscles,  and  mark 
the  beginning  of  the  suppurative  process. 

While  these  points  of  suppuration  are  being  formed  in  the  more  in- 
tensely engorged  central  parts  of  the  inflamed  structure,  in  the  less  en- 
gorged parts  toward  the  circumference,  the  wiiole  amount  of  the  exudate 
retains  its  integrity,  simply  causing  increased  bulk,  density,  redness  and 
heat.  The  central  points  of  suppuration  soon  unite,  forming  an  abscess, 
bounded  by  the  denser  part  of  the  tissue,  thus  constituting  the  typical 
phlegmonous  nhscess  of  the  older  writers,  whose  plastic  lymph  meant  the 
same  thing  as  the  exudate  or  plasma,  with  its  leucocytes,  proliferating 
cells,  etc.,  of  the  histologists  of  our  time. 

In  the  asthenic  grades  of  inflammation,  with  the  properties  of  the  struct- 
ure impaired,  and  the  exudative  material  diminished  in  its  plasticity,  if 
the  amount  of  the  latter  proves  sufficient  to  so  far  distend  the  interstitial 
spaces  as  to  crowd  the  white  corpuscles  and  cell  elements  beyond  the 
vitalizing  influence  of  the  tissue  properties,  they  sufi"er  purulent  degenera- 
tion still  more  rapidly  than  in  the  cases  just  described.  And  as  no  part 
of  the  exudate  becomes  more  than  partially  oro-anized,  the  points  of  puru- 
lent degeneration  are  not  limited  or  circumscribed  by  dense  tissue,  as  in 
the  sthenic  or  phlegmonous  variety,  but  multiply  rapidly  throughout 
the  whole  of  the  inflamed  structure,  constituting  what  is  called  diffuse 
suppuration,  and  often  involving  extensive  softening  or  destruction  of  the 
part. 

In  the  specific  inflammations,  or  those  caused  by  the  presence  of  some 
special  poison  in  the  l)lood,  if  suppuration  takes  place,  it  will  be  either 
circumscribed  or  diffuse  according  to  the  nature  of  the  poison,  and  the 
previous  constitutional  condition  of  the  patient.  Some  of  the  specific 
poisons  excite  inflammations  that  are  always  accompanied  by  suppuration. 
Such  is  the  poison  of  variola  and  vaccinia,  each  cutaneous  pustule  they 
produce  being  a  miniature  phlegmon. 


31B  IXFLAMMATIOiS". 

The  inflammations  caused  by  others  are  accompanied  by  suppuration 
only  in  cases  of  unusual  severity,  and  then  the  suppurative  process  is  gen- 
erally  difl'use.  Such  are  the  poisons  causing  scarlatina,  measles,  diph- 
theria, and  erysipelas;  while  the  inflammations  of  gout  and  rheumatism 
seldom  present  any  degree  of  purulent  formation. 

Gangrene. — Death  of  more  or  less  of  the  inflamed  part,  or  gangrene, 
was  mentioned  as  a  fourth  result  of  the  inflammatory  process. 

In  the  ordinary  sthenic  and  asthenic  grades  of  inflammation,  gangrene 
or  loss  of  vitality  in  the  structure,  is  caused  by  simply  increasing  the  same 
conditions  that  give  rise  to  suppuration.  The  exudation  is  not  only  copi- 
ous enougii  to  overdistend  some  of  the  insterstitial  spaces,  and  produce 
stasis  in  some  of  the  capillaries,  but  to  completely  arrest  the  circulation  of 
blood  in  a  portion  of  the  inflamed  structure.  Such  complete  arrest  of  cir- 
culation is  necessarily  followed  by  the  cessation  of  all  molecular  change, 
and  consequently  the  cessation  of  life  in  tiie  part.  It  is  probable  that  in 
some  of  the  inflammations  caused  by  specific  poisons  of  the  more  virulent 
class,  gangrene  may  be  owing,  in  part  at  least,  to  the  direct  action  of  the 
poison  on  the  properties  of  tiie  tissue,  diminishing  the  susceptibility  and 
so  far  diverting  the  afiinity  as  to  arrest  all  nutritive  or  molecular  changes. 
In  speaking  thus  far  of  the  results  of  inflammation  I  have  omitted  to  men- 
tion that  when  membranes  are  the  seat  of  the  disease,  much  of  the 
exudate  is  from  the  watery  element  of  the  blood,  and  consists  chiefly  of 
water  holding  in  solution  a  small  proportion  of  albumen  and  saline  con- 
stituents, and  sometimes  the  red  corpuscles  of  the  blood.  When  the  mu- 
cous membranes  are  inflamed,  their  surfaces  having  free  outlets,  the  exu- 
date passes  off' in  the  form  of  evacuations,  composed  of  either  water,  mucus, 
blood,  or  pus,  and  not  unfrequently  of  all  these  mixed  in  difi"erent  proportions 
at  diff"erent  stages  in  the  progress  of  the  case.  When  the  serous  membranes 
are  affected,  the  liquid  part  of  the  exudate  is  more  largely  composed  of 
water,  with  only  a  small  proportion  of  albumen,  and  as  these  membranes 
are  shut  sacs,  the  fluid  accumulates,  distending  the  sac,  or  pressing  inju- 
riously upon  the  contained  viscera,  as  the  lungs,  heart  or  brain.  These 
cases  are  more  frequently  called  eff"usions  than  exuJat.ons,  and  the  accumu- 
lations are  called  dropsies.  Inflammation  in  any  of  the  membranes  may 
also  t-rminate  in  suppuration  by  the  same  process  that  I  have  already  de- 
scribed, only  the  pus  will  appear  principally  upon  the  surface  of  the  mem- 
brane involved,  and  in  the  shut  sacs  accumulate  like  the  serous  fluids  and 
is  often  mix  id  with  them.  From  the  analytical  review  I  have  now  given, 
you  have  seen  that  the  morbid  process  called  inflammation,  like  that  of  fever, 
always  involves  at  its  beginning  certain  elements  or  factors,  some  of 
which  are  constant,  and  others  subject  to  such  variations  as  to  cause  ma- 
terial alterations  in  the  progress  and  results  of  uiff'erent  cases.  There  is  a 
oneness  or  unity  in  all  inflammations,  inasmuch  as  they  all  involve  the 
same  elements  or  factors  at  the  beginning,  but  a  wide  diversity  in  the  prog- 
ress and  results  of  diff"(;rent  cases,  on  account  of  tiie  variable  condition  of 
two  of  the  primary  factors,  as  well  as  the  diverse  character  of  the  remote 
and  exciting  causes.  You  have  seen  aiso  that  all  the  varieties  of  inflam- 
mation when  uninterfered  with,  pass  through  the  same  stages,  namely,  that 
of  tissue  irritability  and  vascular  engorgement,  that  of  exudation,  and  that 
of  decline.  The  first,  the  same  in  kind  in  all  cases,  varying  only  in  the 
degree  of  intensity.  The  second  varying  much  both  in  regard  to  the  quan- 
tity and  quality  of  the  exudate.  And  the  third  still  more  variant  both  in 
regard  to  the  character  of  the  changes  that  accompany  it,  and  the  ultimate 
results.  I  thus  restate,  in  explicit  language,  the  points  of  unity  and  the 
lines  of  divergence  seen   in   studying  the  pathology  of   all   varieties  of  in 


TEEATMENT.  310 

fl:immation,  and  the  distinct  stages  which  mark  their  progress,  because  I 
deem  a  clear  recognition  of  them  of  the  greatest  practical  importance  at 
the  bedside  of  the  sick.  In  the  first  stage,  I  recognize  the  co-equal  impor- 
tance of  the  quantity  and  quality  of  the  blood,  and  of  the  disturbed  prop- 
erties of  the  tissues  by  which  the  molecular  changes  and  tonicity  of  the 
vessels  are  regulated;  in  the  second,  of  the  combined  influence  of  blood 
pressure  on  overdistended  and  partially  oljstructed  vessels  and  capillaries, 
and  of  the  altered  affinity  or  attraction  between  the  tissue  elements  and 
those  of  the  blood,  in  determining  the  amount  and  rapidity  of  the  exuda- 
tion; and  in  the  third,  of  the  mutual  influence  of  the  tissue  properties,  and 
of  he  amount  and  quality  of  exudative  material,  in  determining  whether 
the  result  will  be  resolution,  new  tissue  evolution,  suppuration  or  gan- 
grene. By  so  do'ngi  hope  to  guard  you  against  the  extreme  views  of 
Hunter  and  his  followers,  who  place  all  the  essential  pathological  phenom- 
ena of  inflammation  in  the  blood  and  the  blood  vessels;  and  till  more  against 
the  partial  and  narrow  views  of  Virchow,  Hughes,  Bennett,  and  their  fol- 
lowers, who  would  have  us  regard  the  inflammatory  process  as  essentially 
one  of  simple  cell  irritation  and  proliferation,  I  would  not  have  you 
neglect  or  undervalue  the  important  additions  made  to  our  knowledge 
concerning  the  histological  changes  in  the  development  and  progress  of 
inflammation  by  such  men  as  Virchow,  Waller,  Recklinghausen,  Conheim, 
etc.;  but  I  would  have  you  fully  aware  of  that  trait  in  the  human  mind 
which  disposes  it  to  magnify  the  importance,  and  unduly  extend  the  ap- 
plication of  each  new  discovery  it  makes,  and  as  physicians,  whose  pri- 
mary object  is  the  prevention  and  alleviation  of  human  suffering,  I  would 
have  you  careful  to  avoid  conclusions  based  on  only  a  part  of  the  facts  be- 
longing to  any  question  or  case,  and  to  bring  every  man's  theories  to  the 
test  of  impartial  clinical  as  well  as  dead  house  observations. 

As  you  have  already  noticed,  inflammation  is  not  a  simple  uniform  morbid 
process;  consequently  when  you  have  decided  that  a  patient  is  laboring  un- 
der an  attack  of  inflammation  in  some  organ  or  structure,  you  have  not 
completed  your  diagnosis.  A  more  delicate  and  equally  important  task 
still  remains;  namely,  to  judge  accurately  of  the  special  character  of  the 
inflammation  by  appreciating  clearly  the  quality  of  the  patient's  blood,  the 
condition  of  the  elementary  properties  of  nis  tissues,  and  the  nature  of  the 
causes  which  have  been  efficient  in  determining  the  attack. 

Frinciples  of  Treatment. — P>om  the  views  I  have  presented  concerning 
the  nature  and  tendencies  of  the  different  grades  of  inflammation,  you  see 
clearly  the  futility  of  all  the  great  controversies  that  have  been  had  (and 
they  are  many)  concerning  the  treatment  of  inflatnmation  on  the  theory 
that  it  is  a  uniform  morbid  process.  To  claim  that  all  inflammations  must 
be  treated  antiphlogistically,  by  depletion,  sedatives,  evacuants  and  low 
diet;  or  by  stimulants,  tonics,  and  nourishment;  or  by  simple  rest,  mild 
diet,  and  patience;  is  equally  unphilosophical  and  almost  equally  injurious 
to  a  large  part  of  the  patients.  Either  of  these  methods  would  succeed  in 
some  cases  and  signally  fail  in  others.  And  yet  there  is  too  much  of  the 
old  idea  still  lingering  in  the  minds  of  the  profession,  that  inflammation  is 
a  specific  and  uniform  morbid  process,  and  all  you  have  to  do  is  to  deter- 
mine its  existence  and  location  and  then  treat  it  according  to  the  general 
routine.  There  are,  however,  certain  leading  objects  to  be  accomplished 
in  the  treatment  of  all  inflammations  whether  sthenic,  asthenic,  or  specific. 
These  are  founded  on  the  pathological  conditions  existing  in  each  stage 
of  the  inflammatory  process,  and  may  be  placed  in  tabular  form  on  the 
blackboard  as  follows: 


320 


IISrFLAMMATION". 


INDICATIONS 
FOR    TREATMENT 

IN   ALL 
INFL\MMATIONS. 


f  a      To  dimin'sh  the  susceptibility  or  irrita- 
I       bility  of  the  structure,  and  correct  the  vital 
1st  Stage,    -i       affinity. 

1   h.    To  relieve  the  vascular  fullness  or  ac- 
i       cumulation  of  blood. 


2d  Stage. 


a.  To  limit  the  amount  of  exudation,  and 
lessen  the  general  fever. 

h.  To  prevent  the  injurious  accumulation  of 
effete  material  from  the  interference  with 
excretory  functions,  by  promoting  elimina- 
tions. 


f  a.     To  promote  the  removal  of  the  exudate 
I       by  resolution. 

I   h.     To  sustain  the  functions  of  nutrition  and 
3d  Stage.      ■{       excretion. 

c.  To  promote  the  repair  of  structures  in- 
jured, either  by  suppuration,  gangrene, 
sclerosis,  or  atrophy. 

While  the  indications  to  be  fulfilled  or  objects  to  be  accomplished  in 
each  stage  of  the  inflammatory  process  are  the  same  as  just  stated  in  all 
cases,  the  means  appropriate  for  fulfilling  them  will  vary  with  each  varia- 
tion in  the  grade  of  the  disease;  and  to  some  extent  also,  with  the  differ- 
ences in  the  structure  and  function  of  the  parts  involved.  For  example: 
in  the  first  stage  of  the  sthenic  grade  of  the  disease,  the  chief  agents  for 
correcting  the  properties  of  the  inflamed  structure  are  anodynes  and  ner- 
vous sedatives,  and  for  relieving  the  vascular  fullness  or  accumulation  of 
blood,  direct  depletion  and  vascular  sedatives.  In  the  same  stage  of  the 
asthenic  grade,  direct  depletion  must  be  omitted  and  the  nervous  and  vas- 
cular sedatives  must  give  place  to  tonics,  especially  of  the  vasomotor 
class  and  such  as  sustain  the  vital  affinity  or  molecular  action  in  the  struct- 
ures involved.  And  in  the  corresponding  stage  of  the  specific  grades, 
the  leading  remedies  are  such  as  will  suspend  the  further  action  of  the 
specific  cause  by  neutralizing  (antiseptics)  or  expelling  (eliminants)  such 
cause,  aided  by  anodynes,  and  either  sedatives  or  tonics,  according  to  the 
condition  of  the  vascular  and  nervous  functions  in  each  case.  The  rela- 
tive importance  of  the  two  leading  indications  to  be  fulfilled  in  the  treat- 
ment of  the  first  stage  of  inflammation,  will  depend  much  upon  the  ana- 
tomical character  and  function  of  the  part  afi"ected.  If  the  structure  is 
dense  and  but  little  vascular,  like  the  cartilages,  ligaments,  periosteum, 
and  some  of  the  serous  membranes,  the  amount  of  tumefaction  or  exuda- 
tion will  seldom  be  sufficient  to  suspend  any  function  essential  to  life. 
Consequently  in  all  such  cases  you  can  properly  depend  much  more  upon 
those  measures  designed  to  reduce  the  morbid  excitement  or  irritation  of 
the  structure,  than  upon  those  aimed  at  the  lessening  of  the  amount  of  blood 
in  the  vessels  of  the  part.  If  the  structure  involved  be  highly  vascular  and 
the  connective  tissue  yielding,  as  in  the  parenchyma  of  the  lungs,  spleen, 
liver,  brain,  etc.,  and  the  function  of  the  part  such  that  its  interruption, 
temporarily,  may  directly  or  indirectly  endanger  life,  then  early  relief  to 
the  vascular  fullness  is  of  paramount  importance  as  the  chief  means  for 
limiting  the  amount  of  exudation  or  effusion.  In  such  cases  the  means  for 
lessening  the  accumulation  of  blood  in  the  part  must  take  the  precedence 
of  all  others,  The  complete  fulfillment  of  either  of  the  objects  I  have 
named  in  the  first  stage  will  render  the  disease  abortive,  ani  the  same  i-e- 
sult  will  be  reached  still  more  certainly,  by  judiciously  directing  the 
means  for  accomplishing  both  at  the  same  time. 


TXFLAMMATION    OF    THE    BEAI^^.  S'Zl 

Tho  accomplishment  of  the  first  object  named  as  desirable  in  the  second 
stage  of  inflammation,  will  be  best  efi'eoted  by  continuino-  the  use  of  the 
same  remedial  agents  that  have  been  mentioned  as  applicable  in  the  first 
stage. 

The  means  for  accomplishing  the  object  marked  b,  in  the  second  stage, 
must  depend  much   upon    the    particular    excretory    functions    interfered 
with  in  any  given  case.     Diaphoretics,  diuretics,  mild  laxatives  and  alter- 
atives or  excitors  of  glandular  secretions  generally,  will  all   be    found    ap 
plicable  in  diiferent  cases,  according  to  the  seat  of  the  disease. 

The  three  indications  named  as  belonging  to  the  third  stage  of  the  in- 
flammatory process,  will  be  best  fulfilled  by  a  moderate  continuance  of 
the  remedies  required  in  the  second  stage,  aided  by  close  attention  to 
nourishment,  good  air,  and  such  tonics  as  promote  assimilation  and  nu- 
trition. 

So  far  as  the  limits  of  a  single  hour  will  permit,  I  have  given  you  an 
analytical  view  of  the  essential  pathology,  modes  of  progress,  and  results 
of  inflammation  ;  and  the  general  principles  that  should  govern  its  treat- 
ment. Your  careful  attention  to  this  general  consideration  of  the  sub- 
ject will  greatly  facilitate  your  study  of  inflammations  of  the  individual 
organs  or  structures,  and  enable  me  to  economize  time  by  avoiding  repe- 
titious. 


LECTURE  XXXiy. 

Inflammation  of  the  Brain  and  Spinal  Cord  and  their  Meninges— The  structures  involved  and 
their  Anatomical  Caaracteristics— Subdivisions  and  Names  Applied  to  Inflammatiou  of  each  Part 
— Their  Clinical  History  or  Symptoms,  and  Diagnosis. 

GENTLEMEX  :  By  the  brain,  spinal  cord  and  their  meninges,  I  mean 
the  masses  of  nerve  matter  called  cerebrum,  cerebellum,  medulla 
oblongata,  and  spinal  cord,  with  their  three  investing  membranes,  called 
dura  mater,  arachnoid,  and  pia  mater.  The  nerve  masses  are  soft, 
inelastic,  minutely  vascular,  and  so  delicate  in  structural  arrangement  as 
to  be  easily  injured,  were  they  not  protected  by  complete  inclosure  with- 
in the  bones  of  the  cranium  and  spinal  column.  The  otiter  membrane  or 
dura  mater  is  thick  and  dense,  with  little  vascularity.  The  second,  or 
arachnoid,  is  very  thin  and  delicate,  only  moderately  vascular,  and  like 
the  outer  one,  spread  over  the  convolutions  and  surface  of  the  brain  and 
cord,  with  only  slight  attachments  to  them.  The  inner  membrane,  or  pia 
mater,  is  also  thin  and  delicate  in  structure,  but  very  vascular  and  by  its 
vessels  closely  connected  with  the  surface  of  the  brain,  dijoping  deeply 
down  between  the  convolutions,  and  extending  into  the  lateral  ventricles. 
I  remind  you  of  these  simple  anatomical  facts  because  they  have  some 
relation  to  the  changes  that  may  be  expected  to  take  place  during  the 
progress  of  an  active  inflammation,  as  I  explained  in  the  preceding 
lecture.  Inflammation  may  attack  either  of  the  membranes  separately,  or 
either  of  the  anatomical  divisions  of  the  nerve  matter  ;  or  it  may  invade 
the  whole  at  once.  Clinical  observations,  however,  have  shown  that  the 
dura  mater  is  rarely  attacked,  except  as  a  secondary  or  remote  effect  of 
syphilis  and  alcoholism,  or  as  a  complication  of  inflammations  of  the  middle 
ear,  or  as  a  chronic  afi'ection  of  old  age.  Neither  is  the  arachnoid  often 
21 


822  PACHYMEmNGITIS. 

attacked,  except  in  children  of  scrofulous  or  tuberculous  tendencies,  or  as 
a  result  of  the  actual  deposit  of  more  or  less  of  the  gray,  miliary  tubercie. 
The  pia  mater  is  generally  the  primary  seat  of  ordinary  attacks  of  acute 
and  subacute  inflammation,  both  in  children  and  adults.  From  its  close 
vascular  connection  with  the  surface  of  the  brain,  the  latter  almost  uni- 
formly becomes  also  immediately  involved  in  the  inflammatory  process. 
Practically,  therefore,  inflammation  of  the  pia  mater  and  convolutions  or 
surface  of  the  nerve  masses  is  one  disease.  Inflammation  of  all  grades 
may  occur  in  the  interior  of  either  division  of  the  brain  or  in  the  cord, 
without  involving  the  surface,  although  such  cases  are  not  of  frequent  oc- 
currence. When  inflammation  attacks  the  hrain  and  its  investing  mem- 
branes generally,  it  is  properly  called  encephalitis.  When  it  attacks  the 
membranes  alone  it  is  called  ineningiiis,  or  the  brain  structure  alone,  it  is 
cerebritis.  As  I  have  already  explained,  however,  meningitis  as  it  affects 
the  pia  mater,  canr^ot  be  clinically  separated  from  inflammation  of  the 
convolutions  of  the  brain.  Consequently  in  the  further  discussion  of  this 
subject  I  shall  use  the  word  pachymeningitis  to  indicate  inflammation  of 
the  dura  mater;  meningitis,  to  indicate  inflammation  of  the  arachnoid  and 
pia  mater  and  surface  of  the  brain  together,  and  cerebritis  to  indicate  the 
disease  when  it  involves  the  interior  of  the  brain  alone.  For  convenience 
of  description,  I  shall  adopt  the  following  nomenclature:  pachymeningitis, 
meningitis,  tuberculous  meningitis,  cerebritis,  cerebral  sclerosis,  cerebro- 
spinal meningitis,  sporadic  and  epidemic;  spinal  meningitis,  and  myelitis. 

Pachymeningitis. — As  I  have  already  stated,  the  dura  mater  is  seldom 
the  seat  of  simple  acute  inflammation  as  a  primary  afll'ection,  but  is  often 
involved  as  the  result  of  blows,  mechanical  injuries,  and  surgical  opera- 
tions, affecting  the  bones  of  the  cranium.  Such  cases,  however  belong  to 
'the  department  of  surgery,  and  are  fully  considered  in  surgical  works,  and 
in  the  courses  of  instruction  in  that  department  of  this  and  other  medical 
•co'leges. 

Chronic  inflammation  is  more  frequently  observed  in  connection  with 
certain  constitutional  impairments  or  diatheses,  and  is  often  difficult  of  diag- 
noses, and  still  more  difficult  to  remove  by  remedial  management.  As  the 
dura  mater  is  composed  of  two  layers,  the  outer  one  attached  to  the  inner  sur- 
face of  the  cranial  bones,  like  ordinary  periosteum,  and  the  inner  one  pre- 
senting a  smooth,  free  surface,  covered  with  epithelium,  most  observers 
have  described  the  existence  of  inflammation  in  the  first  as  pachymenin- 
gitis externa  ;  and  in  the  second  as  pachymeningitis  interna.  If 
we  omit  the  traumatic  cases  as  belonging  to  surgery,  nearly  all 
•of  those  classed  as  belonging  to  the  outer  layer  have  been  found  in 
connection  with  the  cerebral  atrophy  of  old  age.  Many  of  these  had 
presented  no  symptoms  during  the  life  of  the  patient,  while  others 
had  been  characterized  by  long  continued,  dull  pain  in  the  head,  a  creep- 
ing or  crawling  sensation  in  the  pericranium,  and  soinetimes  in  different 
parts  of  the  cutaneous  surface  of  the  body  or  extremities;  general  im- 
pairment of  strength  and  steadiness  in  the  voluntary  muscular  S3'stem;  in 
some  cases  morbid  wakefulness,  and  in  others  almost  constant  drowsiness; 
and  very  generally  impairment  of  the  special  senses,  and  of  memory. 

The  morbid  anatomy  of  these  cases  consists  essentially  in  sclerosis,  or 
thickening  of  the  fibrous  structure  of  the  dura  mater,  with  closer  adhesions 
to  the  bones  of  the  cranium  than  natural,  and  in  some  cases,  the  deposit 
■of  granules  or  nodules  of  bony  matter,  called  osteophytes,  analogous  to  the 
deposits  sometimes  found  in  <  ases  of  old  periostitis  of  the  long  bones.  It 
is  proper  to  state  that  in  nearly  all  these  cases  called  external  chronic 
pachymeningitis,    the   post   mortems    show,    in  addition    to   the    changes 


SYMPTOMS.  323 

in  the  dura  mater,  more  or  less  of  the  general  cerebral  atrophy 
peculiar  to  old  age.  And  it  is  hardly  proper  to  regard  those  cases  which 
have  presented  no  symptoms  during  life,  and  after  death  show  only  slight 
increased  adhesions  of  the  dura  mater  to  the  bone,  with  here  and  there  an 
osseous  granule,  as  in  any  degree  inflammatory.  They  clearly  belong 
rather  to  the  series  of  changes  dependent  on  the  impairments  and  per- 
versions of  nutrition  consequent  on  old  age,  instead  of  on  any  degree  of 
inflammatory  action. 

Under  the  head  of  pachymeningitis  interna,  writers  have  included  a 
variety  of  cases  which  have  occurred  chiefly  in  persons  habitually  addicted 
to  the  use  of  alcoholic  drinks,  or  affected  with  the  general  paralysis  of  the 
insane,  or  with  constitutional  syphilis,  or  undergoing  the  degenerations  of 
old  age.  Sometimes  the  changes  in  the  dura  mater  have  been  traced  to 
the  influence  of  blows,  or  mechanical  injuries  of  the  head.  As  might 
be  expected  from  the  statement  just  made,  far  the  larger  proportion  of 
cases  occur  in  persons  past  the  middle  period  of  life,  and  much  more  fre- 
quently in  males  than  in  females. 

The  symptoms  and  clinical  history  of  the  cases  reported  by  different 
observers  vary  so  much  that  it  is  difficult  to  specify  such  features  as  are 
reliably  diagnostic  of  the  disease.  I  think  this  arises  mainly  from  the 
fact  that  writers  have  included  under  this  head  many  cases  of  hemorrhage 
from  the  inner  surface  of  the  dura  mater  caused  by  changes  thac  are  not 
really  of  an  inflammatory  character,  aiad  many  other  cases  which  were 
associated  with  such  coincident  affections  of  the  brain  as  to  render  it  im- 
practicable to  separate  or  recognize  the  symptoms  of  the  meningeal  disease. 
Of  this  latter  character  were  cases  II  and  IV,  as  reported  by  Dr.  C.  L. 
Dana,  in  the  tToicrnal  of  Mental  and  Nervous  Diseases^  for  January,  1882. 
Of  the  former  class  I  regard  some  of  the  cases  reported  by  Huguenin, 
whose  field  of  observation  was  largely  among  those  afii"ected  with  the 
general  paralysis  of  the  insane.* 

My  own  clinical  observations  incline  me  to  believe  that  all  cases  of  an 
inflammatory  character  in  the  early  stage  are  characterized  by  frequent 
pains  in  the  head,  accompanied  by  morbid  sensations  of  heat  over  the  top 
of  the  head,  much  increased  by  exposure  to  the  sun;  more  or  less  vertigo, 
or  rather  a  feeling  of  insecurity  in  walking  or  making  quick  movements; 
various  morbid  sensations  over  limited  areas  of  the  cutaneous  surface, 
both  of  the  trunk  and  extremities;  and  disturbed  sleep. 

As  the  disease  advances,  the  headaches  are  frequently  accompanied  by 
tinnitus  or  buzzing  in  the  ears;  mental  stupor,  or  somnolence,  accompanied 
by  partial  paralysis,  or  at  least  greater  impairment  of  muscular  action; 
sometimes  muscular  twitchings,  or  temporary  periods  of  rigidity,  or  even 
epileptiform  convulsions. 

After  the  disease  is  well  established,  one  of  the  most  characteristic  feat- 
ures is  the  occasional  sudden  supervention  of  periods  of  profound  somno- 
lence, lasting  from  a  few  hours  to  one  or  two  days,  then  passing  off, 
leaving  the  patient  weak,  but  the  mind  clear,  though  sometimes  a  little 
difficult  to  give  expression  to  the  thoughts,  or  to  command  ready  co-ordi- 
nation of  muscular  movements.  Occasionally  it  will  happen  that  the 
period  of  somnolence  will  be  replaced  by  a  paroxysm  of  incoherent  talka- 
tiveness and  excitement.  Ultimately  the  mental  faculties  become  more 
constantly  impaired,  with  imperfect  control  over  the  sphincters  of  the 
bladder  and  rectum,  ending  in  general  paralysis  and  death.  Some  of  the 
cases  terminate  more  abruptly  by  the  sudden  supervention  of  profound 
coma,  dilation  of  the  pupils,  involuntary  discharges,  slow  and  intermitting 

*  See  Ziemssen's  Cyclopsedia,  Vol.  xii,  p.  385. 


324  PACHYMENINGITIS. 

pulse,  cold  extremities,  and  death  in  from  one  to  thirty-six  hours  after 
thecoma  commences.  Two  well  marked  cases  of  this  kind  have  recently- 
come  under  my  own  observation.  During  all  the  earlier  part  of  the  dis- 
ease, there  will  be  temporary  periods  of  slight  pyrexia,  accompanied  by 
loss  of  appetite,  general  impairment  of  secretory  actions,  and  more  severe 
headaches. 

But  most  of  the  time  the  temperature  is  not  higher  than  natural,  and 
the  patient  takes  food  and  drink  readily.  During  the  paroxysms  of  som- 
nolence the  pupils  are  generally  much  dilated,  or  one  is  largely  dilated 
while  the  other  is  contracted,  and  I  recollect  one  case  in  which  the  pupils 
became  closely  contracted  while  the  patient  was  in  the  paroxysm  of  stupor, 
with  the  lids  closed,  but  when  the  lids  were  separated,  and  efforts  made 
to  arouse  the  patient,  they  became  rapidly  and  fully  dilated. 

Diagnosis. — If  the  peculiarly  variable  train  of  symptoms  I  have  detailed 
are  observed  in  a  patient  previously  long  addicted  to  free  use  of  alcoholic 
drinks,  or  long  subject  to  insanit}'  or  hemiplegia,  or  presenting  indications 
of  degeneration  from  old  age,  you  may  safely  infer  the  existence  of  true 
pachymeningitis  interna.  It  is  only  by  including  under  this  head  cases  of 
meningeal  hgemorrhage  from  cerebral  atrophy  alone,  atheromatous  or  fatty 
degeneration  of  the  coats  of  the  vessels,  and  other  pathological  conditions, 
unaccompanied  by  any  degree  of  inflammation,  that  the  diagnosis  becomes 
difficult  and  uncertain. 

Special  Pathological  Changes. — The  changes  which  are  regarded  as 
specially  characteristic  of  this  form  of  disease  are  the  formation  of  a  deli- 
cate and  highly  vascular  layer  of  membrane  or  organized  structure  on  the 
inner  surface  of  limited  portions  of  the  dura  mater,  chiefly  along  either 
side  of  the  longitudinal  sinus  and  falx  cerebri,  and  sometimes  extending 
in  patches  over  most  of  the  parietal  regions;  and  more  or  less  indications 
of  hsemorrhages,  in  connection  with  the  membranous  formation.  The 
membranous  patches  are  at  first  very  thin  and  easily  overlooked,  often 
appearing  like  a  slightly  yellowish  stain  on  the  surface  of  the  dura  mater. 
Examined  under  a  magnifying  power  they  are  found  to  consist  principally 
of  blood  vessels  with  extremely  thin  walls  and  varicosities,  with  very  little 
fibrous  or  connective  tissue.  The  larger  patches  also  very  generallv  pre- 
sent evidences  of  small  haemorrhages  from  the  vessels,  the  serum  of  which 
had  been  absorbed  leaving  the  stain  of  coloring  matter  and  some  shreds  of 
fibrin  adherent  to  the  membrane.  It  is  these  repeated  small  hemorrhages 
that  cau  e  the  paroxysms  of  temporary  somnolence,  contraction  of  the 
pupils,  and  partial  paralysis,  which  mark  the  progress  of  these  cases. 

In  some  instances  the  hemorrhages  are  more  copious  causing  either 
hemiplegia  or  apoplexy  which  may  prove  speeddy  fatal,  or  from  which 
the  patient  may  slowly* make  a  partial  recovery.  The  new  membranous 
patches  together  with  the  adhering  debris  of  the  blood  clots  are  called 
Junmatomce  and  many  of  them  are  sufficiently  thick  to  press  injuriously 
upon  the  convolutions  of  the  brain,  and  sometimes  to  present  slight  ad- 
hesions to  the  arachnoid  and  pia  mater. 

As  a  large  proportion  of  the  cases  of  pachymeningitis  occur  in  patients 
already  undergoing  more  or  less  cerebral  atrophy,  it  is  highly  probable 
that  the  patches  on  the  surface  of  the  dura  mater  consisting  primarily  of 
delicate. vessels  with  thin  walls  and  many  varicosities,  result  directly  from 
the  diminished  pressure  on  the  surface  of  the  membrane,  for  as  the  mass  of 
the  brain  shrinks,  the  bones  to  which  the  dura  mater  adheres  cannot  follow 
the  shrinkage.  Consequently,  there  will  be  less  pressure  on  the  free  surface, 
and  a  corresponding  tendency  to  distension  of,  and  exudation  and  even  hem- 
orrhage from  the  capillaries  and  smaller  vessels,  without  the  intervention  of 


TKEATMENT.  325 

any  true  iiiflainmatory  process.  In  such  cases  the  views  of  Huo^uet)in, 
who  denies  this  inflammatory  nature,  are  more  nearly  correct  than  those 
of  Virchow  and  his  followers,  who  regard  all  the  patches  as  originating  in 
inflammatory  exudations. 

Prog)iosifi. — The  form  of  disease  under  consideration,  occurring  usually 
in  connection  with  impaired  constitutional  conditions  that  are  often  per- 
manent, has  no  natural  tendency  to  recovery  and  is  not  generally  cured 
by  remedial  agents.  Neither  is  there  any  natural  limit  to  the  duration  of 
the  disease.  It  may  terminate  early  and  suddenly  from  copious  hemor- 
rhage and  fatal  compression  of  the  brain,  or  it  may  continue  for  several 
years. 

Treatment. — The  treatment  must  consist  in  removing  as  far  as  possible 
all  causes  of  mental  and  cerebral  excitement,  in  improving  whatever  con- 
stitutional impairment  may  exist  in  each  case,  and  in  the  use  of  such  rem- 
edies as  are  supposed  to  increase  the  tone  and  contraction  of  the  menin- 
geal vessels,  in  the  hope  of  lessening  the  size  and  fullness  of  the  vessels 
composing  the  membranous  patches  or  ltfEmatomn3,  and  thereby  retard 
their  growth  and  lessen  the  danger  of  hemorrhage.  Perhaps  no  remedies 
do  this  more  reliably  than  ergotine  aided  ijy  digitalis  when  the  cardiac 
action  is  quick  and  weak,  and  by  strychnine  and  iron  when  it  is  slow  and 
irregular  with  antemia  or  impoverishment  of  the  blood.  The  proper  ad- 
justment of  diet  and  exercise  to  the  general  constitutional  condition  of  the 
patient;  the  entire  prohibition  of  the  use  of  any  kind  of  alcoholic  drinks, 
tobacco,  and  all  other  agents  that  exert  an  antesthetic  or  paralyzing  influence 
on  the  vasomotor  nerve  functions;  and  the  judicious  use  of  such  i-eme- 
dies  as  I  have  just  mentioned  will  constitute  the  best  treatment  both  for 
retarding  or  arresting  the  progress  of  the  meningeal  disease,  and  prevent- 
ing the  frequent  hemorrhag^es  to  which  these  cases  are  liable.  When 
such  hemorrhages  do  occur,  it  may  be  necessary  to  add,  temporarily,  the 
use  of  mild  evacuants,  and  moderate  doses  of  iodide  of  potassium,  to 
hasten  the  re-absorption  of  the  serous  part  of  the  efi"used  blood  and  there- 
by lessen  the  pressure  upon  the  brain.  In  such  cases  as  have  a  manifest 
sy'philitic  constitutional  taint,  the  more  persistent  use  of  the  iodides  aided 
by  the  occasional  use  of  mercurial  alteratives  will  be  beneficial. 

Meningitis. — As  I  have  already  stated,  by  meningitis  I  mean  inflamma- 
tion of  the  pia  mater  and  convolutions  of  the  brain.  The  grade  of  inflam- 
mation may  be  either  acute,  subacute,  or  chronic.  It  may  involve  the 
whole  extent  of  the  menibrane  and  surface  of  both  hemispheres,  or  it  mav 
be  limited  to  one  hemisphere,  or  even  to  a  circumscribed  part  extendino- 
over  only  a  few  convolutions.  It  occurs  much  more  frequently  in  children 
under  five  years  of  age  than  in  adults. 

Causes. — Among  the  more  important  predisposing  causes,  are,  the 
greater  vascularity  and  less  maturity  of  s'.ructure  in  early  childhood;  the 
greater  excitability  and  less  tonicity  characteristic  of  the  scrofulous  and 
tuberculous  diatheses;  habitual  excess  of  mental  exercise  and  confinement 
in-doors;  protracted  mental  anxiety  with  deficient  sleep,  and  the  free  use 
of  rich  and  highly  seasoned  food  with  what  are  called  stimulating  drinks. 

The  more  immediate  exciting  causes,  are,  exposure  to  the  extremes  of 
heat  and  cold;  sudden  and  intense  mental  emotions  and  passions;  intense 
and  protracted  mental  exercises  of  any  kind;  the  deposit  of  gray  miliary  tu- 
bercular granules;  and  the  presence  in  the  blood  of  irritative  material 
whether  in  the  form  of  retained  excretory  products  derived  from  the  nat- 
ural tissue  changes,  or  of  toxemic  agents  imbibed  from  without. 

8i/mptoms,or  Clinical  History. — Simple  acute  meningitis  usually  com- 
mences rather  suddenly,  though  it  may  be  preceded  several  days  by  some 


326  MENINGITIS. 

headache,  vertigo,  flushed  face,  with  starting-  and  restlessness  at  night.  At 
the  actual  beginning-  of  the  inflammation  the  pain  in  the  head  becomes  in- 
tense, often,  particularly  in  children,  accompanied  by  a  few  minutes  of 
paleness  of  the  features  and  sudden  ejection  of  the  contents  of  the  stomach 
by  vomiting.  This  is  quickly  followed  by  general  febrile  action,  charac- 
terized by  flush  of  the  face,  congestion  of  the  vessels  of  the  conjunctiva, 
contraction  of  the  pupils,  distracting  pain  and  undue  heat  in  the  head, 
fullness  and  tension  of  the  carotid  and  temporal  arteries,  pulse  full  and 
frequent,  respiration  hurried,  mind  excited  and  generally  more  or  less  de- 
lirious, sometimes  wildly  so,  urine  scanty  and  high-colored,  and  bowels  in- 
active. In  children  under  five  years  of  age  this  stage  is  in  many  cases 
ushered  in  by  one  or  two  general  convulsions,  followed  by  the  asseml)lage 
of  symptoms  just  detailed.  x\nd  when  convulsions  do  not  occur  in  young 
children,  the  intense  pain  and  delirium  are  indicated  by  sudden  startings, 
screechings,  biting  of  the  fingers,  or  whatever  is  put  into  their  mouths, 
pulling  of  their  hair,  and  reckless  tossing-  from  side  to  side.  In  all  cases 
of  acute  meningitis  the  temperature  of  the  head  and  body  rises  rapidly, 
and  usually  ranges  during  the  stage  of  excitement  between  39°  and  40.5° 
C.  (102°  and  105°  F.)  in  the  axilla.  After  a  period,  varying-  from  twelve 
or  eighteen  hours  to  three  or  four  days,  the  symptoms  begin  to  change. 
The  symptoms  indicating  pain  in  the  head  and  mental  excitement  dimin- 
ish, the  temperature  falls  one  or  tv;o  degrees;  the  pulse  is  softer  and  a 
little  unsteady,  the  pupils  vacillate,  being  sometimes  contracted  and  in  a 
few  minutes  dilated,  or  more  frequently  one  pupil  dilates  while  the  other 
remains  small;  and  the  patient  has  brief  periods  of  apparent  sleep,  and  is 
noticed  to  be  much  less  sensitive  to  light  and  noise. 

On  the  supervention  of  these  symptoms  or  rather  abatement  of  the  pre- 
vious symptoms,  the  friends  and  sometimes  the  attending  physician  are 
greatly  encouraged,  thinking  the  patient  better.  But  in  twelve  or  eighteen 
hours  more,  it  is  found  that  the  periods  of  apparent  sleep  have  deepened 
into  stupor;  with  soft,  weak,  irregular  pulse;  unsteady  and  inefficient  res- 
piratoiy  movements;  dilated  pupils  and  strabismus  or  divergence  of  one  or 
both  eyes;  cool  extremities;  and  difficulty  of  deglutition.  In  young  children, 
the  stage  of  transition  from  high  excitement  to  that  of  stupor  and  depres- 
sion, is  in  many  of  the  cases,  marked  by  the  occurrence  of  general  convul- 
sions, followed  speedily  by  coma,  paralysis,  involuntary  discharges  and  death. 
And  in  cases  not  marked  by  convulsions,  whether  in  children  or  adults, 
the  stupor  gradually  deepens  into  profound  coma;  the  respirations  become 
very  slow  or  interrupted;  the  pulse  small  and  frequent;  the  eyelids  only 
partially  closed;  the  pupils  widely  dilated  and  deglutition  suspended;  fol- 
lowed by  general  paralysis  and  death.  There  are  thus  three  distinct  pe- 
riods or  stages  in  the  progress  of  each  case  that  proceeds  to  a  fatal  result. 
The  first  is  the  stage  of  high  irritative  excitement,  lasting,  as  I  have  al- 
ready said,  from  eighteen  hours  to  three  or  four  days.  The  second  is  the 
period  of  transition  from  high  excitement  to  stupor  and  depression,  and  is 
of  much  clinical  importance  as  marking  the  commencement  of  exudation 
and  effusion  from  the  previously  inflamed  and  over-distended  vessels;  and 
usually  lasts  from  twelve  to  twenty-four  hours.  '  The  third  stage  is  that  in 
which  the  inflammatory  products,  consistingof  a  serous  or  seropurulentfluid, 
with  some  fibrinous  material,  has  accumulated  in  sufficient  quantity  to  com- 
press the  brain  and  impair  or  overwhelm  its  functions,  and  varies  in  its 
duration  from  a  few  hours  to  five  or  six  days,  de]:)ending  upon  the  rapidity 
and  extent  of  the  exudation.  In  the  milder  class  of  cases,  and  in  such  as 
are  favorably  modified  by  early  and  active  treatment,  the  first  stage  is 
o-enerally  longer,  but  the  symptoms  of  excitement  are  less  severe,  and  the 


SYMPTOMS.  327 

vascular  fullness  subsides  with  so  little  exudation  or  effusion  that  convales- 
cence follows  instead  of  the  third,  or  stage  of  depression.  You  are  liable 
to  meet  with  a  class  of  cases,  chiefly  in  children  under  ten  years  of  age,  in 
which  the  symptoms  preceding  and  accompanying  the  first  stage  are  more 
obscure  and  much  more  liable  to  be  misunderstood.  In  this  class  of  cases, 
the  child  first  begins  to  look  sad  or  dejected;  has  a  variable  or  capricious 
appetite;  is  restless  or  frequently  starts  or  cries  out  in  his  sleep;  pulse  a 
little  accelerated  in  frequency;  temperature  from  one  to  two  degrees  high- 
er than  natural,  more  particularly  in  the  afternoon  and  evening,  but  looks 
pale  in  the  morning  with  but  little  disposition  to  exercise,  and  sometimes 
promptly  rejects  by  vomiting  whatever  is  first  taken  into  the  stomach  in 
the  morning.  The  bowels  are  usually  costive,  but  in  the  summer  season 
there  is  in  most  of  the  patients  frequent  turns  of  moderate  diarrhoea  with  a 
very  variable  condition  and  color  of  the  discharges.  After  one  or  two  weeks 
of  these  variable  and  apparently  mild  symptoms,  during  which  the  child  is 
usually  dressed  and  up  more  or  less  every  day,  there  comes,  in  some  of  the 
cases,  suddenly  one  or  more  general  convulsions,  which  are  followed  by 
more  fever,  more  signs  of  pain  in  the  head,  more  contraction  of  the  pupils, 
more  gastric  irritability,  a  more  frequent  and  somewhat  variable  pulse, 
and  indisposition  or  inability  to  assume  the  upright  position  for  more  than 
a  few  seconds  at  a  time. 

In  perhaps  a  majority  of  the  cases  the  same  increase  or  exaggeration 
of  the  symptoms  takes  place  without  the  occurrence  of  aeneral  convul- 
sions. After  continuing  with  but  little  variation  in  the  character  of  the 
symptoms,  except  a  steady  increase  in  the  loss  of  flesh  and  strength,  from 
one  to  two  weeks  after  confinement  to  the  bed,  the  patient  begins  to  appear 
more  dull  and  difficult  to  arouse;  one  or  both  pupils  are  observed  to  be 
larger  than  natural  and  the  eye  turned  from  its  natural  position,  and  in 
one  or  two  days  more  all  the  symptoms  I  have  mentioned  as  indicating 
the  accumulation  of  inflammatory  products  sufficient  to  produce  cerebral 
compression,  coma,  paralysis,  and  death.  Many  of  this  class  of  cases  are 
entirely  misunderstood  in  all  the  earlier  part  of  their  progress,  and  their 
symptoms  attributed  to  teething,  worms,  gastro-intestinal  irritation,  or  in- 
fantile remittent  fever;  their  true  character  not  being  suspected  until 
either  convulsions  or  the  symptoms  of  direct  cerebral  conqjression  have 
supervened. 

Scrofulous  or  Tubercular  Meningitis. — The  last  cases  described  may  be 
regarded  as  occupying  an  intermediate  relation,  or  as  forming  a  connect- 
ing link  between  the  ordinary  form  of  acute  meningitis  and  that  which 
occurs  in  connection  with  a  strongly  scrofulous  diathesis  or  an  actual  tu- 
bercular deposit  in  the  membranes  and  surface  of  the  brain.  The  latter 
class  of  cases  was  recognized  and  described  by  the  older  writers  under  the 
names  of  acute  and  chronic  hydrocephalus.  This  name  was  suggested  by 
the  fact  that  post  mortem  examinations  very  uniformly  showed  a  laro-e 
amount  of  serous  fluid  on  the  exterior  surface  of  the  pia  mater,  and  often 
extending  into  the  lateral  ventricles;  and  the  presence  of  the  small,  gray, 
or  miliary  tubercles  in  the  arachnoid,  pia  mater,  and  cerebral  convulutions 
was  not  recognized  until  a  later  period. 

The  symptoms  in  many  of  the  cases  belonging  to  this  class  are  at  first 
obscure  and  very  variable.  They  are  most  apt  to  be  manifested  between 
the  ages  of  one  and  seven  years;  yet  they  have  been  met  with  at  all  periods  of 
life.  In  the  great  majority  of  cases  the  earliest  symptoms  are  frequent  turns 
of  headache,  accompanied  by  slight  fever,  and  sometimes  vomiting;  restless- 
ness at  night,  manifested  by  startings,  crying  out  in  sleep,  and  frightful 
dreams;  gradual  loss  of  flesh,  with  variable  appetite   and    moderate  consti- 


328  TUBEHCULAR     MEISTHSTGITIS. 

pation,  the  latter  occasionally  interrupted  by  a  day  of  diarrhoea;  and  gener- 
ally paleness,  with  a  sad  expression  of  countenance  in  the  morning,  fol- 
lowed by  more  color  and  cheerfulness  in  the  afternoon,  with  slight  accel- 
eration of  pulse,  and  a  rise  of  one  or  two  degrees  in  temperature.  These 
symptoms  are  usually  noticed  more  or  less  for  several  weeks,  and  in  some 
cases  three  or  four  months,  when  suddenly  without  any  known  cause,  the 
little  patient  is  seized  with  a  general  convulsion,  which  may  be  repeated 
at  short  intervals  two  or  three  times,  or  may  occur  but  once.  This  is  fol- 
lowed by  a  more  continuous  moderate  grade  of  fever,  with  headache,  some 
contraction  of  the  pupils,  inability  to  be  up,  indisposition  to  talk  except 
when  directly  questioned,  little  or  no  appetite,  often  vertigo  and  disposi- 
tion to  vomit  when  the  head  and  trunk  are  raised  to  an  upright  position; 
pulse  and  respiration  are  variable,  generally  increased  in  frequency  when- 
ever the  patient  is  disturbed,  but  slower  and  occasionally  intermitting 
when  quiet  in  a  recumbent  position.  In  from  five  to  seven  days  after  the 
patient  is  compelled  to  remain  in  bed,  he  becomes  more  dull  and  somno- 
lent, his  pupils  more  dilated,  and  often  the  neck  stiiF,  or  the  head  turned 
to  one  side;  the  pulse  weaker  and  more  frequent,  respiratory  movements 
feeble  with  an  occasional  sigh,  deglutition  impaired,  bowels  inactive,  and 
abdomen  apparently  empty,  there  being  neither  distension  nor  tympanitis. 
In  the  early  part  of  this  stage,  the  patient  can  be  aroused  b\^  shaking  or 
sharp  questioning  sufficient  to  recognize  those  speaking  to  him  and  an- 
swer in  monosyllables;  but  if  the  answer  requires  the  use  of  sentences,  he 
will  generally  lose  the  thought,  and  leave  the  sentence  unfinished.  The 
supervention  of  these  symptoms  indicate  the  commencement  of  serous  ef- 
fusion and  consequent  pressure  upon  the  surface  and  the  lateral  ventricles  of 
the  brain.  The  symptoms  resulting  from  such  pressure  usually  increase 
from  day  to  day,  until  consciousness  is  entirely  lost;  the  discharges  invol- 
untary; the  limbs  motionless;  the  eyelids  only  half  closed;  pupils  widely 
dilated,  and  the  exposed  surface  of  eyeballs  dry,  with  a  little  muco-puru- 
lent  or  opaque  matter  in  the  inner  angle;  pulse  small,  weak,  and  variable 
in  frequency;  respiratory  movements  extremely  feeble,  with  an  occasional 
interruption,  followed  by  a  sigh  or  deeper  inspiration;  and  no  attempt  at 
deglutition.  In  from  one  to  four  or  five  days  after  the  development  of 
these  symptoms,  a  little  coarse  mucous  rattle  is  heard  in  the  trachea  and 
larger  bronchial  tubes  for  a  few  hours,  when  generally  one  or  two  slight 
convulsive  shudders  run  through  the  muscular  system,  the  chin  drops,  the 
tongue  falls  back  in  the  mouth,  a  few  feeble  gasps  for  breath,  and  life  is 
extinct.  Such  is  the  most  common  course  of  the  disease  as  met  with 
in  children  between  the  ages  of  one  and  seven  years.  It  is  sub- 
ject, however,  to  many  variations.  I  have  seen  children  of  a 
strong  hereditary  tubercular  diathesis,  who  were  subject  to  periods 
two  or  three  times  a  year,  lasting  two  or  three  weeks  at  a  time,  during 
which  they  would  present  all  the  premonitory  symptoms  I  have  just  de- 
tailed, including  one  or  more  convulsive  paroxysms,  yet  so  far  recover  as 
to  appear  bright  and  quite  well  in  the  interval.  In  almost  all  cases,  how- 
ever, the  symptoms  of  the  second,  followed  by  those  of  the  third  stage, 
came  on  before  the  end  of  the  second  year.  These  illustrate  the  more 
chronic  form  of  the  disease.  On  the  other  hand,  I  have  seen  cases  so  rapid 
that  after  the  symptoms  of  disturbed  sleep,  sudden  startings,  with  moder- 
ate gastric  and  intestinal  disturbances  had  lasted  but  two  or  three  days, 
more  continuous  fever  supervened  accompanied  by  drowsiness,  inattention, 
variable  pulse  and  respiration,  with  first  contracted  and  subsequently  di- 
lated pupils,  and  all  the  symptoms  of  cerebral  pressure  increasing  so  rapidly 
as  to  prove  fatal  in  from  five  to  seven    days  from    the  first   appearance  of 


SYMPTOMS.  329 

symptoms  sufficient  to  attract  attention.  In  adults  and  children  over  ten 
years  of  age,  the  disease  is  less  frequently  accompanied  by  convulsions 
during  any  stage  of  its  progress,  and  more  uniformly  continues  un^il  a 
fatal  result  is  reached  without  intervals  of  partial  recovery.  But  when  tho 
inflammatory  action  commences  in  the  pia  mater  before  the  cranial  sutures 
and  fontanelles  have  closed,  these  open,  allowing  the  head  to  enlarge  as 
the  effusion  accumulates,  thereby  lessening  the  direct  pressure  on  the 
cerebral  structure,  and  thus  enabling  the  patient  to  live  for  months  and 
sometimes  several  years.  It  is  but  a  few  weeks  since,  that  I  called  your 
attention  to  a  case  of  this  kind  in  one  of  the  hospital  clinics.  The  head 
of  the  child  was  increased  in  both  the  vertical  and  transverse  diame- 
ters, making  the  top  and  anterior  part  of  the  head  look  high  and  broad, 
with  the  anterior  fontanelles  prominent  and  at  least  fifty  millimeters  (two 
inches)  in  diameter,  while  the  eye-balls  appeared  to  be  crowded  a  little 
outward  and  downward,  giving  both  to  the  face  and  head  a  peculiar  and 
characteristic  appearance.  That  child  was  eighteen  months  old,  the  symp- 
toms of  meningitis  having  commenced  at  the  age  of  six  months.  While 
the  head  had  thus  increased  in  size,  the  body  and  extremities  were  emaci- 
ated and  the  muscles  of  the  neck  hardly  strong  enough  to  hold  the  head 
erect.  Neither  would  its  limbs  support  the  weight  of  its  body;  and  yet  it 
gave  evidence  of  considerable  mental  activity  and  intelligence.  A  few 
years  since  I  had  the  opportunity  of  presenting  to  the  clinical  class  a  girl 
aged  seven  years,  whose  history,  as  related  by  her  mother,  showed  an  at- 
tack of  subacute  meningitis  with  one  or  two  convulsions  when  the  child 
was  only  two  months  old;  after  which  the  head  continued  steadily  but 
slowly  to  increase  in  size  until  the  time  I  presented  her  to  the  clinical 
class.  At  that  tinie  the  sagital  and  coronal  sutures  were  wide  open,  the 
anterior  fontanelle  at  least  seventy-five  millimeters  (three  inches)  in  diam- 
eter, and  the  whole  head  enlarged  in  the  same  proportion.  The  eye-balls 
were  prominent  and  turned  obliquely  downward,  from  the  depression  of 
the  superior  orbital  plate  of  the  frontal  bone,  while  the  small  face  tapering 
to  the  chin  contrasted  strongly  with  the  broad  and  high  forehead.  The 
body  and  extremities  were  emaciated  and  small,  making  the  head  look 
larger  and  feel  heavier  than  the  whole  body.  She  could  move  all  her  limbs, 
but  had  not  strength  to  turn  her  head,  much  less  to  lift  it  from  the  pillow. 
When  allowed  to  remain  quiet  in  a  strictly  horizontal  position,  she  took 
food  and  drink  when  offered  to  her  and  manifested  some  degree  of  intelli- 
gence. But  the  mome:it  her  head  was  raised  up  sufficient  to  bring  the 
pressure  of  the  contained  fluid  upon  the  medulla  oblongata  and  parts  at  the 
base  of  the  brain,  the  whole  system  of  voluntary  muscles  would  become 
tremulous,  the  circulation  and  respiration  irregular,  and  unless  speedily 
returned  to  the  horizontal  position,  more  decided  convulsive  movements 
ensued.     She  died  in  the  eighth  year  of  her  age. 

These  cases  sufficiently  illustrate  the  course  of  chronic  meningitis  com- 
mencing in  early  infancy,  whether  connected  with  tubercular  deposits  or 
not.  The  chronic  form  of  the  disease  occurring  at  any  age  after  the 
cranial  sutures  and  fontanelles  have  closed,  if  accompanied  by  serous 
effusion,  must  necessarily  cause  compression  of  the  brain,  and  its  conse- 
quences, as  I  have  already  described.  There  is,  however,  a  grade  of  chronic 
meningitis  that  is  not  accompanied  by  serous  effusion  or  symptoms  of  com- 
pression, but  simple  hyperaimiaof  vessels  with  plastic  deposits  and  thicken- 
ing of  some  portions  of  the  membrane.  The  early  symptoms  of  such  cases 
are  almost  constant  cephalalgia  with  sensations  of  undue  heat  and  fullness 
in  the  head,  frequent  flushing  of  the  face,  slight  acceleration  of  the  pulse, 
inability  to   sleep,  undue   sensitiveness  to  light   and   sound,  great  mental 


330  CEEEBRITIS. 

excitability,  and  at  a  later  period  more  constant  mental  derangement  This 
form  of  meningitis  is  so  closely  connected  with  some  of  the  forms  of  in- 
sanity that  its  diagnostic  symptoms  will  be  more  fully  considered  in  con- 
nection with  that  subject. 

Oerebritis. — When  acute  or  subacute  inflammation  attacks  the  interior 
portions  of  the  brain  without  involving  the  surface  or  gray  matter  of  the 
convolutions,  the  symptoms  differ  in  some  respects  from  those  of  menin- 
gitis. The  initial  symptoms  are  generally  vertigo,  or  a  disposition  to  go  or 
fall  in  a  certain  direction  when  in  the  erect  position,  accompanied  by  a 
disposition  to  vomit,  and  in  some  cases  chilliness  and  cold  extremities. 
These  symptoms  are  followed  by  general  fever  and  pain  in  the  head,  but 
the  former  is  not  as  ligh  and  the  latter  is  more  circumscribed  or  limited 
to  some  one  part  of  the  head,  than  in  meningitis.  Instead  of  the  intense, 
throbbing,  distracting  pain  over  the  whole  head,  in  cerebritis  the  pain  is 
sharp,  often  running  through  the  head  like  a  knife,  but  so  limited  in  space 
that  the  patient  claims  he  can  cover  it  with  his  finger.  I  nstead  of  early 
and  excited  delirium  the  mind  appears  dull,  taciturn,  indisposed  to  talk, 
and  the  patient  turns  or  moves  his  head  with  reluctance.  In  the  early 
stage  the  pupils  are  contracted,  but  not  always  equally  so,  and  in  many 
instances  there  is  rigidity  of  some  of  the  muscles  of  the  neck  or  extremities 
or  hyperaesthesia  of  the  surface.  In  children  the  thumbs  are  sometimes 
drawn  into  the  palms  of  the  hands  and  the  fiiigers  bent  over  them  from 
tonic  contraction  of  the  muscles  of  the  forearm.  More  rarely  the  toes  and 
feet  are  affected  in  a  similar  manner.  The  temperature  seldom  rises  above 
39°  C  (102.5°  F.);  the  pulse  is  small  and  corded,  but  very  variable  in 
frequency,  in  some  cases  being  slower  than  natural  and  the  respirations 
altered  in  the  same  direction.  The  duration  of  this  first  stage  varies  in 
different  cases  from  three  to  seven  or  nine  days,  during  which  time  the 
abdomen  appears  empty  and  the  bowels  decidedly  costive.  Sooner  or 
later  the  mind  becomes  more  dull  or  wandering  and  difficult  to  arouse;  one 
or  both  pupils  begin  to  dilate;  the  respiration  and  circulation  are  more 
variable  and  often  intermitting;  deglutition  slow  and  difficult;  the 
muscles  previously  rigid  become  relaxed,  constituting  paralysis;  and  the 
evacuations  either  become  involuntary,  or  the  urine  is  retained  until  the 
bladder  is  over-distended.  In  this  condition  the  patient  lingers  from  one 
to  two  weeks  and  dies  in  an  unconscious  and  paralyzed  condition.  In  the 
more  acute  cases  the  disease  will  run  through  its  regular  stages  of  intense 
capillary  congestion,  exudation  and  fatal  compression  in  one  week,  while 
the  subacute  cases  may  occupy  from  four  to  six  weeks  in  reaching  the 
same  result.  You  will  thus  observe  that  the  usual  course  of  cerebritis  is 
slower  than  that  of  meningitis,  and  the  accompanying  symptoms  less 
violent  and  in  some  respects  more  resembling  those  of  typhoid  fever,  for 
which  it  has  been  sometimes  mistaken.  The  particular  part  of  the  brain 
involved  in  the  inflammation  in  any  given  case  is  often  clearly  indicated 
by  the  presence  of  special  symptoms.  Aphasic  symptoms  or  early  loss  of 
speech,  points  to  disease  of  the  inner  part  of  the  anterior  lobes,  or  more 
particularly  to  the  island  of  Reil.  Early  derangements  of,  or  loss  of  vis- 
ion, indicate  disease  near  the  tubercula  quadrigemina,  while  early  and 
prominent  disturbances  of  muscular  action,  as  manifested  either  in  spasms, 
muscular  rigidity,  or  inco-ordination  of  movements,  point  to  the  cerebellum 
or  medulla  oblongata,  as  the  seat  of  disease. 

Cerebral  Sclerosis. — There  is  one  more  form  of  inflammation  occasionally 
met  with  aff^ecting  the  structure  of  the  brain.  Its  primary  seat  is  the  con- 
nective tissue,  which  under  chronic  inflammatory  irritation  becomes  hyper- 
trophied  and  consequently   so  presses   upon  the   nerve  cells   and  fibres  as 


CEREBRAL    SCLEROSIS.  331 

to  interrupt  their  nutrition  and  cause  their  ultimate  disappearance,  leav- 
ing- the  texture  of  the  part  harder  than  natural.  These  cases  ofdiseHse  of 
the  brain  are  strictly  analogous  in  their  pathology  to  the  slow  interstitial 
inflammation  that  leads  to  sclerosis  of  the  connective  tissue  of  the  lungs, 
liver,  and  kidneys,  as  seen  in  what  some  have  called  fibroid  consumption, 
cirrhosis,  and  the  hard  granular  kidney.  Hence  it  has  been  called 
cerebral  sclerosis.  This  affection  is  always  chronic,  and  its  clinical  history 
extends  over  several  years.  I  have  one  case  now  under  observation  that 
has  already  continued  fifteen  years;  but  most  of  the  cases  terminate  in 
from  five  to  ten  years.  The  most  characteristic  symptoms  are  mental  de- 
spondency, with  impairment  of  the  mental  faculties  generally,  but  more 
in  the  direction  of  enfeeblement  than  of  perversion  or  derangement;  a  pe- 
culiar fixedness  of  the  position  of  the  head  in  walking,  generally  leaning  it  a 
little  i'orward  or  to  one  side,  with  a  slightly  tremulous  or  unsteady  condition 
■of  the  voluntary  muscular  movements;  and  as  the  disease  advances,  the  mus- 
cular rigidity  or  paralysis  affects  successively  different  sets  of  muscles  in 
such  order  of  succession,  as  to  indicate  quite  clearly  the  progressive  ex- 
tension of  the  disease  in  the  cerebral  structure.  A  constant  dull  pain  ex- 
tending from  the  occipital  to  the  lower  part  of  the  frontal  region,  throuo-h 
the  base  of  the  brain,  increased  by  motion,  is  a  pretty  (  onstant  accom- 
paniment of  the  disease;  as  is  also  insomnia  and  great  restlessness  at 
night.  In  the  advanced  stage  of  the  disease  the  muscles  concerned  in 
speech  and  deglutition,  become  so  impaired  in  their  action  as  to  render 
both  these  acts  slow  and  difficult.  And  if  the  patient  gains  an  uprio-ht 
position  he  is  disposed  to  move  in  some  special  direction  in  spite  of  his 
efforts,  or  if  he  progresses  forward,  it  is  only  by  a  trotting  gait  with  the 
head  and  body  leaning  in  that  direction. 

In  most  of  this  class  of  patients  the  appetite  and  general  nutrition  con- 
tinue good.  Consequently  there  is  little  or  no  emaciation,  and  in  some 
cases  a  positive  increase  of  fat  and  weight.  More  or  less  fattv  deo-enera- 
tion  generally  accompanies  the  pathological  changes  in  the  brain,  and  the 
mental  faculties  ultimately  become  so  impaired  as  to  constitute  decided 
dementia;  and  death  finally  results  from,  the  hi"emorrhagic  extravasations, 
causing  general  paralysis  or  apoplexy. 

Cerebral  sclerosis  is  very  generally  connected  with  similar  patholoo-ical 
changes  in  some  part  of  the  medulla  and  spinal  cord.  Of  the  symptoms 
indicating  the  existence  of  the  latter,  I  shall  speak  when  considering  the 
inflammations  of  the  cord  generally.  As  the  present  hour  has  expired,  I  must 
reserve  the  consideration  of  the  morbid  anatomy,  diagnosis,  and  treatment  of 
the  different  grades  of  meningitis,  cerebritis,  and  cerebral  sclerosis  until 
we  meet  to-morrow. 


LECTURE  XXXV. 

Inflammation    of  the  Brain,  e*e.,  continued— Meningitis,  Cerebritis,  Cerebral  Sclerosis;  Their 
morbid  Anatomj-,  Diagnosis,  and  Treatment. 

GENTLEMEN:  At  the  close  of  the  preceding  lecture  hour  I  had  com- 
pleted what  was  deemed  necessary  to  say  concerning  the  clinical 
history  or  symptomatology  of  the  different  grades  of  inflammation  affect- 
ing the  membranes  an-i  structure  of  the  "  brain.  As  I  explained  fully 
when  speaking  of  the  general  pathology  of  inflammation,  the  first  stage  is 


332  PATHOLOGY    OF    MEXllS'GITIS,    ETC. 

characterized  by  intense  vascular  fullness  with  increased  excitability  of 
the  inflamed  part.  In  all  cases,  therefore,  in  which  death  has  taken  place 
during-  the  first  stage  of  either  meningitis  or  cerebritis,  a  post  mortem  ex- 
amination of  the  inflamed  structures  shows  complete  engorgement  of  the 
capillaries  and  smaller  vessels  with  correspondingly  increased  redness, 
and  some  disturbance  of  the  molecular  arrangement  of  corpuscles  and  or- 
ganic atoms,  both  in  the  contents  and  walls  of  the  vessels.  When  death 
has  taken  place  during  the  second  or  third  stage,  you  find,  in  addition  to 
the  redness  and  intense  vascular  fullness,  more  or  less  exudation  of  the 
contents  of  the  vessels  both  into  the  interstitial  spaces  and  upon  the 
surface  of  the  inflamed  part.  If  the  case  is  one  of  meningitis  or  inflam- 
mation of  the  pia  mater  and  surface  of  the  convolutions,  you  will  generally 
find  a  stratum  of  serous  fluid  over  the  surface  of  the  membrane,  in  the 
lateral  ventricles,  between  the  convolutions,  and  to  some  extent  in  the 
interstitial  spaces  of  the  gray  matter  under  the  membranes. 

This  serous  fluid  has  escaped  from  the  over  d'stended  vessels  and  con- 
tains, besides  the  water,  more  or  less  albumen,  shreds  of  fibrin,  white  and 
red  corpuscles,  and  sometimes  numerous  pus  cells.  The  amount  of  fluid 
varies  much  in  different  cases.  In  some  of  the  more  active  cases  in  pa- 
tients with  previous  plastic  blood,  numerous  patches  of  thin  pseudo-mem- 
branous exudation   have  been  found  on  the  surface  of  the  pia  mater. 

In  the  tubercular  form  of  meningitis  the  amount  of  serous  eflusion  is 
generally  larger  than  in  simple  inflammation,  but  the  fibrinous  or  plastic 
elements  are  less.  The  chief  structural  peculiarity  of  these  cases,  howev- 
er, IS  the  presence  of  small  gray  miliary  tubercles  chiefly  in  the  pia  mater, 
but  often  also  in  the  arachnoid  and  in  the  gray  matter  of  the  cerebral  con- 
volutions. They  are  found  in  greatest  number  usually  in  the  memlirane 
covering  the  under  surface  of  the  cerebellum  and  posterior  lobes  of  the 
cerebrum,  in  the  fossa  Sylvii,  and  neigh1:)oring  parts,  but  are  also  sometimes 
found  over  the  cerebral  hemispheres,  and  in  the  choroid  plexus.  Many  of 
the  granules  are  very  small,  but  when  several  are  aggregated  together 
they  may  make  a  nodule  the  size  of  a  small  pea.  Examined  under  the 
microscope  they  are  found  to  consist  of  lymphoid  cells  collected  in  nodules 
in  the  walls  of  the  small  arteries  of  the  pia  mater  and  surface  of  the  brain. 
The  large  granular  or  giant  cell  is  rarely  seen,  and  appearances  of  caseous 
degeneration  in  the  center  of  these  small  tubercles  is  less  observable  than 
in  tubercular  deposits  elsewhere.  The  serous  part  of  the  effusion  in  this 
class  of  cases  is  found  mostly  under  the  base  of  the  brain  and  in  the  lateral 
ventricles,  and  often  contains  pus  cells  enough  to  give  it  a  turbid  appear- 
ance. 

In  cerebritis  or  inflammation  of  the  interior  part  of  the  brain,  there  is  a 
decided  tendency  to  suppuration  and  the  formation  of  abscesses.  In 
some  cases  the  collections  of  pus  are  small  and  numerous,  with  the  vessels 
of  the  surrounding  brain  structure  finely  injected  with  blood  and  the  in- 
terstitial spaces  crowded  with  serous  fluid  containing  pus  corpuscles,  giv- 
ing it  an  cedematous  and  somewhat  softened  appearance.  Small  hgemor- 
rhagic  exudations  into  the  perivascular  sheaths,  with  broken  nerve  fibres 
and  fatty  degeneration  of  the  ganglion  cells,  are  also  observable  in  most 
cases.  Instead  of  numerous  small  abscesses,  cases  occasionally  occur 
with  but  one  abscess  and  that  of  large  size. 

In  all  recent  cases  the  walls  of  the  abscess  are  fringed  or  shaggy  and 
destitute  of  a  lining  membrane.  But  in  more  protracted  or  chronic  cases 
the  walls  of  the  abscess  are  generally  lined  with  a  layer  of  condensed  con- 
nective tissue  somewhat  resembling  a  cyst,  and  the  matter  may  emit  an 
ofl'onbive  odor.     "When  death  has  taken   place  early,  there  may  be  no  wel 


DIAGJfOSIS.  333 

defined  abscesses,  but  the  inflamed  structure  when  cut  across,  will  pre- 
sent numerous  points  of  blood  from  the  engorged  vessels,  a  reddish  yellow 
color  of  the  surface,  and  some  interstitial  infiltration  of  the  liquor  san- 
guinis. 

In  the  cerebral  sclerosis,  the  chief  pathological  changes  are,  the  hyper- 
plasia or  increased  growth  of  the  connective  tissue  and  the  coincident 
diminution  of  the  nerve  cells  with  more  or  less  fatty  degeneration  of 
such  cells  as  remain.  This  gives  greater  density  or  induration  to  the 
affected  brain  structure,  instead  of  softening,  as  in  ordinary  cerebritis. 
The  seat  of  this  form  of  disease  is  generally  in  the  white  or  medullary 
part  of  the  brain,  and  is  very  generally  confined  to  particular  tracts  or 
bundles  of  nerve  fi'ires,  and  may  be  traced  through  the  medulla  down 
the  spinal  cord. 

.  Diagnosis. — The  diagnosis  of  simple  acute  or  subacute  inflammation 
of  the  membranes  and  surface  of  the  cerebral  hemispheres,  to  which  I  have 
applied  the  name  of  meningitis,  is  not  difficult.  The  severe  distracting 
pain  and  unusual  heat  in  the  head,  the  fullness  of  the  carotid  and  tempo- 
ral arteries,  the  contraction  of  the  pupils,  the  increased  sensibility  to  light 
and  sound,  and  the  general  nervous  and  mental  excitement,  constitute  an 
assemblage  of  symptoms  that  sufficientlv  indicate  the  early  stage  of  this 
disease  ;  while  the  subsequent  stupor,  dilated  pupils,  variable  pulse,  sigh- 
ing respiration,  and  paralysis,  still  more  strikingly  characterize  the  later 
stages  of  its  progress. 

The  milder  cases  of  the  subacute  and  those  of  the  tubercular  form,  require 
closer  attention  to  prevent  mistakes  during  the  early  stage  of  their  procu- 
ress. The  nervous  symptoms  accompanying  these  cases,  such  as  sudden 
startings,  crying  out  in  sleep,  and  even  the  convulsions,  are  very  often 
attributed  to  teething.,  if  the  patient  is  under  two  years  of  age,  and  to 
V'orms,  if  older. 

So,  too,  the  sudden  turns  of  paleness  and  vomiting,  followed  by  feverish- 
ness  with  the  variable  condition  of  the  intestinal  discharges  already 
described,  are  attiibuted  either  to  the  same  causes  or  to  gastro-intestinal 
irritation.  There  is,  however,  in  all  these  cases  of  meningeal  disease,  a 
continued  sadness  of  expression,  a  carefulness  in  the  movements  of  the 
head,  an  alteration  in  the  size  of  the  pupils,  and  a  lankness  of  the  abdo- 
men or  absence  of  flatulent  distension,  that  T  have  never  seen  in  connec- 
tion with  intestinal  v,"orms  or  any  other  form  of  gastro-intestinal  irritation. 
It  only  requires  careful  and  discriminating  attention  to  the  history  and 
detail  of  symptoms  in  each  case  to  avoid  mistakes  in  the  diagnosis,  even 
in  the  first  stage  of  the  disease. 

The  only  disease  with  which  cerebritis  has  been  confounded,  is  typhoid 
fever.  There  is  a  certain  degree  of  similarity  in  some  of  the  symptoms, 
such  as  the  dullness  and  indisposition  to  talk  freelv,  the  vertigo  or  un- 
steadiness of  the  head  in  the  upright  position,  and  the  low  grade  of  fever. 
But  close  attention  will  develop  the  fact  that  in  the  cerebral  disease,  the 
pain  in  the  head  is  more  circumscribed  and  penetrating;  one  or  both  pu- 
pils are  contracted,  and  the  eyes  unduly  sensitive  to  light;  a  disposition  is 
manifested  to  keep  the  head  in  a  fixed  position,  or  if  moved,  to  have  an  in- 
clination to  fall  in  a  given  direction;  the  bowels  are  not  only  costive,  but 
requiring  full  dosps  of  cathartic  medicines  to  move  them;  and  the  abdo- 
men is  free  from  tympanites  or  fullness  irom  any  cause.  These  are  all  re- 
versed in  the  early  stage  of  typhoid  or  any  other  general  fever.  As  the 
cerebral  disease  advances,  the  further  alteration  of  the  pupils,  the  occur- 
rence of  rigidity  in  the  muscles  of  the  neck  or  extremities,  the  increasing 
3tu   or  or  difficulty  of  speech,  and  the  continued  lankness  or  retraction  of 


'331  MENIJfGITIS,    ETC. 

the  abdominal  muscles,  ought  to  be  regarded  as  sufficient  to  remove  all 
doubts  concerning  the  diagnosis.  The  detail  of  symptoms  I  gave  in  the 
preceding  lecture  as  accompanying  cerebral  sclerosis,  are  sufficiently  di- 
agnostic of  that  form  of  disease,  and  need  not  to  be  repeated  here. 

Prognosis. — All  cases  of  inflammation  involving  either  the  pia  mater, 
cerebral  convolutions,  or  interior  structure  of  the  brain,  are  more  or  less 
dangerous  to  life.  In  simple,  acute  and  subacute  meningitis,  as  I  described 
it  in  the  preceding  lecture,  if  the  diagnosis  is  made  early,  and  the  treat- 
ment promptly  and  accurately  adjusted  during  the  first  stage  of  the  in- 
flammatory process,  there  is  a  reasonable  probability  of  success  in  arresting 
the  disease  before  any  considerable  amount  of  exudation  or  elfasion  has 
taken  place,  and  the  patient  will  recover.  Such  a  result  has  been  ob- 
tained in  many  cases  under  my  ov^n  observation.  If  the  first  stage  has 
passed,  and  symptoms  of  effusion  or  exudation  already  exist,  the  progno- 
sis must  be  regarded  as  decidedly  unfavorable,  although  occasionally  a 
case  may  recover  by  the  absorption  of  the  inflammatory  products.  When 
meningitis  or  cerebritis  occurs  in  a  patient  of  (decided  scrofulous  or  tuber- 
culous diathesis,  and  especially  if  tubercular  deposits  already  exist,  it  is 
not  probable  that  a  permanent  recovery  ever  takes  place. 

I  have  many  times  seen  mild  inflammatory  attacks  in  such  cases  prompt- 
ly checked  by  proper  treatment,  but  the  disease  has  always  returned,  and 
ultimately  proved  fatal. 

Cerebral  sclerosis,  when  well  esta'Jished,  is  also  uniformly  fatal,  but  in 
most  cases  not  until  after  a  period  of  suffering,  varying  from  five  to  fifteen 
years. 

Treatinent. — The  delicacy  of  structure  and  high  degree  of  vascularity 
of  the  brain  and  its  immediately  investing  membrane,  together  with  the 
fact  that  after  the  early  months  of  infancy  the  whole  is  inclosed  within 
the  bones  of  the  cranium  in  such  manner  as  to  allow  of  little  or  no  expan- 
sion from  increased  fullness  of  blood,  makes  that  element  of  the  first 
stage  of  the  inflammatory  process  which  I  have  called  hyperaemia  or  accu- 
mulation of  blood  in  the  inflamed  part,  one  of  paramount  importance  in 
the  diseases  now  under  consideration.  In  all  the  more  acute  inflammatory 
attacks,  whether  involving  the  membranes  or  substance  of  the  cerebral 
hemispheres  it  is  the  pressure,  first  from  the  over-distended  and  engorged 
blood-vessels,  and  second,  from  the  accumulation  of  inflammatory  products, 
that  constitutes  the  chief  danger  to  the  life  of  the  patient.  Consequentlv, 
it  is  of  great  importance  to  commence  the  treatment  of  all  such  cases  as 
soon  after  the  commencement  of  the  attack  as  possible,  and  to  use  such 
remedies  promptly  as  will  be  most  efficient  in  lessening  the  accumulation 
of  blood  in  the  part.  By  so  doing  we  shall  not  only  lessen  the  danger  of 
fatal  pressure  from  the  direct  engorgement  of  vessels,  but  we  shall  most 
t-ffectually  limit  the  amount  of  inflammatory  products  in  the  form  of  exu- 
dations and  effusions.  For  it  matters  not,  gentlemen,  what  theory  of  in- 
flammation you  adopt,  the  clinical  fact  remains  that  you  get  no  inflammatory 
products,  whether  in  the  form  of  cell-proliferation,  migrating  corpuscles  or 
leucocytes,  micrococci,  or  exuded  liquor  sanguinis,  until  you  first  have 
undue  vascular  fullness  or  accumulation  of  blood  and  irritation  of  structure; 
and  the  additional  fact  that  the  further  accumulation  of  such  products 
ceases  as  soon  as  the  vascular  fullness  is  removed.  Therefore  I  repeat 
with  emphasis,  that  the  leading  object  to  be  accomplished  in  the  treat- 
ment of  the  first  stage  of  cerebral  inflammation  is  to  relieve  the  undue 
accumulation  of  blood  before  a  dangerous  degree  of  exudation  has  taken 
place,  and  so  far  as  may  be  practicable  to  coincidently  lessen  the  morbid 
excitability  of  structure.     If  you  succeed  fully  in  accomplishing  this  ob- 


TREATMENT.  66o 

jfiot  yoii  prevent  the  second  stage,  and  it  is  only  necessary  to  continue 
those  maasures  that  are  calculated  to  lessen  irritability  and  prevent  a  re- 
newal of  blood  accumulation,  for  a  few  days,  and  convalescence  will  be 
established.  If,  however,  the  effort  to  relieve  the  hyperfeniia  of  the  first 
sta'jre  has  been  only  partially  successful,  and  the  second  stage  accompa- 
nied by  more  or  less  exudation,  whether  plastic  or  serous,  has  supervened, 
then  the  principal  objects  to  be  accomplished  by  further  treatment,  are,  to 
sustain  the  patient  and  hasten  as  far  as  possible  the  removal  of  the  exuda- 
tive products  by  disintegration  and  re-absorption. 

I  state  thus  distinctly  the  objects  desirable  to  accomplish  in  thetreit- 
ment  of  the  successive  stages  of  both  meningitis  and  cerebritis,  because 
they  are  founded  on  the  nature  of  the  inflammatory  process  and  the  ana- 
tomical characteristics  of  the  structures  involved,  and  will  always  remain 
the  "same.  The  relative  value  of  the  therapeutic  agents  designed  to  ac- 
complish any  given  object,  may  change  with  every  addition  to  our  know.- 
edge  of  new  remedies  or  of  the  modus  o2)eraiidi  of  old  ones,  but  the 
object  itself  will  still  remain. 

In  addition  to  a  definite  knowledge  of  the  objects  to  be  accomplished, 
it  is  desirable  that  you  have  an  equally  clear  con  prehension  of  the  modes 
by  which  they  may  be  effected.  For  instance,  the  accompl  shment  of  the 
first  object  I  have  named,  may  be  reached  either  by  the  use  of  remedies  that 
reduce  the  force  and  frequency  of  the  action  of  the  heart,  and  thereby  lessen 
the  quantity  of  blood  sent  to  the  inflamed  part  in  a  given  time;  or  by  the  re- 
moval of  a  quantity  of  the  lilood  itself  sufficient  to  lessen  the  general  full- 
ness, as  by  venesection  and  leeches;  and  by  such  as  are  capable  of  induc- 
ing contraction  of  the  hyperjemic  vessels  themselves.  In  other  words  the 
amount  of  blood  in  the  vessels  and  capillaries  of  a  part,  may  be  influenced 
by  cardiac  sedatives,  direct  depletion,  and  vasomotor  excitants  or  tonics. 
The  relative  value  and  applicability  of  each  of  these  classes  of  remedies 
in  any  given  case  must  depend  upon  the  special  character  of  the  inflam- 
mation as  influenced  by  the  quality  of  the  blood  and  the  elementary  prop- 
erties of  the  structure  involved.  In  acute  active  inflammation  of  the 
membranes  and  structure  of  the  brain,  in  subjects  not  previously  debili- 
tated by  specific  causes,  the  prompt  af)Straction  of  a  libei-al  quantity  of 
blood  by  one  free  bleeding  in  adults  and  by  leeches  in  children,  aided  by 
the  judicious  use  of  cardiac  sedatives,  is  by  far  the  most  efficient  mode  of 
checking  or  arresting  the  inflammatory  process  in  its  first  stage,  that  can 
be  devised.  That  many  of  the  milder  class  of  cases  can  be  controlled  by 
the  sedatives  without  the  loss  of  blood  has  been  proved  by  clinical  epe- 
rience. 

But  in  my  estimation  the  same  kind  of  experience  has  equally  proved 
that  in  the  more  acute  and  active  cases  the  danger  to  the  life  of  the  pa- 
ixent  is  greatly  increased  by  such  omission.  Bleeding  should  be  resorted 
to  only  during  the  stage  of  active  excitement,  before  any  symptoms  of  ex- 
udation or  effusion  are  manifest.  Elevate  the  head  and  shoulders  of  your 
patient  a  little,  cord  the  arm  and  make  an  opening  in  the  vein  sufficient 
to  allow  the  blood  to  flow  in  a  free  stream,  and  let  the  flow  continue  until 
the  pulse  becomes  soft,  the  face  free  from  flush,  and  small  drops  of  sweat 
appear  on  the  forehead.  When  you  get  these  effects,  lower  the  head  and 
shoulders  more  nearly  to  the  horizontal,  loosen  the  cord  upon  the  arm  lit- 
tle by  little  so  that  the  flow  of  blood  stops  rather  gradually  instead  of  sud- 
denly, dress  the  arm  by  a  compress  over  the  incision  and  a  bandage  to 
keep  it  in  place.  If  the  bleeding  has  been  continued  until  the  efi^ects  I 
have  mentioned  have  been  produced,  without  regard  to  the  mere  quantity 
of  blood  taken,  you  will  find  it  immediately  followed  by  general  moisture 


336  MENINGITIS,    ETC. 

of  the  skin,  sometimes  faintness  or  a  momentary  approach  to  syncope,  and 
great  relief  to  the  pain  in  the  head.  The  amount  of  blood  required  to  be 
taken  to  produce  a  given  eifect,  differs  much  in  different  patients.  I  have 
seen  some  patients  with  meningitis  from  whom  I  was  compelled  to  ab- 
stract one  litre  (?xxxii)  of  blood  to  obtain  the  same  effect  on  the  circula- 
tion and  general  condition  of  the  patient,  as  I  have  obtained  in  other 
cases  of  the  same  disease  by  taking  only  half  that  quantity  (fxvi).  By 
one  prompt,  free  bleeding,  as  I  have  described,  you  directly  lessen  the 
force  of  the  heart's  action,  diminish  the  general  vascular  fullness,  and 
make  the  blood  less  stimulating  by  materially  diminishing  the  relative 
proportion  of  its  red  corpuscles.  To  hold  the  advantage  you  have  thus 
gained,  you  should,  even  while  the  blood  is  flowing,  or  as  soon  after  as 
possible,  commence  the  administration  of  cardiac  or  arterial  sedatives,  ap- 
ply warmth  to  the  extremities  and  an  ice  cap  to  the  head,  and  in  an  hour 
after  the  first  dose  of  the  sedative,  give  a  full  cathartic  of  calomel  and 
jalap.  If  it  does  not  move  the  bowels  freely  in  three  or  four  hours,  hasten 
the  action  by  from  eight  to  twelve  grams  (3ii  to  3iii)  of  sulphate  of  mag- 
nesia, or  an  enema  of  warm  saltwater  sufficient  to  fill  the  rectum. 

In  the  mean  time  the  windows  should  be  a  little  shaded  and  the  sick 
room  kept  as  quiet  as  possible  and  the  doses  of  the  sedative  repeated  every 
two  hours  until  the  frequency  of  the  pulse  is  reduced  nearly  to  the  natural 
standard,  and  then  so  graduated  as  to  time  and  quantity  as  to  hold  this 
control  over  the  circulatioti  without  inducing  vomiting.  The  sedative 
which  I  prefer  for  this  purpose  is  the  saturated  tincture  of  veratrum  viride 
in  doses,  for  adults,  of  0.25  to  0.33  c.  c.  (min.  ivto  v)  every  two,  three,  or 
four  hours  as  may  be  found  necessary  to  produce  the  desired  coiUrol  over 
the  circulation.  In  some  cases  accompanied  by  great  nervous  disturbance 
and  delirium,  I  have  thought  better  effects  were  obtained  by  a  combination 
of  one  part  of  the  tincture  of  veratrum  viride  with  two  parts  of  the  tincture 
of  gelsemium,  given  in  doses  of  0.6  to  1.0  c.  c.  (min.  x  to  xv)  every  three 
or  four  hours.  Of  course  these  doses  must  be  reduced  in  treating  children, 
to  correspond  with  the  age  of  the  child.  All  the  remedies  I  have  now  in- 
dicated should  be  made  to  follow  the  bleeding  as  quickly  as  possible  and 
their  effects  carefully  noted  that  in  dose  and  time  of  administration  they 
may  be  kept  accurately  adjusted  to  the  condition  of  the  patient.  After 
the  bowels  had  been  freely  moved  b}'  the  cathartic,  in  severe  cases,  I  have 
given  alterative  doses  of  calomel  between  the  doses  of  veratrum  for  twen- 
ty-four hours  and  followed  them  by  a  saline  laxative  sufficient  to  produce 
a  moderate  evacuation  of  the  bowels. 

In  a  large  proportion  of  the  cases  in  which  the  measures  I  have  indicated 
were  commenced  early  and  prosecuted  judiciously,  the  disease  was  ar- 
rested, or  the  symptoms  so  much  relieved  as  to  obviate  danger  to  life  be- 
fore the  end  of  the  third  day,  and  an  early  convalescence  followed.  If,  in- 
stead of  this,  however,  symptoms  of  commencing  effusion  or  exudation  are 
developed  as  I  described  when  speaking  of  the  symptoms  wliich  mark  the 
beginning  of  the  second  stage  of  the  inflammatory  process,  the  cardiac 
sedatives  should  be  promptly  discontinued  or  much  reduced  in  quantity, 
and  fair  doses  of  iodide  of  potassium  substituted  in  their  place.  The 
following  formula  is  one  of  the  most  efficient  that  I  have  used  at  this 
critical  stage  of  the  disease: 

5.      Potassii  lodidi  10.00  grams  3iiss 

Tincturae  Digitalis  15.00  c.  c.  3iv 

Tincturae  Hyoscyami  15.00  "•  "  3iv 

Aquje  Ment'hje  90.00  "  "  liii 


TKEATMENT.  337 

Mix.  Give  four  cubic  centimeters  (fl.  3')  every  two  or  three  hours,  in 
a  little  sweetened  water.  At  the  same  time  blisters  may  be  applied  to 
the  mastoid  spaces  or  back  of  the  neck,  or  to  both;  and  the  cold  appli- 
cations to  the  head  allowed  gradually  to  increase  in  temperature  until 
they  become  decidedly  warm  instead  of  cold.  Sometimes  these  measures, 
if  broug-ht  into  requisition  at  the  beginning  of  the  transition  from  active 
excitement  and  hyperjemia  to  that  of  depression  and  exudation,  will  check 
the  progress  of  the  latter  in  time  to  prevent  entire  stupor  and  paralysis, 
and  the  patient  will  slowly  recover.  But  they  often  fail  and  the  fatal  re- 
sult soon  follows. 

In  many  of  the  milder  cases,  both  of  meningitis  and  cerebritis,  the  free 
application  of  leeches  to  the  temples  and  mastoid  regions  may  take  the 
place  of  the  first  general  bleeding.  The  same  remark  is  applicable  to  the 
more  active  cases  of  tubercular  meningitis;  while  the  milder  cases  of  this 
class  are  better  intrusted  to  the  cautious  use  of  cardiac  sedatives,  iodides, 
hyoscyamus,  and  blisters,  without  the  loss  of  blood  by  either  leeches  or 
venesection. 

If  the  disease  assumes  a  chronic  form  with  effusion  and  enlargement  of 
the  head,  as  it  often  does  when  the  attack  occurs  in  infancy,  I  have  seen 
more  benefit  from  the  protracted  use  of  moderate  doses  of  iodide  of  potas- 
sium, internally,  and  the  repeated  application  of  small  blisters  over  the 
mastoid  spaces,  than  from  any  other  remedies.  In  such  cases  the  diet 
should  be  simple  and  easily  digested,  yet  sufficiently  nutritious  to  sustain 
the  patient. 

During  the  first  stage  of  active  excitement  in  ordinary  cases  of  acute 
cerebral  inflammation,  the  patients  need  no  other  nourishment  than  toast- 
water  or  thin  gruel,  and  in  the  latter  stages  milk  in  small  doses.  During 
convalescence  the  nourishment  should  still  be  mild  and  unstimulating,  the 
exercise  very  moderate,  with  a  careful  avoidance  of  all  mental  excitement 
or  active  mental  application. 

In  cerebral  sclerosis  or  chronic  inflammation  of  the  connective  tissue  in 
certain  portions  of  the  brain,  no  remedies  have  been  found  to  possess  any 
certain  control  over  the  progress  of  the  disease.  In  the  cases  that  have 
come  under  my  own  observation,  I  have  obtained  more  benefit  from  the 
protracted  use  of  a  combination  of  iodide  of  sodium,  bichloride  of  mercury, 
and  conium,  than  from  all  other  remedies.  The  following  is  a  convenient 
formula  for  its  administration: 

IJ      Sodii  lodidi  12.000  grams  3iii 

Hydrargyri  Chloridi  Corosivi    0.066        "  gr.  i 

Extracti  Conii  Fluidi  15.000  c.  c.  3iv 

Elixir  Simplicis  105.000    "  "  ?iiiss 

Mix.  Give  four  cubic  centimeters  (fl.  3i)  at  breakfast,  noon,  tea- 
time  and  at  bed-time,  in  a  little  water. 

You  may  say  that  the  iodide  and  the  mercurial  in  this  prescription 
unite  and  form  an  iodide  of  mercury,  and  ask  me  why  I  do  not  prescribe 
the  latter  directly.  I  answer  that  the  sixty-six  milligrams  ot  corrosive  chlo- 
ride can  combine  with  only  a  very  small  part  of  the  twelve  grams  of  iodide 
of  sodium,  and  that  the  excess  of  the  latter  constitutes  a  very  important 
part  of  the  prescription.  And  numerous  trials  have  shown  that  the  admin- 
istration of  the  iodides  of  mercury  alone  do  not  produce  the  same  degree 
of  benefit  as  when  combined  with  the  excess  of  iodide  of  sodium  as  in  the 
prescription  just  named. 

22 


338  CEEEBRAL  SCLEROSIS. 

Patients  who  have  not  acquired  a  previous  undue  susceptibility  to  the 
influence  of  mercurials  can  generally  continue  the  use  of  this  combination 
several  weeks  without  aiFecting  the  mouth  or  gums.  Still  the  effects  of 
mercurial  preparations  in  this  direction  should  be  watched  with  reasonable 
care. 

Some  of  the  cases  coming  under  the  head  of  sclerosis  are  closely  allied 
to,  if  not  identical  with,  chronic  rheumatic  inflammation.  In  such,  some 
benefit  may  be  derived  from  the  use  of  fair  doses  of  salicylate  of  sodium 
or  bromide  of  lithium,  more  especially  if  given  in  connection  with  the 
tincture  or  fluid  extract  of  the  phytolacca  decandra.  The  phosphide  ol 
zinc  (Ur.  Flint),  the  chloride  of  barium  (Dr.  Hammond),  and  the  nitrate 
of  silver  have  been  occasionally  used  with  advantage  and  recommended 
by  men  of  eminence.  When,  as  is  often  the  case,  the  patient  suffers  from 
much  pain  and  restlessness  during  the  night,  a  single  dose  of  bromide  of 
potassium  or  ammonium  and  hydrate  of  chloral,  one  to  two  grams  each  (gr. 
XV  to  gr.  xxx)  given  about  eight  o'clock  in  the  evening,  will  often  pro- 
cure rest  for  the  night.  Many  recommend  the  bromides,  and  use  them 
in  full  doses  in  the  active  stage  of  the  more  acute  cerebral  inflammations. 
While  I  have  found  these  agents  of  very  great  value  in  allaying  nervous 
hyperfesthesia  and  insomnia,  I  have  not  been  fortunate  enough  to  obtain 
much  effect  from  their  administration  in  any  stage  of  active  inflammation. 
And  in  a  few  cases,  in  which  the  attending  physician  had  continued  their 
use  after  the  mental  dullness  or  partial  stupor  had  appeared  from  the  ac- 
cumulation of  inflammatory  products,  the  effect  appeared  to  be  injurious 
by  adding  to  the  depression.  I  have  seen  a  few  cases,  both  in  children 
and  adults,  in  which  depletion  and  cardiac  sedatives  had  relieved  the  ac- 
<?umulation  of  blood  and  effectually  checked  the  tendency  to  effusion,  yet 
the  patients  continued  restless,  wakeful,  and  the  special  senses  morbidly 
acute,  with  a  soft  but  quick  or  irritable  pulse.  In  the;  e.  giving  fair  doses 
•of  some  reliable  preparation  of  ergot  alternately  with  the  iodide  of  jDOtas- 
sium,  and  a  dose  of  the  compound  powder  of  opium  and  ipecacuanha, 
(Dover's  powder),  in  the  evening,  has  had  a  very  happy  effect.     In   such 

■  cases,  the    morbid   excitability   and   impaired  tonicity  of  the  structure  re- 
mains   after  the  actual  hyperfemia  has  been  relieved.     Consequently,  the 

■  ergot,  aided  by  the  opiate  at  night,  exactly  meets  the  indication,  and  much 
^relieves  the   patient;   when   further   cardiac  sedatives  or  depletion  would 

only  have  increased  his  suffering,  and  endangered  ultimate  exhaustion  and 

fatal  collapse. 

Convalescence. — The  stage  of  convalescence  following  all  grades  of  in- 
flammation of  the  hemispheres  of  the  brain  and  their  investing  membranes, 
is  one  of  much  practical  importance,  on  account  of  the  readiness  with 
which  the  local  hyperfemia  and  excitement  may  be  rekindled  by  either 
mental  or  physical  activity.  It  makes  it  necessary  that  the  patient  should 
not  resume  active  exercise  either  of  body  or  mind  until  the  general  tone 
of  health  is  well  restored;  and  even  then,  the  resumption  of  exercise  should 
be  very  gradual,  with  frequent  intervals  of  rest.  The  diet,  for  several 
weeks,  should  be  chiefly  of  milk,  farinaceous  articles,  the  ligliter  vegeta- 
bles and  fruits,  with  but  little  meat.  In  those  cases  of  scrofulous  and  tu- 
berculous meningitis  in  which  one  attack  is  recovered  from,  as  often 
happens,  it  is  not  only  necessary  to  take  all  the  precautions  I  have  just  in- 
dicated during  the  ordinary  period  of  convalescence,  but  all  those  means 
for  counteracting  the  faulty  constitutional  condition  and  tendencies,  which 
were  urged  upon  your  attention  in  the  lecture  on  the  treatment  of  scrofula 
should  be  diligently  used  for  months  or  even  years  with  the  hope  of  pre- 
venting a  renewal   of  the   local   inflammation.     Special   care   should   be 


CEREBRO-SPINAL  MENINGITIS.  339 

taken  to  prevent  parents  and  teachers  from  allowing  children  of  this  class 
to  apply  the  mind  too  intently  or  persistently  iu  the  process  of  education. 

Neither  should  their  physical  exercises  be  too  exciting  or  protracted. 
The  aim  should  be  to  give  such  patients  that  habitual  moderate  out-door 
exercise  that  promotes  nutrition  and  muscular  strength,  without  positive 
fatigue  or  exhaustion;  and  that  degree  and  kind  of  mental  occupation 
which  favors  cheerfulness  and  mild  discipline  without  high  excitement, 
anxietj'',  or  intensity  of  application. 

And  do  not  forget  that,  in  all  directions  for  physical  exercise  to  this 
class  of  subjects,  the  muscles  of  tha  arms  and  chest  need  quite  as  much 
discipline  as  those  of  the  lower  part  of  the  trunk  and  legs. 


LECTURE    XXXVI. 

Cerebro-Spinal  Menia^itis— ■Sporadic  and  Epidemic    Spinal  Mjnin^itis ;  Myelitis,  and   Spinal 
Sclerosis;  Their  History,  Causes,  Symptoms,  AlarbLd  Anatomy, .Diagnosis,  Prognosis,  and  Treatment. 

GENTLEMEN:  Ordinary  sporadic  attacks  of  inflimmition  located  in  the 
membrane  and  under  surface  of  the  brain,  including  the  med- 
ulla oblongata  and  its  junction  with  the  spinal  cord,  and  constituting 
cerebro-spinal  meningitis,  are  not  of  very  frequent  occurrence  at  any 
period  of  life,  but  are  met  wiih  more  frequently  among  children  than 
adults.  They  miy  arise  from  the  same  causes,  and  under  the  same  cir- 
cumstances, as  inflimmation  of  the  pia  mater  and  surface  of  the  convex 
part  of  the  hemisplieres.  The  symptoms,  prograss  and  results  diff  3r  from 
those  accompanying  inflammation  of  other  parts  of  the  cerebral  surface,  only 
on  account  of  the  difference  in  the  functions  performid.  The  intimate 
connection  of  the  m3dalla  and  gray  misses  near  the  bisa  of  the  brain 
with  the  nerves  of  special  sense  and  those  controlling  respiration  and  cir- 
culation, is  such  that  any  inflammatory  action  set  up  in  those  parts,  more 
speedily  disturbs  the  hearing,  vision,  and  respiratory  movements,  and  in 
consequence  of  the  latter,  more  frequently  leads  to  an  early  fatal  termi- 
nation. 

Symptymi. — Acute  attacks  are  generally  ushered  in  by  a  brief  period 
of  paleness,  coolness  of  the  surface  and  extremities,  vertigo,  one  or  two 
sudden  turns  of  vomitiiig,  immediately  followed  by  intense  pain  in  th  ; 
occipito-frontal  region  through  the  base  of  the  brain,  buzzing  or  nois  »s 
in  the  ears,  flashes  of  light  or  dimness  of  vision,  increased  heat,  flush  of 
the  face,  contraction  of  the  pupils,  frequency  and  fullness  of  the  pulse, 
retraction  of  the  head  from  rigidity  of  the  muscles  of  the  posterior  part  of 
the  neck,  hurried  breathing,  and  more  or  less  delirium.  In  from  six  to 
twelve  hours  the  hearing  and  vision  are  both  suspended;  one  or  both 
pupils  begin  to  dilate,  and  the  eyeballs  to  be  turn  'd  from  their  natural 
direction  and  parallelism;  the  mental  faculties  more  dull;  the  head  more  re- 
tracted, either  directly  backward  or  obliquely  toward  one  side;  frequent 
automatic  movements  of  the  extremities;  respiration  irregular  with  fre- 
quent sighing;  pulse  variable  in  frequency  and  sometimes  intermitting,  but 
retaining  its  volume  and  a  fair  degree  of  force,  while  the  renal  and  all 
other  secretions  are   maoh  diminished.     If  the  attack  is  severe  and    not 


340  CEREBEO-SPINAL  MENINGITIS. 

moderated  by  treatment,  in  from  tw.f-lve  to  twenty-four  hours  more,  the 
automatic  movemeii  s  of  the  extremities  will  have  ceased  trom  the  super- 
vention of  paralysis;  the  face  will  appear  less  flushed;  the  pupils  more 
completely  dilated;  the  intestinal  discharges  involuntary,  and  the  renal 
secretion  suppressed;  the  pulse  smaller,  weaker,  and  more  irregular;  res- 
piration sometimes  hurried  and  panting,  at  other  times  slow,  weak,  and 
intermittent;  deglutition  either  difficult  or  altogether  lost,  and  the  mind 
either  wandering  or  comatose.  A  little  later,  the  increasing  paralysis  of 
the  muscles  of  deglutition  and  respiration  permits  the  mucus  to  accumu- 
late in  the  air  passages,  causing  coarse  mucous  rales,  soon  followed  by 
death.  You  observe  in  this  description  of  the  symptoms,  the  same  stages  or 
order  of  phenomena  as  in  the  acute  meningitis,  already  fully  considered. 
First,  a  brief  period  of  intense  injection  of  the  vessels  with  high  excite- 
ment; second,  a  period  of  transition,  during  which  exudation  or  effusion 
is  taking  place,  causing  the  contracted  pupils,  excited  delirium,  frequent 
and  full  pulse  to  give  place  to  dilatation,  dullness,  variable  pulse,  etc.; 
and  third,  the  period  of  general  failure  of  functional  action,  or  paralysis. 
These  several  stages  are  accompanied  by  the  same  pathological  changes, 
and  followed  by  the  same  kind  of  post  mortem  appearances  in  the  mem- 
brane and  surface  of  the  base  of  the  brain  and  medulla  oblongata,  as  I 
pointed  out  to  you  when  speaking  of  the  results  of  inflammation  of  the 
membranes  and  surface  of  the  upper  part  of  the  cerebral  hemispheres. 

Diagnosis. — The  special  symptoms  which  serve  to  distinguish  inflam- 
mation of  the  base  of  the  brain  and  medulla  oblongata  from  all  other  affec- 
tions, either  of  a  functional  or  inflammatory  character,  are  the  rapid  devel- 
opment of  disturbances  of  respiration,  heai'ing,  seeing,  muscular  contrac- 
tions and  rigidity,  especially  in  the  posterior  cervical  region,  in  direct 
connection  with  intense  pain  in  the  head,  and  general  fever.  Mere  reflex 
or  functional  disturbances  are  not  accompanied  by  the  rapid  rise  of  tem- 
perature and  increased  tension  of  the  carotid  and  vertebral  arteries  which 
mark  the  first  stage  of  the  inflammation;  and  when  the  latter  attacks  other 
parts  of  the  brain  and  its  membranes,  the  contraction  of  the  cervical  mus- 
cles, retracting  the  head,  and  the  loss  of  vision  and  hearing,  supervene  at 
a  later  stage  in  the  progress  of  the  case,  are  generally  less  prominent,  and 
sometimes  absent,  or  nearly  so. 

Prognosis. — Almost  any  grade  of  inflammation  involving  the  nervous 
centers  of  respiration  and  circulation  in  the  medulla  oblongata  and  gan- 
glia at  the  base  of  the  brain,  is  of  serious  import.  So  essential  are  these 
functions  to  the  maintenance  of  life  that  they  can  not  be  interrupted,  even 
for  a  few  minutes,  without  fatal  results.  Consequently  all  acute  attacks 
of  inflammation  in  the  nervous  centers,  controlling  these  functions,  are 
highly  dangerous,  and  a  very  large  proportion  of  those  attacked  die  in  from 
three  to  seven  days.  And  in  many  of  the  cases  that  do  not  prove  fatal, 
the  recovery  is  not  complete,  there  remaining  more  or  less  permanent  im 
pairment  of  hearing  or  vision,  or  of  both;  and  a  smaller  number  in  which 
there  remains  decided  weakness  of  the  cervical  and  dorsal  muscles  and 
much  unsteadiness  or  impairment  of  locomotion. 

Treatment. — In  cases  of  ordinary  sporadic  inflammation  of  the  meni- 
hranes  and  base  of  the  brain,  the  objects  to  be  accomplished  by  therapeutic 
management,  and  the  means  for  accomplishing  them,  are  the  same  as  in 
the  treatment  of  the  same  grades  of  meningitis  and  cerebritis,  which  were 
fully  discussed  during  the  lecture  hour  of  yesterday.*  If  there  is  any  dif- 
ference, it  consists  in  the  more  urgent    necessity  for  the  early  and  efficient 

*  See  pages  334-5  of  this  volume. 


EPIDEMIC    CEREBKO-SPINAL  MENINGITIS.  341 

use  of  all  those  means  which  are  capable  of  lessening  the  accumulation 
of  blood  in  the  vessels  and  capillaries  of  the  inflamed  parts  during  the  first 
stao-e;  in  the  hope  of  so  modifying  the  inflammatory  process  as  to  prevent, 
or  very  much  diminish,  the  amount  of  the  exudation  which  would  follow 
in  the  second  stage,  and  which  is  so  liable  to  prove  sufficient  to  overwhelm 
functions  essential  to  life.  If  you  remembei- the  shortness  of  the  several 
stages  of  the  disease,  and  the  consequent  necessity  for  the  most  prom[)t 
and  vigilant  attention  to  each  case,  you  will  be  enabled  to  so  adjust  the 
means  best  adapted  to  meet  the  pathological  exigencies  of  each  stage 
under  the  rules  I  gave  you  in  the  lecture  of  yesterday,  as  will  give  your 
patients  the  best  chance  of  recovery.  There  is,  however,  another  form  or 
grade  of  inflammation  whicii  attacks  the  base  of  the  brain  and  its  append- 
ages, to  which   I  must  now  direct  your  attention. 

Hpidetnic  (J erebro- Spinal  Meningitis. — The  disease  to  which  I  allude 
is  seldom  met  with  in  isolated  or  sporadic  cases,  but  usually  presents  the 
character  of  an  epidemic,  sometimes  extending  rapidly  over  large  districts 
of  country,  but  more  frequently  limited  to  neighborhoods  or  single  town- 
ships or  counties,  to  military  camps,  or  even  single  buildings.  Although 
not  recognized  and  described  as  a  distinct  disease  until  the  beginning  of 
the  present  century,  yet  under  names  indicating  some  form  of  typhus, 
pretty  accurate  descriptions  of  the  disease  can  be  reco:^nized  in  the  histo- 
ries of  epidemics  occurring  in  France,  Spain  and  Italy,  as  early  as  1310, 
and  at  various  times  during  the  fifteenth,  sixteenth,  seventeenth  and 
eighteenth  centuries,  in  most  of  the  other  European  countries.  It  has 
been  called  typhus  syncopalis,  cerebral  typhus,  petechial  typhus,  cold 
plague,  malignant  purpuric  fever,  febris  nigra,  spotted  fever,  apoplectic 
typhus,  cerebro-spinal  typhus,  cerebro-spinal  meningitis,  epidemic  cerebro- 
spinal meningitis,  and  in  the  present  nomenclature  of  the  R  jyal  College 
of  Physicians,  cerebro-spinal  fever.  Perhaps  the  first  plain  description 
of  the  disease  in  this  country  was  by  Dr.  John  Bard,  who,  in  1749,*  de- 
scribed the  prevalence  of  a  disease  in  Rhode  Island  and  some  other  parts 
of  New  England  which  was  undoubtedly  the  disease  under  consideration; 
and  Dr.  Hugh  Williamson  gives  an  interesting  account  of  the  prevalence 
of  a  similar  disease  in  North  Carolina  in  1792. |  Most  writers  represent 
it  as  making  its  first  appearance  in  the  United  States  in  the  valley  of  the 
Connecticut  river,  as  it  passes  through  portions  of  Massachusetts,  Con- 
necticut and  Vermont,  in  1806  and  1807.  From  this  time  it  continued 
to  manifest  itself  in  limited  districts  of  New  York,  Pennsylvania,  New- 
Jersey,  and  as  far  south  as  Norfolk,  in  Virginia,  until  1812.  There  was  a 
limited  prevalence  of  it  in  New  York,  in  1816;  in  Middletown,  Connecti- 
cut, in  1833;  and  in  Trumbull,  Ohio,  in  1838.  From  the  last  date  I  have 
found  no  account  of  the  prevalence  of  the  disease  until  1840-1,  when  it 
reappeared  in  Vermont  and  Massachusetts,  and  apparently  extended  west- 
ward through  New  York  in  1843-3,  prevailing  severely  in  some  places, 
especially  in  the  western  part  of  the  State.  It  made  its  appearance  in 
different  parts  of  Michigan  an  1  Illinois  in  1843-4,  and  during  these  and 
the  four  following  years,  it  visited  different  localities  in  all  the  States  oc- 
cupying the  valley  of  the  Mississippi  and  its  tributaries  from  the  Great 
Lakes  to  the  Gulf  of  Mexico.  Its  general  habit  was  to  prevail  in  limited 
districts  for  one  season,  disappear,  and  appear  in  another  series  of  places 
the  next  season.  It  rarely  prevailed  in  the  same  place  two  years  in  suc- 
cession; and    equally  rare  that  it  spread  by  continuity  of   territory.     On 

*  See  Med.  and  Phil.  Reg.  Vol  1. 

t  See  Med.  Repository,  1st  series,  Vol.  II. 


di2  EPIDEMIC    CEREBRO-SPINAL    MENINGITIS. 

the  contrary,  it  appeared  in  numerous  places  almost  simultaneously,  havinpf 
no  special  connection  of  one  with  another.  From  1850  to  1862,  I  find  no 
mention  of  the  prevalence  of  cerabro-spinal  meningitis  in  any  part  of  our 
country,  except  one  or  two  limited  outbreaks  in  1852  and  1858.  Tn  the 
winter  and  spring  of  1862-3,  it  reappeared  almost  simultaneously  in  a 
great  number  of  localities,  scattered  through  the  Western  and  Southern 
States,  and  in  several  places  in  the  Middle  and  Eastern  States.  From  the 
last  mentioned  date  to  1866,  the  disease  invaded  many  new  places  each 
year.  It  then  became  less  p.  evalent  until  1872,  when  another  marked  in- 
crease in  its  prevalence  was  observed  in  different  parts  of  the  country.  It 
prevailed  in  this  c.ty  (Chicago)  sufficiently  severe  to  merit  the  name  of  an 
epidemic  in  1863-1  and  in  1872-3,  and  sporadic  cases  have  occurred  in  other 
years. 

Causes. — The  predisposing  causes  or  circumstances  which  appear  to 
favor  the  development  of  epidemic  c  ^rebro-spinal  meningitis,  are:  expos- 
ure to  cold  and  da-np  air,  overcrowded  and  badly  ventilated  dwellings, 
poor-houses,  prisons,  military  camps,  etc.;  to  which  may  be  added  exces- 
sive fatigue  coupled  with  mental  excitement  or  depression,  age  and  sex. 
In  regard  to  the  influence  of  atmospheric  conditions  I  may  state  in  gen- 
eral terms  that  the  disease  has  hitherto  prevailed  chieflv  in  the  northern 
and  middle  part  of  the  temperate  zone,  and  far  more  frequently  dui'ing 
the  last  half  of  winter  and  the  early  part  of  sp"ing  than  at  any  other  sea- 
son of  the  year.  Dr.  Joseph  A.  Gallup,  who  wrote  in  1815,  while  the  facts 
lelating  to  the  epidemics  in  this  country  from  1806  to  1812  were  fresh 
and  familiar  to  him,  personally,  says:  "With  few  exceptions  it  has 
iiroken  out  in  the  coldest  seasons,  and  spread  most  alarmingly  at  such 
tinjes  in  the  different  places  it  has  visited.  The  months  of  Januarj'-  and 
February  have  oftenest  given  rise  to  it  in  point  of  season.  When  it  rages 
considerably,  it  continues  perhaps  to  the  middle  of  the  month  of  May,  and 
then  passes  off  gradually  like  other  epidemics."  *  Dr.  J.  Adams  Allen,  who 
saw  much  of  the  disease  as  it  prevailed  epidemically  between  1842  and 
1850,  says:  "  According  to  the  writer's  (Dr.  Allen's)  observation,  it  is 
more  likely  to  occur  in  winters  with  a  variable  temperature — where  a  few 
days  of  intense  cold  are  rapidly  followed  by  days  of  thaw,  mud  and  rain. 
Neither  uniformly  cold  nor  warm  weather  are  so  likely  to  engender  it. 
But  other  influences  unquestionably  co-operate.  It  does  not  seem  always 
confined  to  a  particular  season. "f  In  examining  the  particular  season  of 
prevalence  of  a  large  number  of  the  more  severe  outbieaks  of  the  disease 
in  the  epidemic  period  extending  from  1862  to  1872,  I  find  them  to  have 
commenced  in  almost  all  instances  during  the  months  of  January,  Febru- 
ary and  March,  and  to  have  ended  before  the  middle  of  June.  The  dis- 
ease has  at  no  time  pievailed  as  severely  in  this  city  (Chicago)  as  in  many 
of  the  country  districts  in  this  and  the  adjoining  States.  A  few  cases  oc- 
curred in  the  month  of  June,  1863,  while  during  the  three  preceding 
months  cases  of  erysipelas  were  more  numerous  than  usual.  The  only 
epidemic  of  much  note  commenced  in  February,  1872,  and  continued 
through  March  and  April,  during  which  more  than  one  hundred  deaths 
were  reported  to  the  health  office  as  resulting  horn  this  disease.  During 
the  same  months  it  prevailed  with  considerable  severity  in  many  of  the 
most  populous  towns  in  the  northern  part  of  Iowa,  Illinois,  Indiana,  the 
southern  part  of  Wisconsin  and  Michigan,  and  in  the  western  part  of  New 
York.     From  all    the  foregoing  facts  it  is  evident  that  there  is  something 

*  See  "  Sketches  of  Epidemic  Diseases  in  the  Ptate  of  Vermont,  from  its  first  settlement  to  the 
year  1815,"  etc.,  etc.    By  ,Jo  eph  A.  Gallup.  M.  D.,  p  225.    ]8!5. 
t  See  paper  read  to  the  Illinois  State  Med  cal  Society  in  May,  ISfrl.    Vol.  Trans,  p  141. 


CAUSES.  343 

more  than  mere  accideutal  coincidence  between  the  prevalence  of  the  dis- 
ease and  tlio  inontlis  of  winter  and  spring.  In  other  words,  the  usual  at- 
mospheric conditions  present  during  the  months  of  January,  February, 
March  and  April,  exei't  a  positive,  predisposing  influence  of  much  im- 
portance in  the  development  of  the  disease.  So  far  as  allusions  are  made 
to  the  special  meteorological  conditions  existing  at  the  outbreak  of  the  dis- 
ease in  the  numerous  reports  to  medical  societies  and  articles  in  medical 
periodicals,  they  generally  mention  the  predominance  of  cold  and  damp- 
ness with  sudden  and  severe  thermometric  changes.  That  the  impure  air, 
caused  by  the  overcrovvding  of  dwellings,  prisons,  and  military  camps, 
favors  the  occurrence  of  cerebro-spinal  epidemics,  is  abundantly  proved 
by  the  many  special  outl)reaks  of  the  disease  in  such  places  which  are  on 
record;  more  especially  in  connection  with  military  operations  both  in  this 
country  and  in  Europe.* 

There  are  many  facts  on  record  that  clearly  indicate  the  important  in- 
fluence of  excessive  fatigue  in  connection  with  mental  anxiety  and  fear  in 
the  fostering  of  attacks. 

Af/e. — Although  no  period  of  life  is  exempt  from  attacks  of  the  disease 
under  consideration,  yet  in  all  places  where  it  has  prevailed  among  the 
population  generally,  much  the  larger  number  of  cases  have  occurred  in 
childhood  and  youth,  and  next,  in  the  early  part  of  adult  life.  Hirsch 
states  that  of  391  fatal  cases  359  were  under  fifteen  years  of  age.  Of  forty 
cases  that  came  under  my  care  in  the  winter  and  spring  of  1872,  six  were 
between  twenty  and  thirty  years  of  age,  ten  between  five  and  fifteen  years, 
and  twenty-tbur  between  six  months  and  five  years.  I  think  this  is  a  fair 
representation  of  the  ratio  of  prevalence  of  the  disease  at  the  different 
periods  of  life,  in  the  epidemics  that  have  occurred  in  cities  and  country 
districts  throughout  this  country;  but  when  it  makes  its  appearance  at 
military  posts,  in  barracks  and  prisons,  the  statistics  will  show  a  large  ratio 
of  prevalence  in  adult  life.  This  was  the  case  in  France  during  the  ten 
3'-ears  following  1835,  when  the  disease  prevailed  severely  among  the 
soldiers  in  the  barracks  and  camps  in  different  parts  of  that  country. 
Hence  Lefevre  and  other  French  writers  state  that  the  greatest  mortality 
occurred  between  the  ages  of  thirty  and  forty  years. 

/Sex. — AVriters  generally  agree  in  the  statement  that  the  disease  is  more 
prevalent  among  males  than  females.  In  military  camps,  barracks  and 
prisons  this  would  necessarily  be  the  case,  as  the  number  of  females  pres- 
ent in  such  places  is  relatively  very  small.  In  civil  life  the  difference  is 
not  great. 

/Specific  or  JlJxciting  Cause, — In  addition  to  the  predisposing  influences 
I  have  mentioned,  it  is  claimed  by  most  of  the  recent  writers  and  observ- 
ers that  the  disease  arises  from  a  specific  exciting  cause,  the  nature  and  ori- 
gin of  which,  however,  is  entirely  unknown.  It  is  generally  conceded  that 
the  essential  cause  is  not  a  contagium,  communicable  from  one  individual  to 
another,but  is  supposed  to  be  some  form  of  infection,  analogous  to  that  which 
causes  typhus  and  other  forms  of  continued  fever.     The  reasoning  upon  the 

*  As  a  sample  of  f  icts  touching  this  subject  I  copy  the  following  paragraph  from  an  interesting 
letter  in  the  Chic  igo  Medical  Examiner,  Vol.  V.  p.  402,  ISo-t.  by  Dr.  E.  Y.  Yager,  giving  an  account 
of  two  epidemics  in  Chillicothe,  Missouri.  He  says  :  "  The  epidemic  of  both  1862  and  '64  was  pre- 
ceded by  verv  cold  weather.  You  will  observe  that  no  cases  occurred  until  after  the  commence- 
ment of  the  thaw.  The  wind  was  generally  from  the  east  and  very  chilly.  There  was  a  dense  fog 
preceding  both  epidemics.  At  the  time  of  its  prevalence  in  1862  the  e  were  quartered  near  twelve 
hundred  soldiers  iu  different  parts  of  the  town.  They  were  very  much  crowded;  whole  companies 
in  houses  that  were  not  capable  ot  ace  )mmodating 'more  than  fifteen.  Measles  pr^-vailed  to  an 
alarming  extent  among  soldiers  and  citizens.  There  was  a  very  large  mortality  attending  the  epi- 
demic of  measles,  and  later  in  the  season  pneumonia  typhoides  was  very  prevalent.  *  *  « 
The  quarters  and  hospitals  were  in  the  worst  pjss.ble  condition.  Following  the  epidemic  of  18o4, 
we  have  erysipelas  and  pneumonia  typhoides." 


344  EPIDEMIC    CEREBEO-SPINAL    MEXIXGITIS. 

subject  is  not  conclusive.  It  is  assumed  that  the  epidemic  character  of  the 
disease  proves  it  to  be  dependent  upon  a  specific  cause.  Assuming  that 
it  depends  upon  a  specific  cause  is  made  the  reason  for  classing  it  with  the 
idiopathic  general  diseases,  instead  of  placing  it  with  the  local  inflamma- 
tions. It  has  been  suggested  by  some  that  while  the  disease  maybe  a 
general  fever  caused  by  some  organic  poison,  such  poison,  instead  of  being 
zymotic  or  mibibed  from  without,  is  developed  from  morbid  molecular  proc- 
esses in  the  system.*  My  own  clinical  observations,  aided  by  a  careful 
study  of  the  more  noted  epidemics  on  record,  show  two  facts  of  much 
etiological  interest.  First,  that  there  are  marked  differences  in  the  clinical 
history  of  the  disease  under  consideration,  as  it  has  prevailed  in  different 
times  and  places.  Second,  that  all  the  more  noted  epidemics  have  been 
either  coincident  with  or  closely  allied,  both  in  time  and  place,  to  the  prev- 
alence of  erysipelas  or  typhoid  and  typhus  fevers,  while  a  much  smaller 
number  have  been  coincident  with  the  prevalence  of  malarious  fevers.  For 
instance,  during  its  unusual  prevalence  in  France  and  Spain  from  1836  to 
1845,  the  circumstances  under  which  it  originated,  and  many  of  the  symp- 
toms accompanying  the  disease,  were  such  as  to  cause  the  profession  in  those 
countries  to  regard  it  as  a  form  of  typhus. 

So  the  epidemic  that  commenced  at  Medfield,  in  Massachusetts,  in  1806, 
and  continued  to  recur  in  different  places  in  this  country  until  1820,  was  so 
closely  connected  with  the  prevalence  of  typhoid  and  typhus  fevers  that  it 
was  almost  universally  designated  as  typhus  petechialis,  maculated  typhus, 
cerebral  typhus,  etc.  And  it  often  happened  that  while  the  cerebro- 
spinal fever  was  prevailing  in  one  neighborhood,  in  another  the  local  mani- 
festations were  developed  in  the  lungs,  causing  pneumonia  typhoides, 
more  frequently  designated  in  those  days,  peripneumonia,  and  sometimes 
malignant  pleurisy;  and  which  often  proved  as  rapidly  fatal  as  when  the 
cerebro-spinal  axis  was  involved.  Yet  during  all  the  periods  alluded  to, 
both  in  Europe  and  in  this  country,  erysipelas  was  also  unusually  prev- 
alent, as  you  may  learn  by  studying  the  history  of  that  disease.  The 
second  very  extensive  epidemic,  which  prevailed  in  different  places,  from 
the  New  England  States  west  to  the  Mississippi  river,  and  southward  to  the 
Gulf,  between  1841  and  1850,  was  so  completely  identified  with  the  coin- 
cident great  epidemic  of  erysipelas,  that  the  history  of  one  necessarily  in- 
volved that  of  the  other.  In  most  of  the  places  where  they  prevailed,  the 
cerebro-spinal  disease  occurred  in  the  winter  and  spring,  and  the  erysipelas 
in  the  summer  and  autumn  either  preceding  or  following.  And  in  some 
places  they  were  as  intimately  intermingled  as  are  cases  of  intermittent 
and  remittent  fevers.f  The  same  close  connection  between  the  epidemic 
prevalence  of  cerebro-spinal  meningitis  and  erysipelas  was  observed  dur- 
ing the  severe  prevalence  of  these  diseases  from  1862  to  1868,  in  the 
States  of  Illinois,  Wisconsin,  Michigan,  Indiana,  and  as  far  east  as  the 
western  part  of  New  York.  During  the  autumn  of  1863  and  the  winter 
and  spring  of  1864  both  erysipelas  and  typhoid  fever  were  unusually 
prevalent  m  this  city  (Chicago),  the  former  sufficiently  so  to  constitute  a 
noted  epidemic.  During  the  latter  part  of  the  same  winter  and  spring 
many  cases  of  cerebro-spinal  disease  also  occurred,  while  the  two  former 
diseases  were  still  prevailing.  Perhaps  the  best  account  we  have  of  the 
prevalence  of  these  epidemics  in  the  interior  of  this  State,  is  from  Drs. 
Lodge   and  Samuels   who   practiced   extensively   in   Williamson    countv, 

*  See  Transactions  of  111.  State  Med.  Society,  Vol.  for  ISM,  p.  141. 

t  See  short  paper  on  cerebro-spinal  meninsjltis,  as  it  appeared  in  C'  rk  countv,  Illinois,  in  l'<4'>-6, 
18')8 ;  and  1863~l-.5.  By  F.  R.  aine,  M.  D.  in  the  Trans.  Ill  State  Med.  ociety  for  lbi56.  See  also 
Drake  on  the  Principal  Diseases  of  the  Interior  Valley,  etc.,  second  Vol.,  p.  759. 


EXCITING   CAUSES.  345 

where  the  cerebro-spinal  meningitis  made  its  appearance  in  a  very  severe 
form  in  the  latter  part  of  the  winters  of  both  1862  and  1863,  and  continued 
tiirough  the  spring  months.  The  erysipelas  commenced  in  the  summer  of 
1863  and  continued  during  the  following- autumn  and  winter.* 

That  severe  cerebro-spinal  symptoms  may  occur  in  connection  with 
periodical  or  malarial  fevers,  is  so  we  1  known  that  when  they  occur  they 
are  generally  recognized  as  indicating  one  phase  of  the  pernicious  inter- 
mittents.  I  have  called  your  attention,  gentlemen,  to  the  intimate  rela- 
tions between  the  prevalence  of  epidemic  cerebro-spinal  meningitis  and 
the  well  known  acute  general  febrile  diseases,  which  have  been  named,  for 
the  purpose  of  enabling  you  to  see  more  clearly  the  bearing  of  the  ques- 
tion, whether  the  cerebro-spinal  disease  is  a  part  of  a  distinct  general 
fever  dependent  on  a  specific  zymotic  cause,  or  whether  it  is  simply  a 
local  disease  occurring  as  an  important  complication  in  severe  epidemics 
of  erysipelas,  typhoid,  typhus,  and  malarial  fevers.  In  other  words,  shall 
we  regard  the  epidemics  of  dysentery,  pneumonia  typhoides,  malignant 
pleurisy,  and  cerebro-spinal  meningitis,  as  so  many  distinct  general 
febrile  affections,  each  dependent  on  a  specific  cause,  or  as  local  comjjli- 
cations  sometimes  based  upon  the  special  cause  of  typhoid  and  typhus, 
sometimes  on  that  of  erysipelas,  and  at  others  on  that  oi  periodical  fevers 
known  as  malaria?  For  a  few  years  pf\st  the  tendency  of  medi  -1  investi- 
gators has  been  strongly  in  the  direction  of  increasing  the  number  of 
general  acute  diseases  or  fevers,  and  of  assigning  a  specific  cause  for  each. 
It  is  under  this  tendency  that  acute  dysentery,  pneumonia,  and  cerebro- 
spinal meningitis,  have  already  been  taken  from  the  list  of  local  inflamma- 
tions and  transfer,  ed  to  the  class  of  idiopathic  fevers  by  most  oi"  the  recent 
writers  on  practical  medicine.  I  must  acknowledge,  however,  that  the 
more  I  observe  these  affections  at  the  bedside  of  the  sick,  and  the  more 
minutely  I  study  the  histories  of  the  past  epidemics,  as  recorded  by  those 
who  actually  witnessed  them,  the  more  nearly  am  I  brought  to  the  con- 
clusion that  they  are  simply  local  affections  modified  in  their  ph«nomena 
and  results  by  whatever  general  miasmatic  or  infectious  cause  may  be 
existing  at  the  time,  whether  it  be  the  idio-miasms  that  produce  typhoid 
and  typhus,  the  infection  of  erysipelas,  or  the  malaria  of  the  periodical 
fevers.  This  view  affords  a  much  more  complete  explanation  of  the  noted 
differences  in  the  symptoms  and  results  accompanying  these  diseases  at 
different  times  and  in  different  localities,  and  also  of  the  equally  diverse 
results  of  the  same  methods  of  treatment  in  different  places  and  epidemic 
periods.  It  is  also  much  better  calculated  to  lead  the  practitioner,  when 
he  meets  these  importunt  outbreaks  of  disease,  to  observe  carefully  the 
coincident  character  and  tendencies  of  the  general  febrile  affections  that 
have  immediately  preceded  or  are  accompanying  them,  and  to  base  his 
treatment  on  the  actual  pathological  conditions  present,  instead  of  being 
influenced  largely  by  the  theoretical  idea  of  the  presence  and  action  of 
some  one  specific  organic  poison,  on  which  he  is  led  to  believe  the  disease 
before  him  always  depends. 

Symjytoms. — The  general  group  or  assemblage  of  symptoms  that  accom- 
pany attacks  of  epidemic  cerebro-spinal  meningitis,  so  closely  resemble 
those  I  mentioned  as  characterizing  attacks  in  sporadic  cases,  in  the  first  part 
of  the  present  lecture,  as  to  render  their  full  repetition  unnecessary.  In 
some  of    the  epidemics,  the  initial  symptoms  have  developed    less  rapidly; 

*  Dr  J  '^.  Jewell,  speaking  of  the  two  dlseas'S  as  seen  by  Drs.  Lodge  and  Paranels.  says  :  "  The 
two  epidemics  (spotted  fever  and  erysipelas)  were  commingled  in  the  practice  of  these  gentlemen, 
occurring  at  the  same  time  and  in  tiie  same  place,  inducing  in  them  the  opinion  that  tlie  tw  form? 
oi' disease  were  connected  by  some  linli  common  to  both."  See  Trans.  II..  State  ISted.  Society  lor 
ISGi,  p  25. 


346  EPIDEMIC  CEREBRO-SPINAL    MEiyiNGITIS. 

the  pulse  has  been  softer,  more  variable  and  more  frequent;  an  1  while  the 
patients  retained  their  conscious'iess,  they  complained  of  great  lassitude 
and  weariness,  with  severe  pains  in  different  parts  of  the  body  and  limbs, 
in  addition  to  that  in  the  head.  In  other  epidemics,  one  of  the  noted  feat- 
ures was  the  shortness  of  the  initial  stage  and  the  sudden  onset  of  the  more 
dangerous  symptoms,  often  so  rapidly  overwhelming  the  cerebro-spinal 
functions  as  to  cause  a  fatal  result  in  a  few  hours.  In  still  other  epidem- 
ics, a  large  majority  of  the  cases  were  ushered  in  by  a  distinct  chill,  and 
the  fever  following  exhibited  well-marked  exacerbations  and  remissions. 
Such  was  the  character  of  the  epidemics  that  occurred  in  the  middle  and 
lower  parts  of  the  Mississippi  Valieyx,  from  1842  to  1850,  as  described  by 
Drs.  S.  Ames,  of  Montgomery,  Alabama;  E.  D.  Fenner,  of  New  Orleans; 
D.  Drake,  of  Cincinnati,  and  others.*  The  well-marked  though  moderate- 
ly severe  epidemic  of  1872,  as  it  occurred  in  this  city,  was  faithfully  de- 
scril)od  in  a  clinical  lecture  at  the  time,  as  follows: 

"  The  cases  have  varied  much,  both  in  the  severity  and  variety  of  symp- 
toms, and  yet  have  preserved  enough  of  uniformity  to  identify  them  as 
belonging  to  one  group,  and  dependent  on  some  common  pathological 
conditions.  For  instance,  in  all  the  cases  the  access  of  the  disease  was 
sudden  or  abrupt.  They  all  give  evidence,  at  first,  of  unusually  severe 
pain  in  the  head,  with  very  variable  neuralgic  pains  in  distant  parts,  espe- 
cially in  the  abdomen,  thighs  and  legs;  and,  in  from  one  to  three  days, 
rigidity  of  the  muscles  of  the  neck,  with  some  retraction  of  the  head,  and 
general  hyperae3thesia  sufficient  to  cause  even  the  youngest  child  to  mani- 
fest signs  of  distress  on  being  touched  or  moved.  In  nearly  all  the  cases 
there  has  been,  during  the  first  twelve  hours,  active  vomiting,  increased  by 
raising  the  head  to  the  erect  position;  and  in  some,  coincident  purging. 
These  gastric  and  intestinal  symptoms  have  seldom  continued  beyond  the 
first  one  or  two  days.  The  temperature  is  generally  increased,  especially 
in  the  back  of  the  head;  the  pulse  is  frequent  and  firm;  the  respirations  in- 
creased in  frequency,  and  m  most  cases,  pantifu/,  like  one  excessively  fa- 
tigued from  severe  exercise;  face  flushed,  and  expression  excited  and  anx- 
ious at  first,  but  subsequently  dull,  with  dilation  of  the  pupils;  urine  gen- 
erally scanty  and  high-colored,  but,  in  some  cases,  abundant  throughout 
the  whole  course  of  the  disease;  tongue  covered  with  a  white  fur;  mouth 
moist;  and  after  the  first  one  or  two  days,  the  bowels  inclined  to  consti- 
pation, with  the  abdomen  flaccid,  and  entirely  free  from  tympanitis.  About 
one  third  of  the  cases  presented  some  red  erythematic  spots  on  the  skin, 
between  the  third  and  seventh  days  of  the  disease.  These  spots  varied 
much  in  size  and  number,  as  well  as  in  shade  of  color.  In  the  milder  cases 
they  were  bright  red,  and  often  so  few  in  number  as  to  attract  no  attention, 
unless  looked  for  particularly;  and  in  others  they  were  so  numerous  as  to 
create  the  impression  that  the  case  might  be  one  of  scarlatina.  In  the  more 
severe  cases,  the  spots  were  darker  in  color,  larger  in  size;  and  in  two  cases 
they  were  accompanied  with  tumefaction,  from  subcutaneous  infiltration,  as 
in  erysipelas.  In  a  young  woman  who  died  on  the  fifth  day  after  the  attack, 
but  whom  I  did  not  see  until  the  day  previous  to  her  death,  there  were  nu- 
merous large,  pui'ple,  ha?morrhagic  spots  on  the  lower  extremities,  and  an 
oblong,  elevated,  purplish  red  spot,  from  one  to  two  inches  long,  and  from 
half  to  three  quarters  of  an  inch  in  width,  on  the  front  part  of  each  ankle 
and  the  outer  facie  of  each  wrist.  The  head  was  held  rigidly  and  obliquely 
to  one  side;  the  eyes  were  divergent;    the  pupils  dilated,  and  mind  entire- 

*PeeDiake  on  the  Principal  Diseases  of  tlie  Interior  Valley  of    North  America,    second    vol 
p  758. 


MORBID  ANATOMY.  347 

ly  unconscious.  In  amijority  of  the  cases,  however,  I  failed  to  discover  any 
special  eruptions  or  spots  on  the  surface.  Nearly  all  the  cases  manifested 
daring  their  progress,  paroxysms  of  excited  delirium;  and  in  the  children 
some  of  the  first  turns  of  vomiting  were  followed  by  protracted  turns  of  wild 
screeching  and  crying-,  and  sometimes  trembling,  as  if  under  the  influence  of 
a  terrible  fright.  Only  four  cases  out  of  the  forty  that  came  under  my  care 
were  accompanied  by  general  convulsions,  three  of  which  died  and  one 
recovered,"* 

Morhid  Anatomy. — During  the  epidemic  just  described,  I  had  an  oppor- 
tunity to  make  hut  one  post  mortem  examination.  This  case  was  an  aiult 
male,  who  died  in  the  Mercy  Hospital  on  the  third  day  after  admission, 
and  on  the  seventh  day  from  the  commencement  of  the  attack.  The 
characteristic  symptoms  of  the  disease  had  all  been  strongly  marked  dur- 
ing the  progress  of  the  case.  The  autopsy  revealed  from  ninety  to  one 
hundred  and  twenty  cubic  centimeters  (fl.  riii  to  riv)  of  reddish  serum  be- 
tween the  arachnoid  and  pia  mater,  and  in  the  lateral  ventricles,  with  the 
most  intense  injection  or  turgescence  of  the  vessels  of  the  pia  mater  cov- 
ering the  base  of  the  brain,  medulla  oblongata,  and  upper  p  irt  of  the 
spinal  cord.  The  vessels  of  the  brain  substance  were  also  fuller  than  nat- 
ural ;  but  there  had  been  no  exudation  of  lymph  or  plastic  material  ;  and 
there  were  no  other  morbid  appearances  apparent  to  the  unaided  eye.  My 
colleague,  Dr.  J.  S.  Jewell,  in  his  paper  on  the  cerebro-spinal  meningitis, 
read  to  the  Illinois  State  Medical  Sjciety  in  LSUO,  collected  and  examined 
accounts  of  about  two  hundred  autopsies.  From  these  examinations,  and 
from  many  others  since,  it  appears  that  the  most  constant  of  all  the  post 
mortem  phenomena  are  congestion  with  more  or  less  inflammation  in  the 
pia  mater  and  surface  of  the  base  of  the  brain,  msdulla  oblongata,  and 
upper  part  of  the  spinal  cord.  In  a  large  majority  of  the  cases  there  is 
also  some  serous,  sero-purulent,  or  purulent  exudation  or  effusion  upon  the 
surface  of  the  pia  mater,  between  it  and  the  brain  structure,  and  in  the 
lateral  ventricles.  The  amount  of  serum  varies  from  one  or  two  cubic 
centimeters  to  as  many  hundred,  (fl.  3u  to  fvi)  ;  its  color  is  usually  a  little 
turbid,  sometimes  reddish  from  intermixture  of  blood  corpuscles,  and  at 
other  times  more  purulent,  and  of  a  creamy  consistence.  In  only  a  small 
number  of  cases  has  there  been  any  true  plastic  exudation,  either  in  the 
serum  or  upon  the  surface  of  the  membranes.  The  vessels  of  the  brain 
structure  were  often  seen  congested,  and  sometimes,  though  rarely,  the 
structure  itself  softened. 

Microscopic  examination  shows  migrating  white  corpuscles  in  the  con- 
gested parts  of  the  brain,  medulla,  and  spinal  cord  ;  and  abundance  of  pus 
corpuscles  in  the  effused  serum,  with  some  fil)rin,  and  occasionally  red 
corpuscles.  In  a  few  cases,  the  effused  fluid  has  appeared  gelatinous  from 
the  amount  of  mucin  it  contained.  As  a  rule,  the  more  speedily  fatal  an 
attack  proved,  the  less  were  the  anatomical  changes  recognizable  after 
death.  The  same  rule,  however,  is  applicable  to  all  severe  epidemic  dis- 
eases. No  changes  specially  characteristic  of  this  disease  have  been  found 
in  other  parts  of  the  body.  In  the  epidemics  which  prevailed  in  this 
country  from  1806  to  1820,  and  in  France  from  1835  to  1845,  many  of  the 
post  mortems  revealed  important  changes  in  the  thoracic  organs  ;  such  as 
severe  engorgement  of  the  lungs  with  dark  blood  in  some  ;  pleurisy,  and 
pleuro-pneumonia  in  others  ;  serous  and  sometimes  purulent  deposits  in 
the  cavities  of  the  pleura  and  pericardium  in  a  few  ;  while  in  others  there 
was  only  hypostatic  congestion  or  no  change  of  any  kind.      Many  of  the 

*  f^ee  Clinical  Lectares  on  Important  Dissasas.    By  N.  S.  Da/is,  M.  D.  etc,  pp.  24o-6-7,  2d  Ed. 
l!:74. 


318  EPIDEMIC   CEREBRO-SPIiSrAL    MENINGITIS. 

samo  examinations  showed  hyperoamia  and  slight  tumefaction  of  the  glands 
of  Peyer  and  Branner  in  the  ilium,  and  in  a  very  few  cases,  some  degree 
of  ulceration. 

The  autopsies  made  during  the  epidemics  prevailing  in  this  country 
from  1841  to  1850,  and  from  1863  to  1870,  revealed  much  less  pathological 
changes  in  the  viscera  of  the  chest,  and  decidedly  more  in  the  kidneys, 
small  intestines,  and  mesenteric  glands.  The  most  noted  change  in  the 
blood  itself  was  an  increase  in  the  relative  proportion,  both  of  fibrin  and  red 
corpuscles,  with  an  unusual  tendency  to  form  coagula  in  the  cavities  of 
the  heart  and  larger  vessels. 

Special  Pathology. — Whether  you  are  to  regard  the  disease  under  con- 
sideration as  a  general  cerebro-spinal  fever  arising  from  a  special  zymotic 
cause,  or  a  local  inflammation  engrafted,  in  some  pariols,  upon  a  general 
typhous  epidemic;  in  others,  upon  an  erysipelatous  epidemic;  and  in  still 
others,  upon  some  mod  fication  of  the  malarial  poison,  in  either  event,  both 
the  symptoms  during  life  and  the  pathological  changes  revealed  by  post  mor- 
tem examinations  show  that  the  principal  seat  of  d  s^aseand  source  of  dan- 
ger to  the  patient,  is  in  that  part  of  the  nervous  centers  composing  the  base 
of  the  brain,  medulla  oblongata,  and  upper  part  of  the  spinal  cord  with 
the  immediately  investing  membrane.  They  also  show  that  the  disease 
affecting  the  parts  named,  is  really  an  asthenic  grade  of  inflammation,  in 
which  tne  elementary  properties  of  the  paits  are  so  altered  as  to  impair 
the  tonicity  or  contractility  of  the  smaller  vessels  and  the  natural  molecu- 
lar movements,  thereby  inducing  rapid  accumulation  of  blood,  aplastic 
exudations,  and  the  early  suspension  of  functions  essential  to  the  contin- 
uance of  life.  In  cases  of  the  highest  grade  of  severity,  the  properties  of 
the  tissues  involved  are  so  profoundly  altered,  as  to  arrest  the  natural 
molecuiar  movements  entirely  and  cause  death  in  a  few  hours,  leaving  but 
little  traces  of  c"bngestion  or  other  inflammatory  appearances  visible  to  the 
unassisted  eye. 

Diagnosis. — The  diseases  with  which  epidemic  cerebro-spinal  meningitis 
is  most  liable  to  be  confounded  are  typhus  fever,  malignant  scarlet  fever, 
pernicious  intermittents,  and  ordinary  sporadic  inflammation  of  the  brain. 
From  the  first,  it  is  to  be  distinguishjd  by  the  suddenness  of  the  attack, 
usually  accompanied  by  vomiting,  and  the  early  occurrence  of  rigidity  of 
the  cervical  muscles  and  retraction  of  the  head.  Attacks  of  the  second 
and  third  may  be  equally  sudden,  and  are  also  accompanied  by  vomiting 
in  a  large  proportion  of  cases;  but  they  present  neither  the  stiffness  of 
the  neck  nor  the  retraction  of  the  head,  which  so  uniformly  characterizes  the 
cerebro-spinal  disease;  unless  the  latter  actually  exists  as  a  complication, 
which  sometimes  happens.  You  will  also  derive  some  aid  from  the  pres- 
ence or  absence  of  a  general  prevalence  of  either  scarlatina  or  periodical 
fevers.  To  differentiate  between  the  epidemic  and  the  ordinary  sporadic 
cases  of  cerebro-spinal  inflammation,  is  more  difficult.  If  you  keep  in  mind 
the  facts  that  the  former  usually  occur  suddenly  without  any  known 
exciting  cause;  that  several  cases  occur  nearly  simultaneously  in  the  same 
community,  or  foUovv  each  other  in  quick  succession,  that  the  pulse  is 
softer  and  more  variable  in  frequency,  with  less  rapid  rise  of  temperature, 
and  earlier  retraction  of  the  head;  while  the  latter  are  generally  JDreceded 
by  known  exciting  causes;  occur  singly;  develop  early  a  higher  temper- 
ature and  fuller  pulse,  and  more  uniformly  contracted  pupils,  and  are  not 
marked  by  any  purple  or  petechial  spots  on  the  cutaneous  surface  in  the 
middle  and  latter  stages  of  their  progress,  you  will  be  able  to  keep  the 
line  of  distinction  with  reasonable  certainty. 

Prognosis. — The  disease  unJer  consideration  is  always  attended  by  a 


PROGNOSIS.  349 

h'l'rh  ratio  of  mortality.  Most  of  the  foreign  writers  make  the  ratio  vary 
from  50  to  75  percent.  In  tliis  country  there  have  been  very  great  iliffer- 
ences  in  the  death  rate,  in  different  epidemic  periods  and  in  different 
places  during  the  same  period.  From  Dr.  Gallup's  detailed  account  of 
the  epidemics  in  Vermont  from  1(S07  to  1815,  I  find  the  number  of  deaths 
in  proportion  to  the  whole  number  of  cases  given,  in  only  a  few  instances. 

During  its  prevalence  in  the  toWii  of  Reading  in  the  winter  of  1811,  of 
55  cases  only  8  died.  In  the  same  town  in  the  winter  of  1812,  of  GO 
cases  9  died;  while  in  the  neighboring  town  of  Plymouth  during  the  same 
season,  of  30  cases  4  died.  These  aggregate  145  cases  and  21  deaths,  or  1 
in  6.90.  During  the  yeai's  1812  and  1813  the  disease  prevailed  severely  in 
the  environs  of  Philadelphia  and  in  neighboring  towns,  an  account  of 
which  may  be  found  in  the  Medical  and  Philosophical  Register,  vol.  i'i. 
During  that  epidernic,  the  mortality  is  stated  by  Dr.  Philip  S.  Wales,  U. 
S.  N.,  as  one  in  four  or  five  cases.  The  epidemic  that  occurred  during  1  he 
great  epidemic  period  of  erysipelas,  from  1841  to  1850,  produced  a  larger 
ratio  of  mortality  than  those  occurring  during  the  first  two  decades  of  the 
present  century,  and  has  been  equaled  since  only  by  the  prevalence  of 
the  disease  in  the  States  occupying  the  middle  and  lower  parts  of  the 
Mississippi  Valley,  from  1862  to  1868,  commencing  while  extensive  mili- 
tary operations  were  going  on  in  these  States. 

Dr.  S.  Ames,  of  Montgomery,  Alabama,  whose  Monograph,  published  in 
1848,  contained,  perhaps,  the  best  account  of  the  disease  as  it  prevailed 
in  the  Southwestern  States  during  the  period  between  1841  and  1850,  is 
very  generally  quoted  by  more  recent  writers  as  making  the  ratio  of 
mortality  60  per  cent.  This  is  manifestly  incorrect.  Dr.  Ames  grades 
the  whole  number  of  cases  into  three  classes,  the  mild,  the  grave,  and  the 
malignant,  and  expressly  states  that  of  the  last  named  class  60  per  cent  died. 
He  further  states  that  but  few  of  those  cases  classed  as  grave  cases  died, 
and  none  of  those  ranked  as  mild.  He  further  represents  the  malignant 
class  as  embracing  a  little  more  than  one  half  of  the  whole  number  of 
cases  that  occurred.  It  is  evident,  therefore,  that  in  the  epidemic 
described  by  Dr.  Ames  the  ratio  of  deaths  to  the  whole  number  of  cases 
was  not  far  from  33  per  cent.  And  this  is  probably  very  nearly  the  cor- 
rect ratio  of  deaths  from  the  disease  throughout  the  whole  of  that  epidemic 
period.  For  while  in  some  isolated  or  very  limited  outbreaks  of  the 
disease  nearly  all  the  cases  died,  in  the  great  majority  of  places  where  the 
whole  numljer  of  cases  from  the  beginning  to  the  end  of  the  epidemic 
can  be  ascertained  with  an  approximation  to  accuracy,  the  death  rate 
ranged  between  1  in  1.5  and  1  in  7,  or  a  general  average  of  1  in  3.* 

Of  the  forty  cases  that  came  under  my  own  care  during  the  months  of 
February,  March  and  April,  1872,  thirty-two  recovered  and  eight  died. 
Of  the  eight  fatal  cases,  one  died  in  about  twenty  hours  from  the  com- 
mencement of  the  attack,  two  in  four  days,  one  in  five,  one  in  six,  one  in 
seven,  one  in  twelve,  and  one   in   twenty-eight  days. 

It  has  been  very  generally  observed,  that  the  attacks  which  occur  at 
the  beginning  of  an  epidemic,  in  any  given  locality,  are  more  malignant 
and  cause  a  much  larger  ratio  of  deaths  than  those  which  occur  after  the 
epidemic  has  passed  its  crisis  and  the  number  of  new  cases  is  diminishing. 
The  same  rule,  however,  applies  to  all  severe  epidemic  diseases. 

Having  spent  more  time  than  I  had  intended  in  the  consideration  of 
the  history,  causes,  and  relations  of  the  disease,  I  must  defer  the  discussion 
of  its  treatment  until  the  next  lecture  hour. 

*  .'■"ee  Report  on  Practical  Medicine  and  Epidemic  Diseases,  by  D.  Francis  Condie,  M.  D.,  In  the 
Trans.  Amer.  Med.  Association,  Vol.  ii.  pp.  156-7,  18ii). 


350  EPIDEMIC    CEKEBKO-SPIXAL    MEXIXGITIS. 


LECTURE   XXXVII. 

Epidemic  Cerebro-Spinal   ^^ening;tis    Continued. — Tts  Treatment   and  Seqnelre.— Spinal  Men- 
ingitis and  Myelitis  ;  Tlieir  Causes,  Symptoms,  Morbid  Anatomy,  Diagnosis  and  Treatment. 

GENTLEMEN:  In  regSLrd  to  the  treatment  of  epidemic  cerebro-spinal 
meningitis,  or  spotted  fever,  very  much  might  be  said  of  historic 
interest,  strikingly  illustrating  the  tendency  of  the  human  mind  to  resort 
to  heroic  and  even  reckless  medication,  in  combating  diseases  of  sudden 
development  and  fatal  tendency.  Bleeding,  general  and  local;  vomiting 
and  purging;  calomel,  opium,  quinine,  alcoholic  anaesthetics,  and  blister- 
ing, have  all  been  resorted  to  at  different  times  and  places,  and  used  with 
an  unsparing  hand.  Each  has  been  commended  by  some  and  condemned 
as  worse  than  useless  by  others.  In  the  epidemics  occurring  during  the 
first  two  decades  of  the  present  centurj^,  venesection  was  practiced  very 
freely  by  a  large  proportion  of  the  practitioners  in  the  New  England 
States.  For  instance,  we  are  told  by  Dr.  Gallup,  that  seventy-three  cases 
of  spotted  fever  occurring  in  the  towns  of  Greeusborough  and  Hardwick, 
in  the  spring  of  1811,  were  treated  by  Dr.  Huntington  without  a  single 
fatal  case.  "  He  bled  from  one  to  five  times,  sweated,  gave  also  val. 
tincture  of  gum  guaiac,  ether  ,  etc."* 

In  another  place.  Dr.  Littlefield,  who  treated  many  cases  during  an 
epidemic  in  the  winter  and  spring  of  1813,  is  represented  as  bleeding  the 
patients  from  two  to  four  times,  from  twelve  to  twenty-four  ounces  each 
time,  with  very  great  success. f 

Dr.  Gallup  himself  treated  eighty-one  well  marked  cases,  embracing 
all  ages  and  both  sexes,  during  ihe  epidemic  of  1811,  without  anv  opium, 
but  with  from  one  to  four  bleedings,  in  more  than  half  of  the  cases,  and 
with  the  loss  of  only  one  of  the  whole  number.  Others  used  emetics, 
cathartics  and  calomel  very  freely  during  the  same  epidemic,  bat  with 
very  little  evidence  of  goo  1  results.  Of  all  the  remedies  used,  howv'ver, 
none  were  used  more  lavishly  than  opium  and  the  alcoholic  liquors. 
Throughout  the  Connecticut  Valley,  where  the  doctrines  of  Drs.  Miner 
and  Tulh'  in  regard  to  the  use  of  opium  in  fevers,  exerted  much  influence, 
these  remedies  were  given  in  cas3Sof  spotted  fever  in  doses  and  quantitie's 
so  large  as  to  suggest  doubts  concerning  the  sanity  of  those  who  directed 
their  administration.  Dr.  Miner  says  that,  "  Opium  was  the  most  important 
remedy  in  the  severe  form  of  this  disease.  *  *  *  ^  few  cases  imperi- 
ously required  half  an  ounce  of  the  tincture  in  an  hour,  or  half  a  drachm 
in  substance,  in  the  course  of  twelve  hours,  *  *  *  and  even  some 
cases  required  a  drachm  in  the  s  une  time.  All  these  patients  recovered.'''' 
Dr.  B.  H.  Catlin,  of  Meriden,  Connecticut,  cites  cases  in  which  from  three 
to  five  grams  (gr.  xlv  to  Ixxv)  of  opium  were  given  each  day  for 
two  or  three  daj's  in  succession.  Concerning  a  young  lady  of  fifteen  or 
sixteen  years  of  age,  to  whom  he  was  called  on  account  of  the  sickness  of 
her  attending  physician,  he  says:  ''She  was  taking  a  large  pill  of  opium, 
between  twoand  three  grains,  every  four  hours;  a  large  dose  of  laudanum, 
nearly  a  teaspoonful,  every  four  hours;  infusion  cort.  cinchona,  brandy, 
and  pepper  tea,  all  the  stomach  would  bear."  Dr.  Catlin  does  not  say, 
however,  that  "all  these  patients  recovered."  On  the  contrary,  he  admits 
that   many  of  them    died;   and    plainly   suggests   that   many    cases   were 


*  'ee  Gallup  on  Epidemics,  p.  67, 
t  Ibid,  p.  73. 


TREATMENT.  351 

altogether  fictitious,  the  cerebral  symptoms  and  sinking  being  prodnced 
by  the  remedies  instead  of  the  disease.* 

Equal  extravagances  have  characterized  the  treatment  of  many  cases 
during  the  later  epidemics,  as  in  those  of  the  first  two  decades  of  the  pres- 
ent century.  For  example,  Dr.  J.  Adams  Allen,  in  the  paper  read  by  him 
to  the  Illinois  State  Medical  Society,  in  ISGi,  says:  "T  have  known  fifty 
grains  of  morphine  given,  within  a  dozen  hours,  to  a  boy  of  fifteen,  to 
relieve  him  from  the  terrible  pain  and  suffering,  with  no  avail,  save  that 
death  followed."  And  he  adds:  "  Incalculable  quantities  of  brandy  and 
quinine,  of  capsicum  and  carbonate  of  ammonium,  have  been  poured  into 
the  stoma -hs  of  the  comatose."  f 

I  have  made  these  brief  allusions  to  what  may  be  called  the  extrava- 
gances of  the  past,  for  the  purpose  of  giving  you  some  idea  of  the  variety 
of  treatment  to  which  the  disease  has  been  subjected,  and  still  more  to 
show  the  extent  to  which  the  human  system  can  be  rendered  insensible 
to  the  action  of  the  most  powerful  drugs  by  the  presence  of  certain  con- 
ditions of  disease. 

You  all  know  that  the  human  system  in  its  healthy  or  normal  state  of 
susceptibility  aiid  molecular  movements  would  be  dangerously  if  not  fatally 
narcotized  by  less  than  one  third  of  the  five  grams  (gr.  Ixxv)  of  opium 
which  were  given  two  and  three  days  in  succession,  and  in  some  instances 
without  fatal  effects.  Similar  want  of  susceptibility  to  the  action  of 
opiates  and  alcoholics,  is  also  seen  in  cases  of  tetanus,  delirium  tremens, 
and  many  of  the  more  malignant  cases  of  general  fever.  But  such  toler- 
ance of  any  particular  drug,  neither  proves  that  the  drug  is  indicated, 
nor  its  administration  in  unusual  quantity  free  from  danger.  On  the  con- 
trary, it  rather  points  to  the  necessity  of  using  something  more  directly 
calculated  to  arouse  the  general  susceptibility  and  vasomotor  activity, 
and  thereby  avert  the  danger  of  entire  suspension  of  molecular  move- 
ments in  the  nervous  centers  as  occurs  in  the  more  rapidly  fatal  cases  on 
the  one  hand,  and  on  the  other,  establish  a  better  response  to  the  impres- 
sion of  remedial  agents  of  all  kinds.  The  danger  of  administering  enor- 
mous or  unusual  quantities  of  any  narcotic  or  anaesthetic  during  a  stage  of 
extreme  pain  or  temporary  suspension  of  susceptibility  from  a  morbid  con- 
dition, consists  in  the  fact  that  a  sufficient  quantity  of  the  drug  may  remain 
in  the  system  after  the  pain  ceases  or  the  susceptibility  to  its  action  returns, 
to  produce  dangerous  toxic  effects.  When  it  was  customary  to  treat 
tetanus  and  delirium  tremens  with  very  large  and  frequently  repeated 
doses  of  opium,  not  a  few  of  the  patients  died  from  excessive  narcotism 
»  after  the  tetanic  spasms  and  delirium  had  ceased.  Even  during  the  last 
few  years  no  less  than  three  cases  of  delirium  tremens  have  come  under 
my  own  observation  in  which  the  attending  physician  after  giving  large 
and  frequent  doses  of  bromides,  chloral  hydrate  and  morphine,  fiudUy  in- 
duced sleep,  but  it  was  a  sleep  from  which  they  never  awoke.  In  one  of 
the  cases  the  last  dose  was  a  hvpodermic  injict  on  of  morphine. 

The  leading  indication  to  be  fulfilled,  or  object  to  be  accomplished,  by 
treatment  in  the  special  form  of  disease  under  consideration,  is  to  obtain 
an  early  abatement  of  the  morbid  action  and  vascular  fullness  in  the  cere- 
bro-spinal  nervous  centers,  thereby  relieving  the  pain,  relaxing  the  mus- 
cular rigidity,  and  preventing  fatal  paralysis.  F^rom  what  I  stated  in  the 
preceding  lecture  concerning  the  close  association  of  the  disease  with  ery- 
sipelas on  the  one  hand   and  with  tvphus  on  the  other,  you  will  infer  that 

*  See  Report  on  the  Clima  ology  and  Epidemic  Diseases  of  Connecticut    By  B.  H.  Catlin,  M.  D. 
in  the  Trans.  Amer.  Med.  Association,  Vol    16,  pp.  486-48S,  490. 
t  tee  Trans.  Ill  State  Med  ^ociety  for  1864. 


352  EPIDEMIC    CEREBRO-SPINAL    MENINGITIS. 

the  nature  of  the  inflammatory  process  or  morbid  action  in  the  cerebro- 
spinal textures  will  either  partake  of  the  specific  qualities  of  the  former  or 
of  the  asthenic  grade  of  the  latter.  Consequently  direct  depletion  by 
bleeding-  could  be  beneficial  only  in  the  beginning  of  such  exceptional 
cases  as  presented  unusual  cardiac  force  and  arterial  tension.  x\nd  the 
same  rule  would  apply  to  the  use  of  such  cardiac  sedatives  as  the  veratrum 
viride  and  aconite.  In  the  great  majority  of  cases  we  must  rely  upon 
those  agents  which  are  known  to  be  capable  of  so  acting  upon  the  vaso- 
motor nerves  as  to  induce  contraction  of  the  cerebro-spinal  vessels,  thereby 
lessening  the  fullness  of  blood  and  checking  the  tendency  to  exudation  and 
effusion.  Perhaps  the  most  reliable  agents  we  possess  for  that  purpose  are 
the  ergot,  physostigma  and  belladonna.  In  the  epidemic  of  1872,  in  this 
city,  I  treated  the  first  three  case-;  that  came  under  my  care  with  local 
bleeding  by  leeches,  followed  by  blisters;  the  internal  use  of  bromides, 
iodides,  and  mild  laxatives,  aided  by  ice  bags  to  the  head  and  neck,  but 
with  no  marked  benefit.  The  first  case  terminated  fatally,  and  the  next 
two  were  doing  badly,  when  I  substituted  for  the  remedial  agents  just 
mentioned,  the  administration  of  the  tincture  of  physostigma  with  decided 
benefit.  From  that  time  to  the  end  of  the  epidemic  I  gave  the  physostigma 
and  ergot  combined,  to  nearly  all  of  the  cases  that  came  under  my  care,  as 
the  leading  remedies  during  the  active  stage  of  the  disease.  When  called 
soon  after  the  commencement  of  the  attack,  I  usually  directed  a  sack  or 
pillow  of  pounded  ice  to  the  occiput;  or  if  this  could  not  be  obtained, 
cloths  wet  in  cold  water  and  frequently  renewed;  and  the  following  pre- 
scription to  be  given  internally: 

Tfi      Tincturje   Physostigmatis  45.0  c.  c.  |iss 

Extract!  Ergotae  Fluidi  75.0  c.  c.  fiiss 

Mix.  Give  to  an  adult  four  cubic  centimeters  (fl.  3i)  every  two  or  three 
hours,  according  to  the  urgency  of  the  symptoms. 

If  there  was  gastric  irritability  with  more  or  less  vomiting,  I  directed 
four  cubic  centimeters  (fl.  3i)  of  the  following  formula  to  be  given  half 
way  between  the  doses  of  the  physostigma  and  ergot: 

5.      Acidi  Carbolici  0.40  arraras         gr.    vi 


Acidi  Carbolici 

0.40  arraras 

gr. 

Glycerinfe 

15.00  a  c. 

3iv 

Tincturfe  Gelsemini 

15.00  c.  c. 

3i_v 

Aquae 

90.00  c.  c. 

3111 

Mix. 

If  there  had  been  no  movement  of  the  bowels  during  the  preceding 
twenty-four  hours  or  more.  I  gave  a  single  powder  containing  three  deci- 
grams (gr.  v)  each  of  calomel  and  bicarbonate  of  sodium,  and  if  it  did 
not  move  tlie  bowels  in  four  hours,  aided  it  by  a  moderate  dose  of  the 
Rochelle  salts  or  citrate  of  magnesium.  If  after  the  first  one  or  two  days  the 
dispositioti  to  vomit  ceased,  which  was  usually  the  case,  the  carbolic  acid 
and  gelseminum  mixture  was  omitted.  Whenever  the  rigidity  of  the 
muscles  of  the  neck  and  the  pain  in  the  head  had  abater),  the  interval  be- 
tween the  doses  of  physostigma  and  ergot  were  lengthened  to  three,  four, 
six  and  finally  to  eight  hours.  If  as  convalescence  approached,  the  patient 
was  restless,  mentally  wandering,  or  sleepless  during  the  night,  I  found  a 
single,  fair    dose   of   the    compound  powder  of   opium    and   ipecacuanha 


TREATMENT.  353 

with  pulverized  gum  camphor,  given  at  bed-time  each  night  to  procure 
good  rest  and  to  materially  hasten  the  establishment  of  convalescence. 
As  soon  as  the  latter  v?as  fairly  established,  the  ergot  and  physostigma 
wore  omitted;  for  when  continued  longer,  they  appeared  to  increase  the 
tendency  to  that  cerebral  anaemia  and  general  emaciation  which  in  some 
instances  greatly  protracted  the  period  of  convalescence.  In  a  few  cases, 
after  the  crisis  or  active  stage  of  the  disease  had  passed,  an  exacerbation 
of  fever  would  occur  about  the  same  time  each  day.  These  were  quite 
uniformly  interrupted  by  two  or  three  moderate  doses  of  sulphate  of  qui- 
nia  each  day.  After  the  first  day  the  patients  were  carefully  sustained 
by  simple  nourishment,  consisting  principally  of  milk  and  beef  tea,  given 
in  small  doses,  regularly,  at  short  intervals.  By  the  foregoing  manage- 
ment, carefully  adjusting  the  doses  to  the  age  of  the  patient  and  the  ac- 
tivity of  the  disease,  of  tlie  whole  number  that  came  under  my  care  one  out 
of  six  died.*  You  must  remember,  however,  that  every  epidemic  of 
this  disease  needs  to  be  studied  carefully,  both  in  relation  to  the  special 
character  of  the  symptoms  it  presents,  and  its  relation  to  the  coincident 
prevalence  of  other  diseases.  And  the  treatment  must  be  varied  to  suit 
the  special  character  of  each  epidemic.  If  the  disease  should  manifest 
itself  at  a  time  when  coincident  diseases  were  manifesting  an  active  in- 
flammatory tendency,  as  was  evidently  the  case  in  Vermont  from  1811  to 
I8I0,  I  should  not  hesitate  to  take  one  free  bleeding  from  the  arm  at  the 
begitniing,  following  it  promptly  by  arterial  sedatives  and  a  mercurial  ca- 
thartic, after  which  the  ergot  would  be  applicable,  and  most  of  the  other 
measures  I  have  indicated.  If  it  should  come  in  the  midst  of  a  general 
epidemic  of  erysipelas,  as  was  the  case  from  1841  to  1850,  I  would  place 
less  reliance  on  cold  applications  to  the  head  and  neck  and  the  use  of  ergot 
and  physostigma,  and  more  on  early  douches  of  warm  water  to  the  occiput, 
followed  by  blisters  and  the  internal  use  of  hyposulphites  of  sodium  and 
belladonna,  tincture  of  chloride  of  iron,  tincture  of  cantharides,  and  due 
attention  to  the  action  of  the  kidneys  and  bowels.  And  if  there  should  be 
present  also  a  strong  malarious  influence,  causing  most  of  the  attacks  to  be 
ushered  in  by  a  decided  chill  and  imparting  to  the  subsequent  fe^^er  some 
degree  of  remittent  character  as  was  the  case  in  many  places  in  the  middle 
and  lower  part  of  the  Mississippi  valley,  both  in  the  epidemics  of  1841-50,  and 
1862-8,  I  should  expect  to  obtain  much  benefit  frsni  the  timely  use  of  fair 
anti-periodic  doses  of  sulphate  of  quinia.  In  regard  to  cpium,  which  many 
writers  place  at  the  head  of  the  list  of  remedial  agents  for  the  treattrent 
of  this  disease,  I  can  only  say  that  its  use  during  the  active  stage  of  the 
disease  in  such  cases  as  have  come  under  my  observation,  has  proved  posi- 
tively injurious.  But  in  the  stage  of  decline,  to  allay  restlessness  and 
procure  sleep  at  night,  and  to  control  neuralgic  pains  during  convales- 
cence, it  has  proved  very  beneficial,  especially  when  given  in  connection 
with  camphor  or  quinine.  If  given  in  the  early  stage  of  the  disease  at  all, 
it  should  be  in  moderately  full  doses  just  after  a  general  or  local  bleeding 
sufficient  to  temporarily  relieve  the  vascular  fullness.  With  the  systolic 
force  of  the  heart  and  the  tension  of  the  vessels  abated  by  the  loss  of 
blood,  or  less  certainly  by  the  use  of  cardiac  sedatives,  the  efficient  influ- 
ence of  opium  in  overcoming  the  morbid  excitability  of  the  structures, 
would  have  a  strong  tendency  to  prevent  the  renewal  of  the  vascular  full- 
ness, and  help  to  cut  short  the  inflammatory  process.  If  whatever  reme- 
dies are  used  in  the  first  stage  of  the  disease  should  fail  to  arrest,  or  so  far 
modify  the  morbid  conditions  as   to  prevent  exudation  and  effusion,  and 

*  For  further  details  see  volume  of  Clinical  Lectures  on  Various  Important  Diseases,  edited  by- 
Frank  H.  1  avis,  M.  JJ.,  2d  ed.,  pp.  241-50,  1874. 

23 


.354  EPIDEMIC    CEREBRO-SPINAL    MENIXGITIS. 

stupor,  coma  and  paralysis  ensue,  there  is  little  reason  to  hope  for  a  favora- 
ble result  from  further  treatment.  And  yet  it  may  be  well  to  apply  blis- 
ters and  mercurial  inunction,  and  give  internally  full  doses  of  iodide  of 
potassium,  either  bv  the  mouth  or  in  nutritive  enemas  when  deglutition  is 
difficult  or  suspended,  for  the  purpose  of  preventing  further  exudation  and 
promoting  the  absorption  of  what  mav  already  exist;  as  recoveries  have 
occasionally  taken  place  from  conditions  apparently  hopeless.  In  all 
cases  in  which  convalescence  follows  attacks  of  this  disease,  great  care 
should  be  taken  to  have  the  patient  avoid  all  active  mental  or  physical  ex- 
ercise or  excitement  until  strength  and  nutrition  are  well  restored.  Much 
rest  in  a  recumbent  position,  good  air,  a  moderate  variety  of  plain,  easily 
digested  food,  and  the  avoidance  of  strong  tea  and  coffee,  and  of  all  kinds 
of  fermented  or  distilled  drinks,  will  insure  the  most  rapid  and  complete 
recovery  with  the  least  danger  of  relapses.  If  any  medicine  is  used  during 
convalescence,  such  as  will  aid  in  re-establishing  healthy  nutrition  will  be 
the  most  useful.  For  this  purpose  you  may  direct  the  patient  to  take  four 
cubic  centimeters  (fl.  3i)  of  the  syrup  of  lacto-phosphate  of  lime,  or  of 
the  compound  syrup  of  the  hypophosphites,  just  after  each  meal,  and  the 
same  quantity  of  the  fluid  extract  of  the  humulus  lupulus  at  bed-time.  The 
latter  will  allay  nervous  restlessness  and  promote  natural  sleep. 

Sequelae. — The  important  pathological  conditions  liable  to  follow  as  a 
result  of  the  epidemic  cerebro-spinal  meningitis,  are,  a  spaneemic  or  im- 
poverished condition  of  the  blood  with  general  impairment  of  nutrition; 
frequent  and  severe  neuralgic  pains,  often  changing  their  location  from 
one  set  of  nerves  to  another,  with  difficulty  of  maintaining  the  erect 
position  without  inducing  vertigo  and  muscular  trembling,  and  more  or 
less  permanent  impairment  of  vision,  and,  in  some  cases,  of  the  mental 
faculties  also.  The  first  condition  I  have  mentioned  is  best  remedied  by 
a  continuance  of  the  same  management  that  I  have  just  mentioned  as 
.proper  during  the  stage  of  convalescence.  The  cases  included  in  the  second 
condition  or  sequel,  differ  from  the  first  in  the  fact  that  they  are  still 
affected  with  a  certain  degree  of  irritation  or  morbid  sensitiveness  in  the 
■cerebro-spinal  centers  in  addition  to  the  general  anfemia.  And  it  is  the 
^continuance  of  this  central  irritation  that  causes  the  tormenting  neuralgic 
pains  without  the  least  regularity  as  to  time  or  place;  although  in  a 
-majority  of  cases  they  are  most  frequent  and  severe  in  the  heads  of  the 
gastrocnemii  muscles,  in  the  abdomen,  and  in  the  head.  In  nearly  all  the 
cases  of  this  kind  that  came  under  my  observation,  I  gave  a  mixture  of 
two  parts  of  camphorated  tincture  of  opium  with  one  part  of  the  tincture 
■  of  physostigma  each  morning,  noon,  and  tea  time,  and  a  moderately  full 
dose  of  the  compound  powder  of  opium  and  ipecacuanha  with  quinine  at 
bed-time,  with  early  and  permanent  relief.  Some  of  this  class  of  cases 
were  troubled  less  with  neuralgia,  and  while  at  rest,  appeared  quite  well, 
but  every  attempt  to  maintain  the  erect  position  or  walk,  would  cause 
marked  dilation  of  the  pupils,  vertigo,  and  trembling  of  the  voluntary 
muscles  to  such  an  extent  as  to  threaten  convulsions  unless  the  recumbent 
position  was  immediately  resumed.  One  of  the  most  prominent  cases  of 
this  kind  was  that  of  an  adult  male,  naturally  strong  and  healthy^  to  whom 
I  was  called  in  consultation  nine  weeks  after  he  had  been  attacked  Avith 
the  epidemic  cerebro-spinal  disease  in  1872.  He  passed  through  the  active 
stage  of  the  disease  and  reached  apparent  convalescence  at  the  end  of  the 
second  week.  The  only  symptoms  that  remained  were  a  moderate  enlarge- 
ment of  the  pupils,  a  pallid  or  ansemic  hue  of  the  surface,  slowness  of  the 
pulse  when  resting  in  the  recumbent  position,  which  became  quick  and  vari- 
able when  the  patient  attempted  any  muscular  exertion,  and  wide  dilation  of 


SEQUELS.  355 

both  pupils,  with  vertigo  and  universal  muscular  trembling  to  such  an 
extent  as  to  render  him  incapable  of  remaining  one  minute  in  the  erect 
position.  His  temperature  was  natural,  appetite  fair,  renal  secretion  good, 
and  mental  faculties  unimpaired.  His  attending  physician,  regarding  the 
symptoms  I  have  mentioned  as  the  result  of  serous  effusion  into  the 
lateral  ventricles,  had  kept  him  on  a  spare  diet  and  from  three  to  six  gram 
doses  (gr.  v  to  x)  of  iodide  of  potassium  up  to  the  time  of  my  visit,  but 
with  no  improvement  in  the  condition  of  the  patient. 

The  natural  expression  of  countenance,  the  ready  use  of  the  mental 
faculties,  the  ability  to  command  the  movements  of  any  of  the  voluntary 
muscles  when  at  rest  in  the  reruml:)ent  position,  appeared  to  me  incom- 
patible with  the  existence  of  effusion  either  into  the  ventricles  or  upon  the 
surface  of  the  brain;  while  the  dilation  of  the  pupils,  the  vertigo,  and  the 
muscular  agitation  produced  by  an  erect  position  clearly  indicated  cere- 
bral amaemia  and  defective  nutrition.  I  consequently  persuaded  his  phy- 
sician to  omit  the  further  use  of  the  iodides,  and  substitute  in  their  place 
fair  doses  of  the  compound  syrup  of  the  hypophosphites;  to  allow  a  more 
liberal  diet  of  plain  food,  and  avoid,  as  far  as  possible,  all  muscular  exertion 
or  change  from  the  recumbent  position.  Under  this  simple  method  of 
treatment  he  soon  began  to  show  signs  of  improvement,  and  in  about 
three  months,  fully  recovered,  and  subsequently  resumed  his  occupation 
as  an  engineer. 

Those  cases  of  decided  impairment  of  the  hearing  and  vision,  with 
partial  paralysis  and  imperfect  use  of  the  mental  faculties,  which  are  occa- 
sionally met  with  as  the  sequel  of  severe  attacks  of  epidemic  cerebro- 
spinal disease,  are  but  little  influenced  by  any  treatment  that  has  been 
devised.  In  these  cases,  the  structural  changes  in  the  inflamed  portions 
of  the  brain  have  become  permanent;  and  though  the  patient  may  live  for 
months,  or  even  years,  very  few  ever  gain  the  normal  condition  of  their 
cerebro-spinal  functions. 

The  next  subject  to  which  I  must  direct  your  attention  is 

SPINAL  MENINGITIS. 

By  spinal  meningitis,  I  mean  inflammation  of  the  membranes  and  surface 
of  any  part  of  the  spinal  cord  from  its  junction  with  the  medulla  oblono-ata 
to  its  caudal  extremity.  Simple  idiopathic  inflammation  of  this  part  of  the 
central  portion  of  the  nervous  system,  is  not  of  frequent  occurrence,  if  we 
exclude  from  our  considera.tion  those  cases  that  arise  from  the  causes  of 
constitutional  syphilis  and  rheumatism,  both  of  which  have  been  sufficiently 
discussed  in  lectures  thirty  and  thirty-one  of  the  present  course.  The 
outer  membran®,  or  dura-mater,  of  the  cord  is  liable  to  the  same  forms  of 
disease  as  that  which  envelops  the  brain,  and  which  I  have  described 
under  the  names  of  pachymeningitis  externa  and  interna.  But  they  arise 
from  the  same  causes,  and  are  so  generally  associated  with  the  correspond- 
ing pathological  conditions  within  the  cranium  that  a  separate  description 
is  not  necessary.  Inflammation  of  the  arachnoid  and  pia  mater  may  be  met 
with  in  all  grades  of  activity  from  the  most  acute  to  the  most  chronic  form 
of  the  inflammatory  process. 

Etiology. — The  most  common  causes  of  simple  spinal  meningitis  are 
mechanical  injuries,  such  as  concussions,  contusions,  twisting,  or  wrench- 
ing, etc.,  and  sudden  exposures  to  wet  and  cold.  The  first  class  of  causes 
are  most  liable  to  induce  a  subacute  grade  of  inflammation,  limited  to  some 
one  section  of  the  cord,  while  the  sudden  exposures  to  wet  and  cold  more 
generally  induce  acute  attacks,  embracing  the  whole  length  of  t'  e  cord. 


356  SPINAL    MENINGITIS 

Symptoms. — The  commencement  of  acute  inflammation  of  the  pia  ma- 
ter and  surface  of  the  cord  is  usually  characterized  by  chilliness  or  rigors, 
with  paleness  of  the  features,  and  severe  pain  in  the  back.  The  first  two 
symptoms  continue  only  from  one  to  three  quarters  of  an  hour,  and  give 
place  to  some  flush  of  the  face,  moderate  elevation  of  temperature,  greater 
frequency  and  fullness  of  the  pulse,  respiration  shorter  and  more  frequent, 
and  very  severe  pain  in  the  affected  part  of  the  spine,  much  increased  by 
motion.  There  is  also  generally  hypeieesthcsia  or  increased  sensibility  of 
the  cutaneous  surface,  with  acute  pains  following  the  course  of  the  S23inal 
nerves  both  around  the  body  and  in  the  extremities,  and  often  accompa- 
nied by  muscular  contractions  causing  a  sense  of  constriction  like  the  im- 
pression of  a  hoop  or  band  around  the  body.  The  tongue  becomes  cov- 
ered with  a  whitish  coat,  the  urine  scanty,  high  colored,  and  more  acid 
than  natural,  the  patient  very  restless  yet  tortured  with  great  increase  of 
pain  by  every  attempt  to  move  or  bend  the  spine,  and  frequent  cramps  or 
rigid  contraction  of  some  of  the  muscles.  When  the  inflammation  is  acute 
and  extending  the  whole  length  of  the  spine,  or  even  the  length  of  the  cer- 
vical and  dorsal  portions  of  it,  the  pain  in  the  spine  and  along  the  course 
of  the  intei  costal  and  other  thoracic  nerves  with  the  accompanving  muscular 
cojitractions  or  rigidity,  so  interferes  with  respiration  as  to  cause  intense 
suffering  and  anxiety,  and  sometimes  ca.ses  sudden  death  by  apnoea,  in 
the  early  stage  of  the  disease.  If  the  patient  escapes  this  danger,  in  from 
three  to  seven  days,  according  to  the  grade  of  activity,  the  symptoms  be- 
gin to  change,  the  temperature  diminishes,  the  pulse  becomes  smaller 
and  often  variable  in  frequency;  the  pains  and  hypera^sthesia  diminish, 
with  corresponding  abatement  of  muscular  cramps  and  rigidity;  and  in 
one  or  two  days  more,  the  hyperaesthesia  and  pain  have  given  place  to  anaes- 
thesia or  loss  of  sensibility,  and  the  previously  contracted  muscles  become 
entirely  relaxed.  In  other  words,  paralysis  of  both  sensation  and  motion 
has  followed  the  stage  of  irritation.  These  effects  will  be  manifested  only 
in  such  parts  as  are  supplied  with  nerves  from  the  inflamed  portion 
of  the  spinal  cord  and  the  parts  below.  If  the  upper  part  of  the  cord  is 
involved,  the  paralysis  may  include  the  muscles  of  the  chest  to  such  an 
extent  as  to  cause  a  fatal  result  from  the  suspension  of  respiratory  move- 
ments. If  the  disease  is  limited  to  the  lower  half  of  the  cord,  the  paraly- 
sis may  affect  only  the  lower  extremities,  or  it  may  extend  high  enough  to 
include  the  hips  and  viscera  of  the  pelvis,  and  render  the  patient  incapable 
of  controlling  the  urine  or  faeces.  In  most  cases  of  spinal  meningitis  both 
lateral  halves  of  the  cord  are  involved,  causing  all  the  svmptoms  to  be  bi- 
lateral; that  is,  involving  corresponding  parts  on  both  sides  of  the  body. 
In  some  cases,  however,  the  disease  is  not  equally  severe  on  both  sides. 
In  most  cases,  also,  as  you  will  infer  from  the  symptoms  I  have  detailed, 
the  disease  involves  the  nerves  from  both  anterior  and  posterior  columns 
of  the  cord,  thereby  disturbing  the  functions  of  motion  and  sensation,  at 
the  same  time.  In  many  cases,  however,  the  disease  does  not  progress 
with  equal  rapidity  in  both  colvimns;  causing,  in  some,  the  continuance  of 
sensibility  and  even  hypera3sthesia  after  the  loss  of  motion  in  the  same 
parts  is  complete,  and  in  others  the  order  of  progress  will  be  reversed, 
showing  complete  loss  of  sensibility,  while  the  muscles  of  the  part  remain 
rigidly  contracted.  When  the  lower  part  of  the  body  and  limbs  are  fully 
paralyzed,  with  dribbling  of  urine  and  involuntary  discharge  of  faeces, 
there  is  much  danger  of  the  formation  of  large  and  deep  bed  sores  over 
the  sacrum  and  trochanters,  with  progressive  loss  of  flesh  and  strength 
until  death  results  from  asthenia.  If,  as  happens  in  a  certain  proportion 
of  the  cases,  the  attack  of  inflammation  is  less  severe,  the  resulting  paral- 


MORBID  ANATOMY.  357 

ysis  of  either  sensation  or  motion  will  be  only  partial,  and  by  proper  man- 
agement the  patient  will  slowly  recover. 

Morbid  Anatom)/. — The  patholoo-ical  and  anatomical  changes  which 
take  place  in  the  tlitt'erent  grades  of  spinal  meningitis  are  the  same  as  in 
the  corresponding  grades  and  stages  of  cerebral  meningitis,  already 
described.  During  the  first  stage,  corresponding  with  the  period  of  severe 
pain,  hyperresthesia,  muscular  contractions,  and  general  fever,  the  pia 
mater  and  surface  of  the  cord  are  intensely  red  from  the  congestion  or 
accumulation  of  blood  in  the  vessels  and  capillaries  of  the  inflamed  parts. 
This,  in  a  time  varying  with  the  intensity  of  the  vascular  engorgement,  is 
followed  by  exudations  into  the  membrane  and  portions  of  the  surface  of 
the  nerve  substance,  and  effusions  of  serum,  between  the  arachnoid  and  pia 
mater,  in  some  cases  colored  with  l)lood  corpuscles,  and  in  others  rendered 
turbid  from  the  intermixture  of  pus.  It  is  the  pressure  of  these  accumu- 
lating products  of  the  infbimmation  upon  the  substance  of  the  cord,  that 
causes  the  transition  of  symptoms  from  those  of  active  irritation  and  excite- 
ment, to  those  of  debility,  anaesthesia  and  muscular  paralysis,  which  mark 
the  second  scage  of  the  disease.  If  the  case  has  terminated  fatally  soon 
after  the  second,  or  stage  of  paralysis  has  supervened,  there  will  usually 
be  no  other  morbid  appearances  in  the  interior  of  the  cord  than  slight 
congestion  of  the  vessels.  But  if  life  has  been  protracted  through  a  long- 
period  of  time  after  paralysis  from  the  continued  pressure  of  the  effused  fluid 
and  other  inflammatory  products  on  the  cord,  much  atrophy  or  wasting  of 
the  nerve  structure  may  be  found  to  have  taken  place  in  addition  to  other 
changes.  In  some  cases  the  serous  effusion  is  less  and  there  is  plastic 
material  in  its  place,  both  on  the  surface  of  the  pia  mater  and  l)etvveen  it 
and  the  substance  of  the  cord,  causing  sometimes  adhesions  between  the 
surfaces  of  the  arachnoid  and  pia  mater. 

Diagnosis. — The  chief  diagnostic  symptoms  of  spinal  meningitis  are, 
severe  pain  in  some  part  or  the  whole  of  the  spinal  column,  greatly  in- 
creased by  bending  or  moving  the  part,  hypereesthesia  of  the  whole  sur- 
face, or  of  such  parts  as  receive  sentient  nerves  from  the  part  of  the  spinal 
cord  affected;  more  or  less  contractions  of  the  muscles  supplied  with 
motor  nerves  from  the  same  source;  more  or  less  general  fever  as  indicated 
by  increased  heat  and  frequency  of  pulse;  and  when  the  inflammation 
involves  the  middle  and  upper  sections  of  the  cord,  the  characteristic 
sense  of  constriction,  as  of  a  band  around  some  part  of  the  chest  or  abdo- 
men. There  is  very  generally  ti-nderness  to  pressure  on  each  side  of  the 
spinal  column,  but  not  directly  on  the  spinous  processes.  Neuralgic  and 
hysterical  affections  are  neither  characterized  by  general  fever  nor  the 
persistent  pains  and  muscular  contractions  of  the  first  stage  of  spinal 
meningitis.  From  acute  and  subacute  rheumatic  inflammation  it  is  dis- 
tinguished by  its  fixed  or  non-migratory  character  and  by  its  early  tend- 
ency  to   develop   more  or  less  paralysis  of  sensation  or  motion,  or  of  both. 

I*rognosis. — Acute  inflammation,  occupyino- the  membranes  and  a  large 
part  of  the  surface  of  the  cord,  is  a  dangerous  form  of  disease,  proving 
fatal  in  a  large  percentage  of  cases.  When  it  is  limited  to  a  small  part  of 
the  cord,  and  especially  to  the  lower  third,  the  proportion  of  recoveries  is 
much  larger,  simply  because  it  does  not  involve  paralysis  of  parts  whose 
function  is  essential  to  the  continuance  of  life.  The  longer  any  part  of 
the  cord  remains  under  pressure  from  the  exudation  and  other  inflam- 
matory products,  the  less  will  be  the  prospect  of  ultimate  recovery.  The 
earlier  any  given  case  can  be  brought  under  judicious  treatment,  the  better 
will  be  the  prospect  of  success. 

Treatment. — The  body  should  be  kept  in  a  recumbent  position,  as  free 


358  SPINAL  MENINGITIS. 

from  motion  as  possible,  and  upon  one  side  instead  of  the  back.  In  the 
first  stage  of  all  acute  and  subacute  cases,  free  local  depletion  by  leeches 
or  cups,  followed  by  frequent  douches  or  sponging  with  hot  water  along 
the  spine  for  twenty-four  hours,  and  the  subsequent  application  of  blisters, 
or  other  means  of  efficient  counter-irritation,  will  constitute  the  best 
external  measures  of  treatment.  Internally,  you  can  give  to  an  adult 
from  three  to  six  decigraras  (gr.  v  to  x)  each  of  calomel  and  bicarbonate 
of  sodium,  and  follow  it  in  three  hours  by  sufficient  sulphate  of  magnesium, 
or  other  saline  laxative,  to  secure  a  free  movement  of  the  bowels.  As  soon 
as  this  is  accomplished,  you  can  give  one  gram  (gr.  xv)  of  the  salicylate  of 
sodium  in  solution,  every  three  or  four  hours,  and  a  powder  of  calomel,  six 
centigrams  (gr.  i),  and  the  compound  powder  of  opium  and  ipecacuanha 
four  decigrams  (gr.  vi),  between  the  doses  of  the  salicylate.  If  the  pulse 
is  hard  and  quick  and  the  temperature  high,  from  thi-ee  to  five  minims  of 
the  tincture  of  veratrum  viride  may  be  added  to  each  dose  of  the  solution 
of  salicylate  of  sodium  until  the  acuteness  of  the  symptoms  abate.  "  If 
under  the  use  of  these  remedies  the  temperature  falls,  the  puise  becomes 
slower  and  more  easily  compressed,  the  pains  in  the  back  and  general 
hyperassthesia  diminish,  and  especially  if  muscular  relaxation  and  anaes- 
thesia begin  to  appear,  indicating  the  commencement  of  effusion  or  accu- 
mulation of  inflammatory  products,  both  the  salicylate  and  the  calomel 
should  be  omitted,  and  in  their  place  from  four  to  six  decigrams  (gr.  vi 
to  x)  of  the  iodide  of  potassium,  given  every  three  or  four  hours,  with 
efficient  counter-irritation  over  the  affected  part  of  the  spine.  After  the 
operation  of  the  first  cathartic  the  bowels  may  be  moved  once  each  day  by 
enemas.  If,  prior  to  the  attack,  the  patient  had  been  anaemic,  or  under 
the  influence  of  malaria,  or  other  depressing  agents,  ergot  and  physostigma 
may  be  given  with  the  salicylate  instead  of  veratrum  viride  or  aconite. 
And  when  the  stage  for  using  the  iodide  comes,  it  may  be  alternated  with 
from  two  to  three  decigram  (gr.  iii  to  v)  doses  of  sulphate  of  cjuinia  with 
advantage  to  the  patient.  The  treatment  I  have  detailed  is  such  as  I  have 
found  most  beneficial  in  the  more  acute  and  severe  attacks  of  spinal 
meningitis  in  the  adult.  The  same  remedies  are  indicated  in  the  milder 
cases,  but  they  need  to  be  less  vigorously  used.  And  in  children  the  amount 
of  local  bleeding  and  the  doses  of  medicines  should  be  carefully  adjusted 
to  the  age  and  vigor  of  the  child.  If  the  symptoms  of  inflammation  sub- 
side without  leaving  any  paralysis  of  either  sensation  or  motion,  very  little 
further  medication  will  be  required,  but  the  patient  must  remain  at  rest 
and  carefully  avoid  undue  exertion  or  excitement,  and  live  on  plain,  easily 
digestible  food  until  recovery  is  well  estal)lished. 

If,  however,  when  all  active  inflammatory  symptoms  have  disappeared 
some  degree  of  paralysis  remains,  with  soft  compressible  pulse,  cool  ex- 
tremities, and  general  sense  of  weakness,  there  must  bR  added  to  the  rest, 
avoidance  of  excitement  and  plain  nutritious  food,  the  continuance 
of  such  remedies  as  will  be  most  likely  to  hasten  the  further  removal  of 
inflammatory  products  and  restore  sensibility  to  the  paralyzed  nerves. 
For  these  purposes  we  have  probably  no  better  remedies  than  moderate 
doses  of  the  iodides  with  an  occasional  pill  of  blue  mass  at  night,  the  daily 
use  of  gentle  faradic  currents,  and  at  a  later  period,  small  doses  of  strych- 
nia with  a  teaspoon ful  of  the  compound  syrup  of  the  hypophosphites  after 
each  meal-time,  and  judiciously  applied  massage  to  the  weakened  or  para- 
lyzed parts  To  give  the  patient  the  best  possible  chance  for  recovery, 
the  means  I  have  mentioned  should  be  patiently  used  for  a  long  period  of 
time,  and  the  utmost  care  should  be  given  to  the  prevention  of  bed  sores 
by  scrupulous  cleanliness,  frequent  changes  of  position,  and  the  aid  of  air 


MYELITIS.  359 

or  water  cushions  under  the  parts  most  exposed  to  pressure.     I  next  direct 
your  attention  to 

MYELITIS. 

By  this  word  I  mean  inflammation  of  the  interior  of  some  part  of  the 
spinal  cord  without  involving  its  surface  or  membranes. 

Attacks  of  this  kind  are  more  frequent  in  childhood  and  youth  than  in  the 
middle  and  later  periods  of  life.  It  has  occurred  more  frefjuently  in  males 
than  females.  It  may  arise  from  the  same  causes  that  give  rise  to  spinal 
meningitis,  namely  mechanical  injuries,  exposures  to  cold  and  wet,  excessive 
fatigue,  to  which  may  be  added  as  predisposing  influences  excessive  use  of 
tobacco,  alcoholic  drinks,  and  indulgence  of  the  sexual  instinct.  The  form 
of  myelitis  that  occurs  in  infants  has  been  observed  more  frequently  dur- 
ing the  warm  than  the  cold  months  of  the  year,  and  has  sometimes  followed 
attacks  of  the  eruptive  fevers,  as  though  these  exerted  a  predisposing  in- 
fluence. 

Inflammation  attacking  the  substance  of  the  cord  may  be  limited  to  the 
anterior,  posterior,  or  lateral  columns,  or  it  may  involve  the  whole.  It 
may  be  limited  to  a  small  section  or  extend  the  whole  length  of  the  cord. 
It  may  vary  in  grade  from  the  most  acute  to  the  most  chronic  form  of  in- 
flammatory action.  Though,  beginning  entirely  within  the  substance  of  the 
cord,  myelitis  seldom  continues  long  without  extending  more  or  less  to  the 
surface  and  involving  the  pia  mater  to  some  extent. 

fSjjmptonis. — The  symptoms  of  acute  myelitis  differ  from  those  of  spi- 
nal meningitis  chiefly  in  the  beginning  of  the  attack.  The  pain  in  the 
back  is  m.ore  circumscribed  ;  the  initial  fever  of  shorter  duration;  and  the 
paralytic  symptoms  earlier  developed,  but  much  more  variable  in  their  lo- 
cation. The  latter  depends  upon  the  particular  parts  of  the  cord  involved 
in  the  inflammation.  If  the  inflammation  attacks  the  anterior  gray  matter 
of  the  cord,  as  is  most  common  in  infancy  and  early  childhood  (formerly 
called  "infantile  paralysis,"*  more  recently  Anterior  Poliomyelitis,)  it 
will  be  characterized  by  the  sudden  development  of  general  irritative 
fever,  more  frequently  in  the  night,  which  may  vary  from  a  very  mild 
grade  to  a  high  degree  of  intensity,  accompanied  by  restlessness,  frequent 
pulse,  hurried  breathing,  and  dullness  or  drowsiness,  and  sometimes, 
though  very  rarely,  convulsions.  After  a  continuance  of  this  fever  for  a 
period  varying  from  three  or  four  hours  to  two  days,  motor  paralysis  begins 
to  be  manifested  in  some  part  of  the  system  of  voluntary  muscles  ;  most 
frequently  in  those  of  one  or  both  lower  extremities,  constituting  para- 
plegia and  indicating  that  the  inflammation  is  located  in  the  lower  dorsal 
or  lumbar  part  of  the  cord.  I  have  seen  some  cases  in  which  the  child  was 
put  in  bed  at  night  in  apparent  good  health,  and  though  restless  and  fe- 
verish during  the  last  half  of  the  night,  but  hardly  enough  to  attract  special 
attention,  yet  on  being  taken  up  in  the  morning  both  legs  were  found  as 
helpless  as  two  strings  attached  to  the  body.  In  other  cases  only  one  leg 
was  paralyzed.  If  the  inflammation  is  located  in  the  anterior  gray  mat- 
ter of  the  cervical  or  upper  part  of  the  dorsal  portion  of  the  cord,  the  paralysis 
will  be  likely  to  affect  one  or  both  arms;  and  a  few  cases  have  been  recorded 
in  which  it  involved  simultaneously  both  arms  and  both  legs.  When  the  in- 
flammation is  very  circumscribed  or  limited  to  a  small  area  of  the  gray  matter 
the  resulting  paralysis  may  involve  only  a  single  muscle  or  a  set  of  mus- 
cles either  on  the  trunk  of  the  bodv  or  on  the  extremities.  In  all  these 
cases  the  general  febrile  symptoms,  disappear  on  the  supervention  of  the 

*  First  well  described  by  Heine  in  1840. 


360  MYELITIS. 

paralysis,  and  the  patients  soon  regain  their  appetites  and  general  feelings 
of  health,  but  the  paralysis  remains  with  rapidly  progressing  atrophy  oi 
the  paralyzed  muscles. 

When  "the  disease  in  the  acute  form  attacks  the  same  parts  of  the  cord  in 
adults,  the  resulting  clinical  phenomena  are  the  same  as  in  the  children, 
except  that  the  initial  fever  is  accompanied  by  less  cerebral  symptoms, 
such  as  vertigo,  delirium,  and  convulsions.  When  the  inflammation  in  an 
acute  form  attacks  the  gray  matter  of  the  posterior  part  of  the  cord, 
whether  in  children  or  adults,  the  same  general  febrile  symptoms  accom- 
pany the  first  stage,  but  the  pain  in  the  spine  is  more  severe  and  the  sen- 
sory instead  of  the  motor  functions  are  disturbed  in  different  parts  of  the 
body  and  extremities.  The  resulting  paralysis  is  apt  to  involve  the  blad- 
der and  rectum,  while  in  the  cases  having  the  anterior  gray  matter  as  the 
seat  of  the  disease,  these  important  parts  are  unaffected.  When  the  dis- 
ease primarily  invades  the  gray  matter  of  the  lateral  cornua  of  the  cord, 
the  resulting  disturbances  will  be  mostly  seen  in  the  vasomotor  and  trophic 
or  nutritive  functions.  In  those  rare  cases  in  which  the  inflammation  in- 
vades at  once  all  the  columns  or  tracts  of  gray  matter  in  the  cord,  the  re- 
sulting paralysis,  both  sensory  and  motor,  may  be  so  extensive  as  to  inter- 
fere with  resjDiration  and  lead  to  an  early  fatal  result. 

Pathological  Anatomy. — The  structural  changes  observed  as  the  re- 
sult of  acute  and  subacute  inflammation  of  the  substance  of  the  cord, 
are  the  same  as  occur  in  cerebritis.  First,  congestion  of  blood  in  the  capil- 
laries and  small  vessels;  second,  exudation  of  liquor  sanguinis  and  leu- 
cocytes into  the  structure,  causing  the  walls  of  the  vessels,  the  interstitial 
spaces,  and  the  neuroglia  of  the  nerve  matter  to  be  crowded  with  granule 
and  fat  cells;  and  third,  swelling  and  proliferation  of  the  neurog'ia-cells, 
with  disturbance  or  disintegration  of  the  axis-cylinders,  nerve  filjres  and 
ganglion-cells,  and  finall}'  the  disappearance  of  the  nerve  matter,  leaving 
principally  fat  granules  with  hypertrophied  neuroglia  or  connective  tissue 
and  enlarged  vessels.  To  the  unaided  eye  the  inflamed  parts  present  at 
different  points  a  variety  of  colors  from  the  deep  red  of  the  stage  of  con- 
gestion, reddish  brown  if  there  be  extravasation  ;  the  yellow  color  of  ordi- 
nary exudation;  and  finally  nearly  white,  while  throughout  the  whole,  the 
parts  appear  more  soft  than  natural,  and  sometimes  almost  of  a  creamy  con- 
sistence. 

Diagnosis. — The  only  period  in  the  progress  of  myelitis,  when  there 
could  be  any  difficulty  in  forming  a  correct  diagnosis,  is  in  the  first  or  febrile 
stage,  before  marked  changes  in  the  sensory  or  motor  functions  have  oc- 
curred. Even  in  this  brief  period,  however,  if  the  patient  is  old  enovigh 
to  express  his  feelings,  the  unusual  pain  in  some  part  of  the  spine  greatly 
increased  by  motion,  should  at  once  suggest  the  seat  of  disease.  But  in 
infants,  the  fever  is  often  regarded  as  only  evanescent  or  accidental  until 
the  paralysis  of  some  part  attracts  attention. 

Prognosis. — The  prognosis  in  myelitis  does  not  differ  much  from  that  of 
spinal  meningitis.  When  the  inflammation  is  located  in  the  cervical  and 
upper  part  of  the  dorsal  portion  of  the  cord  and  embraces  both  anterior 
and  posterior  columns  of  gray  matter  it  generally  proves  speedily  fatal 
from  paralysis  of  the  respiratory  organs  and  muscles.  If  it  is  located  low 
enough  to  cause  only  paraplegia  of  the  lower  extremities  the  patient  may 
either  make  a  complete  recovery,  or  recover  very  good  general  health 
with  permanent  loss  of  motion  and  diminished  nutrition  of  one  or  both 
legs,  or  the  continued  paraplegia  may  be  accompanied  by  gradual  impair- 
ment of  the  general  health,  the  foimation  of  bed  sores  over  the  hips  and 
sacrum  and  final  fatal  exhaustion.    The  same  differences  in  the  result  maj 


TREATMENT.  361 

attend  inflammation  in  limited  areas  or  tracts  of  any  part  of  the  cord.  As 
a  general  rule,  whenever  any  muscle  or  set  of  muscles  is  so  completely 
paralyzed  as  to  be  insensible  to  the  galvanic  current  or  to  the  tendon  re- 
flex stimulus,  there  is  little  or  no  prospect  of  the  ultimate  recovery  of  its 
natural  function.  But  so  long  as  there  is  some  response  to  these  stimuli, 
there  is  a  prospect  of  recovery.  In  all  cases  nutrition  goes  on  less  rapidly 
in  paralyzed  parts  than  in  those  not  paralyzed.  This  causes,  even  in 
adults,  a  paralyzed  limb  or  muscle  to  soon  become  smaller  than  natural; 
and  in  children  who  are  still  growing,  the  disparity  between  a  healthy 
and  paralyzed  limb  becomes  in  a  few  years  a  marked  deformity. 

Treatment. — The  therapeutic  management  of  myelitis  does  not  diifer  in 
any  essential  particular  from  that  of  spinal  meningitis.  The  same  reme- 
dies, used  in  the  same  manner,  and  carefully  adjusted  to  the  successive 
stages  of  the  disease,  may  be  used  as  I  described  in  detail  when  speaking 
of  the  treatment  of  the  last  named  affection  during  the  earlier  part  of  the 
present  hour. 


LECTUEE    XXXVIII. 

Chronic  Spinal  jreningitis,  and  Myelitis,  or  Spinal  Sclerosis :  Their  Clinical  History,  Morbid 
Anatomy,  Diagnosis,  PrognoHis,  and  Treatment. 

GENTLEMEN:  Chronic  inflammation  of  the  meninges  and  substance 
of  some  part  of  the  spinal  cord  is  of  more  frequent  occurrence  than 
the  acute  and  subacute  forms  of  the  disease  described  in  the  preceding 
lecture.  It  may  be  chronic  from  the  beginning  and  arise  from  the  same 
causes  that  produce  the  more  active  or  acute  form  of  disease,  or  it  may  be 
the  sequel  of  an  acute  attack.  The  chronic  form  of  disease  may  involve 
a  complete  section  of  the  cord  at  any  part  of  its  length,  or  it  may  be 
limited  to  the  membranes  and  surface  of  the  cord,  or  to  a  part  or  the 
whole  of  either  the  anterior,  posterior,  or  lateral  columns  of  gray  matter 
in  the  substance  of  the  cord.  And  the  detail  of  symptoms  will  vary  in 
accordance  with  the  variations  in  the  location  and  extent  of  the  inflam- 
mation. 

ISymptoms  or  Clinical  History. — Chronic  inflammation  of  a  segment  of 
the  spinal  cord,  or  transverse  meningio-myelitis  occurs  most  frequently 
in  the  lumbar  and  lower  part  of  the  dorsal  region,  and  next  in  the  cervical 
portion.  When  in  the  former  it  is  characterized  by  persistent  pains  in  the 
loins,  increased  by  bending  or  motion  of  the  part;  sharp,  irregular  pains 
in  the  course  of  the  nerves  supplying  the  lower  extremities,  often  accom- 
panied liy  muscular  twitchings,  cramps,  or  persistent  rigidity;  sensations  of 
numl)ness,  prickling,  and  sometimes  heat,  especiallv  in  the  feet  and  parts 
below  the  kn.ee.  The  general  symptoms  are  slight  increased  frequency  of 
pulse;  inactive  condition  of  the  bowels;  a  variable  condition  of  the  urine, 
being  sometimes  scanty  and  red  and  at  others  abundant  and  clear  when 
voided  but  on  cooling  depositing  a  white  sediment  of  aramoniacal  or 
phosphatic  salts.  The  muscles  most  affected  are  generally  the  gastroc- 
nemii  and  soleus  by  the  contractions  of  which  the  heel  is  drawn  up  and  the 
toes  strongly  flexed.  If  the  disease  extends  upwards  (sclerosis  ascendens) 
it  will   involve   in   its   course   the   anterior   crural   and  spermatic,  causing 


362  CHRONIC   SPINAL    MENINGITIS. 

pains  and  muscular  contractions  in  the  anterior  part  of  the  thigh,  the 
psoas  and  iliacus  internus,  as  well  as  the  testicles  and  cremaster  mus- 
cles. At  the  same  time  there  is  liable  to  be  difficulty  in  regulating  the 
passages  from  the  bladder  and  rectum.  The  patient  may  continue  in  the 
condition  I  have  described  from  two  weeks  to  as  many  months,  when  the 
moderate  general  febrile  symptoms  disappear,  the  pains  gradually  give 
place  to  complete  angesthesia  or  loss  of  sensibility,  and  the  muscular  con- 
tractions to  entire  relaxation,  constituting  loss  of  both  sensation  and  mo- 
tion or  complete  paraplegia  of  the  lower  extremities.  If  the  disease  does 
not  extend  above  the'  level  of  the  lower  dorsal  vertebra,  the  patient  may 
continue  in  this  condition  of  paralysis  of  the  lower  extremities  and  enjoy 
fair  general  health  many  months  or  even  j^ears.  If  the  infldmed  segment 
of  the  cord  be  in  the  neck,  it  will  cause  the  same  succession  of  changes 
in  the  muscles  and  nerves  of  the  trunk  of  the  body  and  of  the  upper  ex- 
tremities, ending  in  general  spinal  paralysis  and  death.  But  much  the 
laro-er  number  of  cases  of  chronic  inflammation  of  the  spinal  cord  involve, 
not  a  segment  of  the  whole  cord,  but  only  one,  or  even  part  of  one  of 
its  columns.  If  it  involves  the  anterior  column  of  gray  matter  it  is  de- 
scribed by  different  writers  under  the  names  of  anterior  spinal  sclerosis, 
anterior  poliomyelitis;  chronic  atrophic  spinal  paralysis;  and  progressive 
muscular  atrophy.  If  the  posterior  column  of  gray  matter  is  the  seat  of 
disease,  it  is  called  posterior  spinal  sclerosis,  posterior  poliomyelitis;  pro- 
gressive locomotor  ataxia,  and  tabes  dorsalis.  When  located  in  the 
lateral  columns  or  cornua,  it  has  been  designated  lateral  spinal  sclerosis, 
spastic  spinal  paralysis  (Erb.),  spasmodic  tabes  dorsalis  (Cheviot),  and 
tetanoid  pseudo-paraplegia  (Seguin).  These  numerous  names  used  by 
diflFerent  writers  are  well  calculated  to  confuse  and  mislead  the  student, 
rather  than  to  add  to  his  knowledge  of  diseases.  I  shall  therefore  use 
onlv  the  simple  designations,  anterior,  posterior,  and  lateral  spinal  sclero- 
sis to  distinsruish  chronic  inflammation  as  limited  to  one  or  the  other  of 
the  three  principal  longitudinal  divisions  of  the  cord. 

When  the  disease  is  limited  to  the  anterior  column  of  the  cord  (an- 
terior spinal  sclerosis),  the  chief  symptoms  are  presented  in  some  part  of 
the  system  of  voluntary  muscles,  more  frequently  in  those  of  the  arms, 
shoulders,  and  chest,  but  often  extending  at  a  later  period  to  those  of  the 
lower  part  of  the  trunk  and  lower  extremities.  This  order  is  in  many 
cases,  however,  reversed — the  muscles  of  the  lower  extremities  being 
affected  first.  The  distinctive  symptoms  are,  pricking  pains  in  the  affected 
muscles,  fibrillary  trembling  of  pai-ticu!ar  bundles  of  muscular  fibres,  pro- 
gressive atrophy  or  wasting  of  the  muscular  structure,  and  loss  of  contrac- 
tility or  paralysis.  In  some  cases  there  are  coincident  pains  or  rather 
morbid  sensations  of  restlessness  in  some  part  of  the  back,  general  feel- 
ings of  weakness,  but  no  febrile  phenomena,  and  but  little  derangement 
of  the  secretory  functions.  The  progress  of  the  disease  as  indicated  by 
the  symptoms  is  very  variable.  In  some  cases  it  may  reach  such  a  degree 
of  muscular  atrophy  and  paralysis  as  to  fatally  impair  the  respiratory  move- 
ments, causing  death  by  apnoea,  in  a  few  months;  while  in  others  it  may 
require  as  many  years.  When  the  disease  is  the  sequel  of  an  acute  attack, 
the  progress  is  usually  more  rapid  and  more  generally  progresses  from  the 
muscles  of  the  lower  extr  mities  upward  to  those  of  the  trunk  of  the  body 
and  finally  to  those  of  the  shoulders  and  arms.  There  is  another  class  of 
cases  which  have  not  been  preceded  by  any  acute  or  active  symptoms,  but 
which  develop  mostly  in  individual  muscles,  often  unconnected  with  each 
other,  as  the  pectoral,  the  deltoid,  the  dorsal  interosseous,  the  muscles  of 
the  ball  of  the  thumb,  the  serratus,  latissimus  dorsi,  etc.     In  some  cases 


SYMPTOMS.  363 

parallel  muscles  are  affected  simultaneously  on  each  side  of  the  body,  and 
in  others  they  follow  in  successive  order. 

In  some  stages  of  the  progress  of  these  cases  the  patients  present  a  pe- 
culiar and  most  striking  appearance.  For  instance  the  muscles  of  the 
neck,  shoulders  and  chest  may  be  so  completely  atrophied  as  to  leave  the 
outline  of  each  bone  as  distinct  as  in  the  naked  skeleton,  while  those  of 
the  fore-arms,  hips  and  legs  are  as  full  and  well  nourished  as  ever.  The 
class  of  cases  I  have  just  been  describing  have  been  more  especially  des- 
ignated by  many  as  cases  oi progressive  muscular  atropliy^  in  which  the 
disease  was  primarily  located  in  the  muscles,  and  the  gray  matter  of  the 
anterior  column  of  the  cord  became  involved  secondarily.  This  view  was 
adopted  and  maintained  with  much  ability  by  Friedreich,  of  Berlin,  in 
1873.  But  whether  the  disease  commences  primarily  in  the  muscles  or  in 
the  anterior  gray  matter  of  the  cord,  it  is  certain  that  both  become  seri- 
ously affected  during  its  progress. 

When  the  disease  is  confined  to  the  posterior  column  of  the  cord  (pos- 
terior spinal  sclerosis,  progressive  locomotor  ataxia)  it  is  most  generally 
located  in  the  cervical  portion,  but  sometimes  follows  longitudinal  tracts 
as  low  as  the  lumbar  region  of  the  spinal  cord.  It  may  also  extend  in  cer- 
tain tracts  through  the  medulla  oblongata  to  the  base  of  the  brain.  The 
characteristic  symptoms  are  manifested  chiefly  in  alterations  of  sensibility 
in  different  parts  of  the  periphery  of  the  body,  and  in  impairment  of  the 
co-ordination  of  ?nuscular  movements. 

There  are  generally  pains  in  the  limbs,  sometimes  in  circumscribed  places 
on  different  parts  of  the  body,  accompanied  at  first  by  hypertesthesia;  and 
at  a  later  period,  aneesthesia  or  analgesia;  occasionally  dimness  of  vis- 
ion ;  frequent  turns  of  indigestion  with  some  constipation  ;  inactivity  of 
the  pupil  under  changes  in  the  degree  of  light;  unsteadiness  of  gait  with 
difficulty  of  going  up  steps  except  by  a  special  jerking  or  springing  move- 
ment, and  inability  to  walk  in  the  dark.  As  the  disease  advances  the  loss 
of  sensibility  in  some  parts,  more  especially  in  the  soles  of  the  feet,  is 
more  complete  ;  the  difficulty  of  locomotion'  or  walking  becomes  so  great 
that  the  hands  must  constantly  rest  upon  something  to  aid  in  steadying 
the  movements,  not  because  any  of  the  muscles  are  paralyzed,  but  for  want 
of  co-ordination  in  their  action;  in  some  cases  either  retention  or  inconti- 
nence of  urine  ;  loss  of  control  over  the  act  of  defecation;  and  entire  ina- 
bility to  walk  or  stand  upright  without  support.  Early  in  the  disease  the 
tendon  reflex  and  the  ankle-clonus  are  notably  diminished;  and  at  a  later 
period  lost.  In  the  early  stage,  the  pulse  is  moderately  increased  in  fre- 
quency, but  diminished  in  force,  and  in  the  later  stages  of  many  cases,  it 
becomes  weak  and  irregular  ;  while  the  temperature  seldom  varies  mate- 
rially from  the  normal  standard.  The  progress  of  the  disease  is  generally 
slow;  and  its  duration  may  vary  from  six  months  to  twenty-five  or  thirty 
years.  It  occurs  most  frequently  in  the  middle  period  of  adult  life  ;  and 
much  more  frequently  in  males  than  in  females. 

When  the  chronic  inflammation  is  confined  to  one  or  both  lateral 
columns  of  gray  matter  (lateral  spinal  sclerosis,  spastic  spinal  paralysis, 
tetanoid  pseudo-paraplegia,)  and  occurs  as  a  primary  affection,  it  is  gen- 
erally located  at  the  posterior  border  of  the  lateral  columns  proper,  and  in 
what  is  called  the  crossed  pyramidal  columns  of  Flechsig,  but  in  its  prog- 
ress may  include  the  larger  part  of  the  lateral  columns.  The  symptoms 
which  characterize  the  commencement  of  this  disease,  are  a  sense  of  weight 
or  heaviness  in  the  upper  or  lower  extremities  and  sometimes  in  both, 
with  great  sense  of  weariness  unusually  increased  by  even  moderate  exer-' 
cise.     In  a  little  time  the  weakness  amounts  to  paresis  or  partial  paralysis 


364  CHROXIC   SPINAL   SCLEROSIS. 

of  certain  muscles,  more  frequently  of  the  legs,  with  slight  twitchings  or 
tremors,  and  some  stiffness  or  temporary  rigidity  following  contractions,  as 
though  the  fibres  of  the  contracted  muscles  could  not  relax  in  the  usual 
time.  For  instance  in  walking,  as  the  body  moves  forward  to  the  point 
where  the  weight  rests  on  the  ball  of  the  toes  with  the  heel  up,  the  failure 
of  the  muscles  to  relax  at  the  proper  moment,  keeps  the  toes  down  until 
the  patient  may  be  in  danger  of  falling  forward,  and  gives  him  a  pecul- 
iarly stiff  and  jerky  gait.  At  this  stage,  both  tendon  reflex  and  ankle- 
clonus  are  much  increased,  being  the  reverse  of  their  condition  in  the 
anterior  spinal  sclerosis.  But  there  is  neither  muscular  atrophy  nor  im- 
pairment of  the  functions  of  the  bladder,  rectum  or  sexual  oi'gans  us  occurs 
iu  the  posterior  spinal  sclerosis.  Still  the  symptoms  I  have  enumerated 
as  characteristic  of  the  lateral  sclerosis  continue  slowly  to  increase  until 
the  patient  loses  all  power  over  the  extremities,  upper  and  lower,  and 
many  of  the  muscles  remain  in  a  state  of  rigid  contraction,  constituting 
an  entirely  helpless  condition.  In  this  state  he  may  live  many  years,  the 
mental  faculties  and  nutritive  functions  remaining  active  and  efficient, 
until  some  other  disease  supervenes  to  cut  life  short.  The  same  grade  of 
disease  may  extend  to,  or  primarily  attack  the  motor  nuclei  of  the  medulla 
oblongata,  causing  pains  in  the  neck  at  the  junction  with  the  back  of  the 
head  and  sometimes  dizziness;  slowness  of  speech  and  mastication,  with 
drooping  of  the  lips  and  angles  of  the  mouth,  allowing  dribbling  of  saliva; 
and  a  little  later,  difficulty  of  deglutition,  great  feebleness  of  voice,  and 
sometimes  distressing  paroxysms  of  dyspnoea.  While  retaining  the  mental 
faculties  and  general  sensibility  unimpaired,  all  the  disabilities  I  h  .ve 
named  continue  to  increase  until  the  ability  to  swallow  is  entirely  lost, 
and  the  patient  is  in  danger  of  death  from  ultimate  starvation.  When 
the  disease  develops  thus,  in  the  tracts  of  medulla  I  have  named  as  a 
primary  affection,  it  constitutes  the  gkicso-labio-laryngeal  paralysis  of 
Trousseau,  or  the  Hulbo-nuclear  sclerosis  of  other  writers.  While  most 
of  the  cases  of  lateral  spinal  sclerosis  affect  both  lateral  parts  of  the  cord 
at  the  same  time,  and  consequently  involve  the  muscular  movements  in 
both  arms  or  legs  coincidently,  there  are  some  instances  in  which  the  dis- 
ease is  unilateral,  and  others  in  which  the  disease  in  one  side  follows 
after  that  in  the  other.  It  is  proper  to  state  also,  that  lateral  spinal 
sclerosis  in  its  progress  often  extends  into  some  parts  of  the  anterior  col- 
umns of  gray  matter,  causing  the  case  to  be  complicated  with  more  or  less 
of  the  symptoms  of  anterior  spinal  sclerosis.  This  constitutes  what  has 
been  described  by  Charcot,  as  "Amyotrophic  lateral  sclerosis,"  but  better 
termed  antero-lateral  sclerosis.  The  same  may  be  said  in  regard  to  the 
extension  of  lateral  sclerosis  posteriorly  into  the  posterior  column  of  gray 
matter,  by  which  the  symptoms  of  lateral  sclerosis  beci;me  more  or  less 
complicated  with  those  of  locomotor  ataxia  and  may  be  distinguished  as 
posterio- lateral  sclerosis. 

Again,  eases  are  met  with  in  which  there  is  more  or  less  intermingling 
of  symptoms  Ijclonging  to  sclerosis  of  all  parts  of  the  cord  and  medulla. 
rhese  have  been  designated  as  multiple  or  disseminated  sj^inal  sclerosis. 
They  may  present  the  paresis  or  weakness  and  dragging  of  the  limbs,  fol- 
lowed by  twitching  or  trembling,  as  in  lateral  sclerosis;  with  the  pains 
and  varied  conditions  of  nerve  sensibility  belonging  to  posterior  spinal 
sclerosis;  and  the  well  marked  atrophy  of  some  of  the  muscles  as  in  anterior 
sclerosis.  These  multiple  or  mixed  cases  may  present  a  great  variety  of 
symptoms  and  phases,  according  as  one  set  of  symptoms  or  another  pre- 
dominate. 

Morbid  Anatomy. — While  chronic  inflammation  or  sclerosis  in  different 


MORBID    AXATOMY.  3G5 

pnrts  of  the  spinal  cord,  g-ives  rise  to  different  symptoms,  according'  to  the 
tunctions  of  the  part  involved,  yet  the  molecular  or  structural  changes 
which  take  place  during  its  progress  are  substantially  the  same  in  what- 
ever parts  it  may  be  developed.  These  changes  are,  first,  dilation  of  the 
capillaries  and  smaller  vessels,  with  exudation  or  permeation  of  their 
walls  l)y  leucocytes  and  other  elements  of  the  blood,  followed  by  hyperplasia 
from  enlarg-ement  and  proliferation  of  the  cell  elements;  and  second,  simi- 
lar hyperplasia  of  neuroglia,  nerve-sheaths,  and  reticular  or  connective 
tissue,  and  corresponding  atrophy  and  disappearance  of  the  nerve-cells 
and  medullary  matter  of  the  nerve  tubules,  leaving'  the  axis-cylinders 
either  of  normal  size  or  even  hypertrophied.  These  changes,  which  are 
apparent  fully,  only  when  the  structure  is  properly  prepared  and  examined 
under  the  microscope,  give  to  the  sclerosed  part  greater  density  or  hard- 
ness, which  is  apparent  to  the  touch  or  when  cutting  through  it,  and  to 
the  eye  shows  a  gray  or  yellowish  gray  color,  and  sometimes,  after  expos- 
ure to  the  air,  a  redder  tint.  The  cut  surface  has  a  smooth,  even  appear- 
ance, and  there  exudes  from  it  only  a  small  quantity  of  transparent  fluid. 
In  the  anterior  spinal  sclerosis  these  changes  will  be  found  chiefly  in  the 
anterior  gray  matter  of  the  cord,  and  in  some  cases  extending  to  the 
anterior  roots  of  the  spinal  nerves.  In  the  posterior  and  posterio-lateral 
sclerosis  they  are  found  in  some  part  of  the  gray  matter  of  the  posterior 
column,  more  generally  in  its  cervical  portion,  and  in  the  posterior  roots 
of  the  spinal  nerves;  while,  in  some  cases,  they  are  found  as  low  as  the 
lumljar  part,  and  in  others  as  high  as  the  base  of  the  brain.  In  the  lateral 
spinal  sclerosis,  the  altered  patches  or  tracts  of  the  cord  are  found  mostly  in 
the  posterior  margin  of  the  lateral  column;  while  in  the  complex  or  multiple 
cases  of  sclerosis,  patches  of  sclerosed  structure  will  be  found  in  all 
divisions  of  the  cord,  often  very  irregularly  or  unequally  distributed.  For 
details  as  to  the  best  methods  of  preparing  specimens  and  examining  them 
under  the  microscope,  I  must  refer  you  to  my  colleague  in  the  chair  of 
pathology  and  pathological  anatomy,  or  to  the  text-books  in  that  depart- 
ment. 

Diagnosis. — The  chief  symptoms  characteristic  of  sclerosis  of  the  several 
parts  of  the  spinal  cord  I  have  already  pointed  out  with  sufficient  emphasis 
in  giving  their  clinical  history.  From  corresponding  forms  of  disease  in 
any  part  of  the  brain,  they  are  distinguished  by  the  absence  of  direct 
cerebral  symptoms  and  the  restriction  of  morbid  phenomena  to  the  muscles 
and  parts  supplied  with  nerves  from  the  spinal  cord. 

From  all  the  varieties  of  functional  and  reflex  disturbances  of  the  nervous 
system,  they  are  distinguished  by  their  gradual  development,  persistent 
progress,  and  in  most  cases  by  their  involvement  of  progressive  atrophic, 
or  wasting  nutritive  changes  in  the  muscular  structures  connected  witti 
the  diseased  portions  of  the  spinal  cord.  In  the  purely  lateral  sclerosis  in 
which  there  is  not  marked  muscular  atrophy,  but  often  quivering  and 
trembling  of  muscles  after  voluntary  movements,  there  may  be  danger  of 
confounding  it  with  paralysis  agitans  or  shaking  palsy. 

The  latter,  however,  exhibits  a  much  finer  and  more  purely  tremulous 
motion,  commencing  and  continuing  without  the  slightest  connection  with 
voluntary  motion;  while  the  shaking  of  lateral  sclerosis  is  a  coarser  motion, 
chiefly  accompanying  and  following  voluntary  movements,  and  manifest- 
ing itself  quite  as  often  in  irregular  motions  of  the  head  as  of  the  hands  or 
feet. 

JPrognosis. — When  spinal  sclerosis  has  become  well  developed  in  any 
part  of  the  cord  it  is  seldom  cured  by  any  process  of  treatment.  And  yet 
sases  have  occurred  in  which  recovery  took  place  when  the  symptoms  were 


366  CHRONIC    SPliS'AL    SCLEROSIS. 

so  strongly  characterized  as  to  leave  no  reasonable  doubt  concerning  the 
correctness  of  the  diagnosis.  A  few  such  cases,  more  particularly  of  the 
posterior  spinal  sclerosis — progressive  locomotor  ataxia — have  come  under 
my  own  observation.  The  earlier  chronic  inflammation  in  any  part  of  the 
cord  is  detected  and  brought  under  judicious  treatment  the  better  is  the 
prospect  of  success.  The  slowness  of  development  and  the  equivocal 
character  of  the  earlier  symptoms  of  this  form  of  disease,  cause  the  real 
nature  of  many  cases  to  "pass  without  recognition  until  the  changes  of 
structure  have  become  permanent.  As  constitutional  syphilis  and  habitual 
use  of  alcoholic  drinks  are  among  the  more  frequent  and  recognizable  causes 
of  spinal  sclerosis,  it  is  highly  probable  that  an  early  and  correct  diagnosis 
accompanied  by  the  use  of  proper  sanitary  measures  and  remedial  agents 
would  arrest  the  further  progress  of  the  morbid  action  in  a  large  propor- 
tion of  the  cases,  and  thereby  postpone  the  development  of  the  more  dis- 
tressing symptoms  for  many  years.  So  long  as  the  sclerosis  does  not  in- 
volve those  parts  of  the  medulla  oblongata  controlling  respiration,  or  of 
such  parts  of  the  cord  as  are  connected  with  urination  and  defecation,  life 
and  a  fair  degree  of  health  may  be  continued  from  five  to  fifty  years;  or 
until  the  patients  die  from  some  intercurrent  disease.  Dr.  J.  W.  Holland 
recently  i-eported  to  the  Louisville  Medico-Chirurgical  Society  three 
cases  of  disseminated  or  multiple  sclerosis  of  the  spinal  cord  in  one 
family,  which  consisted  of  one  brother  and  four  sisters,  the  brother  and 
two  of  the  sisters  being  affected  with  the  disease,  while  the  other  two  are 
exempt.  In  the  brother  the  first  symptoms  of  disease  were  manifested 
when  he  was  twelve  years  of  age,  and  have  now  been  slowly  progressing 
fifteen  years.  The  two  sisters  began  to  be  affected  when  eleven  years  of 
aa-e,  and  in  one  it  has  continued  six  years  and  in  the  other  two  years.* 
Both  parents  and  the  other  two  sisters  are  free  from  all  symptoms  of  spinal 
disease,  and  no  cases  were  known  to  have  occurred  in  the  ancestry.  The 
occurrence  of  three  cases  in  one  family,  all  commencing  at  nearly  the 
same  age,  and  that  so  early  as  the  eleventh  and  twelfth  years  is  very 
unusual. 

Treatment. — Although  the  treatment  of  all  varieties  of  spinal  sclerosis 
or  chronic  myelitis,  has  failed  to  effect  a  cure  in  the  great  majority  of 
cases,  yet  there  are  certain  rational  indications  to  be  fulfilled,  which,  if  ju- 
diciously attended  to  through  a  long  period  of  time,  will  greatly  mitigate 
the  suffering  of  the  patients,  prolong  their  lives,  and  occasionally  result  in 
a  positive  recovery. 

In  the  earlier  stage  while  there  is  pain,  hyperesthesia,  or  disturbance 
of  muscular  action,  indicating  that  the  nerve-cells  and  medullary  matter 
are  not  altogether  lost  but  still  retain  a  degree  of  structural  integrity,  the 
leading  objects  of  treatment  are,  to  overcome  the  morbid  excitability  of 
the  structure  and  thereby  lessen  the  pain  and  muscular  rigidity  or  irregular 
muscular  contractions;  to  arrest  the  morbid  molecular  movements  by 
which  the  connective  tissue  of  the  part  is  becoming  hypertrophied  from 
hyperplasia  or  excess  of  nutrition  and  the  contained  nerve  matter  atro- 
phied; and  to  so  regulate  the  habits,  mental  and  physical,  as  to  avoid  the 
further  action  of  either  the  predisposing  or  exciting  causes.  To  ac- 
complish the  latter,  the  patient  should  be  required  to  avoid  all  use  of  alco- 
holic beverages,  whether  fermented  or  distilled;  all  use  of  tob.icco;  and 
all  sexual  indulgences. 

He  should  live  on   plain,  easily  digestible,  and  nutritious  food,  including 
meat  with  tea  and  coifee,  rather  sparingly.     You  should  also  enjoin  much 

*  See  Louisville  Medical  News,  Vol.  XIV.,  No.  363,  p.  283,  Dec,  9,  188^. 


TREAT3IENT.  367 

rest  in  the  recumhent  position.  If  tlie  patient  is  capiilile  of  taking  any 
exercise  out-doors,  let  it  l)e  mostly  passive  by  riding,  never  allowing  long 
walks  or  long  standing  at  one  time.  And  it  is  an  important  rule  to  have  the 
patient  place  himself  fully  at  rest  in  a  position  to  give  the  whole  system  of 
voluntary  muscles  as  complete  relaxation  as  possible,  after  every  effort  at 
]ihysical  exercise  or  exertion.  My  own  clinical  observations  lead  me  to 
think  that  this  rule  in  regard  to  full  rest,  is  deserving  of  more  at'ention 
than  it  has  generally  received  in  the.  management  of  this  class  of  diseases. 
If  the  case  comes  under  your  care  quite  early  in  the  progress  of  the  disease, 
you  will  often  derive  advantage  from  efficient  dry  cupping  over  the  spine 
evei-y  third  day  for  two  or  three  weeks,  with  frequent  sponging  of  the  back 
with  tepid  water  during  the  interval  between  the  cuppings.  The  severer 
forms  of  counter-irritation  by  blisters,  setons,  issues,  moxas,  and  the  hot 
iron  have  all  been  used  freely  in  many  cases,  but  without  material  benefit. 
In  a  few  cases,  I  have  followed  the  dry  cupping  and  hot  water  sponging 
by  a  succession  of  small  blisters,  with  some  benefit;  and  have  followed 
these  by  the  use  of  the  camphorated  soap  liniment,  holding  in  solution 
six  centigrams  (gr.  i)  of  veratria  to  each  thirty  cubic  centimeters  (fl.  3!) 
of  the  liniment,  applying  it  freely  over  the  spine  eaoh  morning  and 
evening.  To  fulfill  the  two  indications  first  named,  we  need  the  influence 
of  such  anodynes  as  will  lessen  morbid  sensibility  witho  it  checking  the 
necessary  secretions  and  evacuations,  combined  with  some  efficient  alterant 
capable  of  diminishing  the  exaggerated  play  of  vital  affinity  by  which  the 
molecular  movements  constituting  cell-proliferation  and  hyperplasia  of  the 
connective  tissue  in  the  diseased  parts  are  regulated.  The  anodynes  best 
fidapted  to  fill  the  requirements  specified  are  the  stramonium,  hyoscyamus, 
and  conium;  the  opiate  preparations,  though  more  efficient  as  anodynes, 
being  too  liable  to  produce  constipation  and  to  diminish  many  of  the 
secretions.  The  most  reliable  alterants  are  the  bichloride  of  mercury  and 
the  iodides.  And  during  the  same  period  of  time  that  I  have  advised  dry 
capping  and  hot  water  sponging  externally,  I  have  been  in  the  habit  of 
giving  internally  a  combination  of  the  bichloride  of  mercury  and  iodide 
of  sodium  with  the  tinctures  of  stramonium  or  hyoscyamus  and  either  the 
cimicifuga  racemosa,  phytolacca  decandra,  or  senecio  aureus,  as  in  the 
following  formula: 

15.      Hydrargyri  Chloridi  Corosivi  0.1  grams.  gr.  1^ 

Sodii  lodidi  15.0       »  3iv 

Tincturae  Stramonii  15.0  c.c.  3iv 

Tincturae  Phytolacca  Decandrae  75.0  "  liiss 

Elixer  Simplices  60.0  "  3ii 

Mix.  Grive  to  an  adult  four  cubic  centimeters  (fl.  3i  )  in  a  little 
additional  water  each  mor!jing,  noon,  tea-time  and  bed-time.  After  two 
or  three  weeks  I  usually  limit  the  use  of  this  combination  to  one  dose  in 
the  morning  and  evening,  and  commence  giving,  after  each  meal-time, 
some  one  of  those  remedies  that  are  supposed  to  promote  general  nutrition, 
such  as  the  syrup  of  lacto-phosphate  of  calcium;  the  compound  syrup  of  the 
hy]iophosphites  of  sodium,  calcium,  and  iron,  etc-,  in  conjunction  with  the 
phosphide  of  zinc.  If  at  any  time  the  gums  or  breath  show  any  indica- 
tions of  the  mercurial  action,  I  immadiately  omit  both  the  bichloride  of 
mercury  and  the  iodide  of  sodium,  and  supply  their  place  with  fair  doses 
of  the  iodide  of  potassium. 

If  the  bowels  fail  to  move  regularly  they  should  be  aided  by  enemas  or 
mild  laxatives.     Unless  I  have  erred  much  in  my  diagnoses,  I  have  seen 


oG8  CHRONIC    SPINAL    SCLEROSIS. 

a  considerable  number  of  cases  of  true  chronic  myelitis,  affecting  different 
parts  of  the  spinal  cord,  recover,  in  which  the  foregoing  management  was 
coramenced  soon  after  the  characteristic  symptoms  were  manifested,  and 
was  continued  with  steadiness  and  perseverance  for  many  months. 

If,  however,  either  from  the  late  stage  at  which  the  case  comes  under 
your  care,  or  in  spite  of  the  foregoing  or  any  other  treatment,  you  find  the 
pain  and  hyperaesthesia  giving  place  to  anassthesia,  and  muscular  con- 
tractions yielding  to  motor  paralysis  with  increasing  atrophy  of  the  affected 
muscles,  you  may  add  to  your  remedial  measures  the  daily  use  of  mild  gal- 
vanic currents  in  connection  with  friction  and  massage,  continued  from 
ten  to  twenty  minutes  each  day,  with  a  reasonable  expectation  of  retard- 
ing the  progress  of  the  disease,  and  rendering  the  putient  more  comfortable 
if  vou  can  not  effect  a  cure.  One  of  the  obstacles  to  your  success  in  the  treat- 
ment of  these  slow  chronic  affections  of  the  spinal  cord,  will  be  that  im- 
]iatience  and  restless  desire  to  see  speedy  results,  which  often  induces  both 
patient  and  physician  to  make  such  frequent  changes  from  one  remedy,  or 
one  method  of  treatment,  to  another,  that  no  one  agent  or  process  is  con- 
tinued long  enough  to  give  a  fair  opportunity  for  developing  its  effects 
either  for  good  or  evil.  Another  obstacle  of  importance  will  be  a  tend- 
ency, encouraged  by  much  of  what  is  published  in  the  current  medical 
literature,  to  try  specific  remedies  more  or  less  indiscriminately,  instead 
of  endeavoring  to  carefully  appreciate  the  exact  pathological  conditions 
and  stage  of  progress  in  each  case,  and  selecting  and  adjusting  remedies 
thereto  on  rational  principles  guided  by  a  knowledge  of  themoc/ziS  operandi 
of  the  remedial  agents  selected.  My  remarks  thus  far,  gentlemen,  have 
relation  to  the  management  of  chronic  inflammation  during  its  progress, 
and  b  ^fore  the  morbid  process  called  sclerosis  is  coinplete.  But  when  the 
cases  coming  under  your  charge  have  advanced  so  far  that  paralysis  of  either 
sensation  or  motion,  or  both,  is  complete,  and  the  muscular  structures  in- 
volvedgreatly  atrophied,  indicating  entire  disintegration  or  disappearance 
of  the  nerve  structure  in  the  sclerosed  patches  or  nerve  tracks,  there  is  left 
no  reasonable  hope  of  recovery;  and  the  only  rational  indication  for  treat- 
ment is  to  so  regulate  the  diet  and  hygienic  surroundings  of  your  patients, 
with  such  careful  attention  to  the  palliation  of  symptoms,  the  prevention  of 
bed  sores,  the  securing  of  proper  evacuation  from  bladder  and  rectum,  as  will 
render  them  most  comfortable,  and  best  contribute  to  the  maintenance  of 
general  health.  Yet,  it  is  best  not  to  be  too  positive  in  pronouncing  par- 
ticular cases  hopeless.  For  I  well  remember  a  case  of  well  marked  loco- 
motor ataxia  or  posterior  spinal  sclerosis  that  came  into  my  wards  of  the 
Mercy  Hospital  a  few  years  since.  The  patient  was  a  working  man,  about 
thirty- five  years  of  age,  who  had  bt  en  much  exposed  to  cold  and  wet,  and 
was  somewhat  addicted  to  the  use  of  alcoholic  drinks.  The  symptoms  of 
locomotor  ataxia  had  been  progressively  developing  for  three  months 
before  his  admission  to  the  hospital.  The  diagnostic  symptoms  of  the 
disease  were  at  that  time  so  complete,  that  he  was  several  times  presented 
to  the  clinical  class  for  illustrating  the  progress  of  typical  cases  of  that 
affection.  I  subjected  him  to  steady  treatment  for  three  months,  embrac- 
ing in  succession,  alteratives,  tonics,  nutrients,  electro-magnetic  currents, 
and  judicious  diet;  but  rather  encouraged  him  to  try  to  walk  every  day  a 
few  minutes  at  a  time,  which  was  doubtless  an  error.  At  any  l-ate  he 
steadily  failed  until  at  the  end  of  the  three  months  he  could  not  walk  a 
step  or  st  ind  upon  his  feet  without  an  assistant  on  each  side  to  hold  him  up. 
Thinking  further  special  treatment  of  no  use,  he  was  directed  to  desist 
from  all  efforts  to  maintain  an  upright  posiiion  even  long  enough  for  the 
making  up  of  his  bed;   but   to   have   strict  attention  given  to  cleanliness, 


NEUKITIS.  3G9 

frequent  chano^es  of  position  in  bed  to  avoid  bed  sores,  proper  attention 
to  his  evacuations,  a  plain  nutritious  diet,  and  no  medicine  except  at  each 
meal-time  eight  cubic  centimeters  (fi.  3ii)  of  a  mixture  of  two  parts  of  a 
thick  syrup  called  extract  of  malt  and  one  part  of  compound  syrup  of 
hypophosphites.  He  was  left  entirely  at  rest  under  these  directions,  ex- 
pecting him  to  continue  failing  until  a  fatal  result  was  reached.  But  much 
to  my  surprise  after  about  three  months  of  this  rest,  he  began  to  make 
efforts  to  help  himself,  and  in  another  month  could  get  out  of  bed  and 
stand  alone,  and  finally  so  completely  recovered  that  he  left  the  hospital 
with  a  steady  firm  step  and  gait  in  walking,  and  in  fair  general  health.  I 
relate  the  case,  first  to  show  that  patients  sometimes  recover  from  condi- 
tions of  chronic  disease  which  render  their  cases  apparently  hopeless;  and 
secondly  to  illustrate  the  value,  in  some  cases  at  least,  of  entire  and  pro- 
tracted rest  in  the  recumbent  position. 

JSfeivritis. — Both  the  sheaths  and  substance  of  the  various  nervous  cords 
are  liable  to  attacks  of  inflammation  in  all  degrees  of  activity.  Specimens 
of  this  are  seen  most  frequently  in  the  roots  of  the  spinal  nerves,  the 
trunk  of  the  sciatic,  and  in  the  tri-facial,  than  elsewhere.  The  inflamma- 
tory process  almost  always  partakes  of  the  rheumatic  character,  and  is 
most  readilv  relieved  by  anti-rheumatic  treatment,  aided  by  narcotic  fo- 
mentations in  the  first  stage,  and  subsequently  blisters  over  the  affected 
nerves.  I  have  now  completed  the  consideration  of  inflammations  of  the 
nervous  apparatus,  so  far  as  the  time  allotted  to  our  present  course  will 
peru^it. 


LECTUKE    XXXIX. 

Inflammation  of  the  Respiratory  Organs  ;  Tlie  Several  structures  included  under  this  Head,  and 
their  ubdivisions — Historical  arid  Etiological  Considerations.— Acute  and  Chronic  Inflammation 
of  the  Nasu-rharyngeal  Membrane;  Their  Symptoms,  Diagnosis,  Prognosis  and  Treatment. 

GENTLEMEN:  The  organs  immediately  concerned  in  the  process  of 
respiration,  are  the  nasal,  laryngeal,  tracheal  and  bronchial  tubes,  the 
parenchyma  of  the  lungs,  and  the  pleura  covering  the  latter.  Considered 
in  regard  to  the  inflammations  we  are  about  to  study,  they  are  composed 
of  three  important  structures,  namely:  The  mucous  membrane  linii  g  the 
tubes  and  over  which  the  air  has  to  pass  in  going  to  and  from  the  air-cells 
of  the  lungs;  the  parenchyma  of  the  lungs;  and  the  serous  membrane 
called  pleura,  which  not  only  forms  the  outer  covering  of  the  lungs,  but 
also  constitutes  the  lining  of  the  walls  of  the  chest.  Each  of  these  struct- 
ures are  liable  to  attacks  of  inflammation  separate  from  the  others,  and  in 
each  the  inflammatory  process  is  m  >dined  in  its  progress  and  results  by 
the  peculiarities  of  structure  and  function  belonging  to  each  part.  In 
this  connection  I  might  mention  a  fourth  structure  consisting  of  the  mus- 
cular and  fibrous  layers  of  the  bronchial  tubes  which  are  sometimes  the 
seat  of  inflammation,  as  you  will  learn  hereafter. 

History. — Inflammation  located  in  the  respiratory  organs,  has  been  rec- 
ognized as  a  frequent  and  serious  form  of  disease  from  the  earliest  j^eriods 
of  medical  history;  both  as  an  idiopathic  affection  and  as  a  complication  of 
most  of  the  acute  general  diseases.     It  was  not  until  the  latter  part  of  the 

24 


370        i]srFLAMMATio:sr  of  the  respiratory  organs. 

eio-hteenth  century  that  anj'  considerable  attempts  were  made  to  differen- 
tiate between  inflammation  in  the  membranous  structures  and  in  the  paren- 
chyma of  the  lungs.  And  even  those  attempts  were  attended  by  only  a 
limited  degree  of  success  until  after  Laennec  had  constructed  a  stethoscope 
and  directed  the  attention  of  the  profession  to  the  aniDlication  of  the 
knowledge  of  the  laws  governing  the  production  and  transmission  of 
sounds  to  the  study  of  the  clinical  phenomena  of  pulmonary  diseases. 

Since  that  period  of  time,  the  familiar  practice  of  auscultation  and  per- 
cussion, added  to  the  study  of  the  general  symptoms,  has  rendered  the 
diao-nosis  of  disease  in  any  part  of  the  respiratory  organs  as  exact  as  that 
of  any  class  of  diseases  to  which  the  human  system  is  liable.  You  have 
already  acquired,  in  connection  with  the  courses  on  general  pathology 
and  clinical  diagnosis  in  the  hospital  and  dispensary,  during  the  second 
year  of  your  studies,  such  a  degree  of  familiarity  with  the  whole  subject 
of  physical  diagnosis  as  to  render  any  elementary  consideration  of  that 
subject  unnecessary  at  this  time.  I  shall  proceed,  therefore,  directly  to 
the  consideration  of  the  different  grades  of  inflammation  affecting  the 
several  structures  of  which  the  respiratory  organs  are  composed,  in  the 
following  order:  First,  those  of  the  mucous  membrane;  second,  those  of 
the  parenchyma  of  the  lungs;  and  third,  those  of  the  serous  membrane  or 
pleural  covering  of  the  lungs.  For  more  convenient  and  accurate  descrip- 
tion, those  of  the  mucous  membrane  may  be  divided  into  such  as  affect 
the  lining  of  the  nasal  passages  or  Schneiderian  membrane;  the  lining  of 
the  larynx  and  trachea,  and  the  lining  of  the  bronchial  tubes.  As  all 
these  sections  of  the  mucous  membrane  are  constantly  exposed  to  contact 
with  the  inhaled  air,  containing  whatever  impurities  may  be  suspended  in 
it,  and  almost  constantly  varying  in  its  temperature,  moisture,  and  electric 
states,  so  we  find  some  degree  of  inflammation  affecting  them,  more  fre- 
■  quently,  perhaps,  than  any  other  structures  in  the  human  body.  And,  as 
a  general  rule,  their  frequency  in  any  given  locality  with  an  equal  popu- 
lation, will  be  in  a  direct  ratio  to  tlie  frequency  and  severity  of  the  atmos- 
pheric changes.  Consequently  you  will  find  them  most  prevalent  in  those 
parts  of  the  temperate  zone,  the  climate  of  which  is  characterized  by  fre- 
quent and  extreme  changes  in  temperature,  coupled  with  a  high  degree  of 
atmospheric  moisture  and  severe  winds.  For  the  same  reason  you  will 
meet  them  most  frequently  in  the  cold  season  of  the  year,  or,  more  accu- 
rately, during  the  last  half  of  autumn  and  the  first  part  of  spring,  when  the 
•atmospheric  vicissitudes  are  most  sudden  and  severe.  The  parts  of  our 
own  country  in  which  these  characteristics  of  climate  and  season  are  .most 
prominent,  are  embraced  in  the  belt  or  zone  lying  north  of  the  40th 
parallel  of  latitude,  and  extending  from  the  Atlantic  Coast  to  the  foot  or 
eastern  border  of  the  great  mountain  ranges  that  separate  the  waters 
which  flow  into  the  Atlantic  and  Gulf  of  Mexico  from  those  flowing  into 
the  Pacific  Ocean.  On  the  other  hand,  they  are  least  prominent  in  the 
belt  or  zone  lying  south  of  the  33d  parallel  of  latitude,  and  on  the 
Pacific  Slope,  west  of  the  great  mountain  ranges  just  mentioned.  The 
prevalence  of  inflammations  of  the  parenchyma  of  the  lungs  and  of  the 
serous  membrane  covering  them,  follow  a  different  rule  or  law.  Instead 
of  being  most  prevalent  in  those  climates  characterized  by  a  predominance 
of  the  cold  season  over  the  warm,  accompanied  by  the  most  frequent  and 
extreme  changes  in  the  thermometric  and  hygrometric  conditions  of  the 
atmosphere,  they  occur  most  frequent  and  most  severe  where  the  summer 
heat  is  long  and  high  and  the  winter  short,  yet  giving  somt?  days  of  very 
low  temperature,  thereby  making  a  wide  range  between  the  hottest  days 
'of  summer  and  the  coldest  of  winter,  with  a  predominance  of  summer  heat. 


ETIOLOGY.  371 

This,  in  the  United  States,  corresponds  with  the  middle  climatic  belt  or 
zone,  bounded  on  the  north  by  the  39th  and  on  the. south  by  the  33d 
parallel  of  latitude,  and  extending  from  the  eastern  foot  of  the  Rocky 
Mountain  chain  to  the  Atlantic  Coast.  From  these  general  remarks,  I  come 
now  directly  to  the  separate  study  of  the 

INFLA.MMATIONSOFTHE  MUCOUS  MEMBRANE  OF  THE  ATR  PASSAGES. 

Etiology. — As  the  same  causes  tend  to  produce  inflammation  in  all  parts 
of  the  respiratory  mucous  membrane,  it  will  economize  time  and  avoid 
repetition  to  study  them  in  their  relations  to  the  whole  extent  of  the  mem- 
brane at  once.  They  may  be  divided  into  two  classes:  predisposing  and 
exciting.  The  first  embrace  all  agents  and  influences  that  are  capable  of 
rendering  the  mucous  membrane  of  the  air  passages  more  susceptible  to 
impressions.  This  may  be  done  by  directly  increasing  the  irritability  of 
the  structure,  or  by  altering  the  quality  of  the  blood  and  lessening  the  tone 
of  the  smaller  vessels.  The  second  embraces  such  agents  and  influences 
as  are  capable  of  so  increasing  the  irritability  of  the  membrane,  coupled 
with  such  alteration  in  the  action  of  the  blood-vessels  as  to  induce  a  direct 
accumulation  of  blood  in  the  capillaries  of  the  part. 

The  most  common  and  important  of  the  predisposing  causes  may  be 
grouped  under  the  heads  of  age,  occupation,  modes  of  life,  or  personal 
habits;  climatic  conditions,  and  season  of  the  year. 

Age. — A  careful  examination  of  the  statistics  of  mortality  resulting  from 
inflammations  of  the  membrane  lining  the  air  passages,  has  led  to  the  infer- 
ence that  childhood  and  old  age  are  much  more  susceptible  to  attacks  of 
this  form  of  disease  than  the  middle  period  of  adult  life.  Consec[uently, 
nearly  all  your  text-books  on  practical  medicine  represent  childhood  and 
old  age  as  exerting  a  decided  predisposing  influence  in  favoring  attacks, 
while  the  active  period  of  adult  life  is  comparatively  exempt.  A  more 
extended  examination  of  the  subject,  however,  has  shown  that  of  a  given 
number  of  attacks  at  different  periods  of  life,  a  very  much  larger  ratio  of 
deaths  result  in  early  childhood  and  old  age  than  in  the  middle  period  of 
life.  Indeed,  this  increased  ratio  of  mortality  at  the  two  extremes  of  life, 
in  proportion  to  the  whole  number  of  cases,  is  sufficient  to  account  for  the 
results  shovvn  by  the  mortuary  statistics,  without  supposing  that  the  number 
of  cases  occurring  in  middle  life  are  any  less  in  proportion  to  the  number  of 
persons  than  in  childhood  or  old  age.  On  the  contrary,  my  own  records  of 
cases  of  acute  diseases,  without  regard  to  the  mortality,  show  a  larger  ratio 
of  attacks  of  inflammation  in  some  part  of  the  mucous  membrane  of  the  air 
passages,  between  the  ages  of  fifteen  and  thirty  years,  than  at  any  other 
period  of  life.  I  am  now  speaking  of  the  inflammatory  attacks  as  they 
occur  independently,  and  not  as  complications  of  some  of  the  acute  gen- 
eral diseases,  such  as  epidemic  influenza,  typhoid  fever,  measles,  etc. 

Occupation. — You  will  find  all  such  occupations  as  confine  those  pursu- 
ing them  much  in-doors,  to  strongly  predispose  to  attacks  of  catarrhal 
inflammation  in  the  air  passages.  And  if  the  air  of  the  rooms  occupied  is 
kept  at  a  temperature  either  too  high  or  too  low,  the  predisposition  will 
be  much  increased.  Habitual  exposure  to  a  warm  and  confined  atmos- 
phere, by  inviting  free  exhalations  from  the  membranous  surfaces  and 
increasing  their  susceptibility,  renders  them  more  sensitive  to  all  external 
impressions.  On  the  other  hand,  much  confinement  in  rooms  at  a  low  tem- 
perature, represses  the  exhalations  from  the  cutaneous  surface,  thereby 
causing  the  retention  of  some  of  the  products  of  tissue  changes  in  the 
blood,  which  renders  the  individual  more  susceptible  to  attacks  of  inflam- 


372  INFLAMMATION    OF    THE    AIR    PASSAGES. 

raation  in  any  of  the  structures  of  the  body  on  the  supervention  of  an 
exciting  case. 

Personal  Habits. — For  the  reasons  just  stated,  the  wearing  of  too  mnch 
or  too  little  warm  clothing,  also  either  increases  the  relaxation  and  suscep- 
tibility of  the  skin  and  respiratory  membranes  from  the  former,  or  holds  the 
cutaneous  exhalations  in  check  and  increases  the  retention  of  waste  and 
irritating  material  in  the  blood  from  the  latter. 

Another  error  of  importance  is  the  unequal  adjustment  of  clothing  to 
different  parts  of  the  cutaneous  surface.  On  children,  especially,  you 
often  see  an  abundance  of  warm  clothing  over  the  whole  body,  while  the 
leo-s  and  feet  and  neck  have  but  a  single  covering  and  sometimes  none. 
And  even  adult  women  often  go  out  loaded  with  warm  clothing,  while 
their  feet  and  ankles  are  protected  only  by  thin  shoes  and  stockings. 

Climatic  Conditi<ns. — It  is  universally  conceded  that  inflammation  of  all 
parts  of  the  mucous  membrane  lining  the  air  passages,  prevails  most  in 
such  countries  as  are  characterized  by  a  cold,  damp,  and  variable  climate. 
This  can  be  well  illustrated  by  comparing  the  prevalence  of  this  class  of 
diseases  in  that  belt  of  our  own  country  lying  north  of  the  39th  parallel 
of  latitude  and  east  of  the  Rocky  Movmtains,  with  the  prevalence  of  the 
same  diseases  in  the  belt  south  of  the  33d  parallel  and  bordering  upon  the 
Atlantic  and  Gulf  of  Mexico.  In  the  former  the  summers  are  compara- 
tively short  with  brief  periods  of  high  temperature;  the  winters  cold;  and 
the  transition  seasons,  spring  and  autumn,  long  and  exceedingly  variable 
with  a  predominance  of  cold  and  dampness.  In  the  latter,  all  the  condi- 
tions just  mentioned  are  substantially  reversed. 

Perhaps  the  earliest  reliable  statistics  we  have  bearing  upon  this  subject, 
are  those  collected  by  Dr.  Samuel  Forrey  from  the  several  military  posts 
occupied  bv  the  United  States  Army,  and  given  in  a  series  of  articles  in 
the  American  Journal  of  Medical  Sciences,  and  subsequently  in  an  octavo 
volume,  on  the  climate  of  the  United  States  and  its  influence  over  the  pniv- 
alence  of  diseases.  The  valuable  facts  presented  by  Dr.  Forrey  were  added 
to  by  Dr.  Daniel  Drake  and  given  in  full  in  his  large  work  on  the  topog- 
raphy and  diseases  of  the  great  interior  valley  of  this  continent.  From 
these  sources  you  can  learn  that  the  average  annual  number  of  attacks  of 
inflammation  of  the  mucous  membrane  of  the  respiratory  passages  in  every 
1,000  soldiers  at  Fort  Snelling,  in  Minnesota,  lat.  44^  5H'  N.,  was  600.  At 
Fort  King,  fifty  miles  from  the  Gulf  of  Mexico,  lat,  28°  58'  N.,  the  annual 
number  of  attacks  average  only  101.3  in  every  1,000  persons.  Again,  at 
Madison  Barracks  near  Sackett's  Harbor,  in  New  York,  the  average  num- 
ber of  attacks  for  every  1,000  persons  was  637.2;  while  at  Key  AVest,  in 
Florida,  the  average  number  of  attacks  was  208.9,  and  at  Baton  Rouge, 
Louisiana,  only  207.2.  Dr.  Drake  after  a  laborious  comparison  of  the  sta- 
tistics at  all  the  military  posts  in  the  great  interior  valley  from  Fort  Snell- 
ing at  the  north  to  Fort  Jessup  in  Louisiana,  the  most  southern,  makes  the 
"ratio  of  decrease  in  bronchial  inflammations  "  as  we  pass  from  the  north 
to  the  south  as  bl.o  for  each  degree  of  latitude.*  A  similar  comparison 
of  the  statistics  of  all  the  posts  on  the  Atlantic  Slope  from  Madison  Bar- 
racks to  Key  West  will  give  you  nearly  the  same  result. 

A  study  of  these  same  military  statistics,  representing  the  mean  ratio  of 
the  prevalence  of  diseases  of  the  respiratory  passages  for  a  period  of  ten 
years  at  nearly  all  the  posts,  will  justify  some  other  inferences  of  interest 
beside  the  one   just  stated.     According  to  this  general  inference  or  rule, 

*  See  a  Systeraa'ic  Treatise  on  the  Principal  Diseases  of  the  Interior  Valley  of  North  America, 
etc.,  etc.  Second  Series,  pp.  795-6. 


ETIOLOGY.  373 

the  three  impoitant  factors  in  the  climates  most  favorable  for  produ(;ing 
inflammations  of  the  air  passages  are  cold,  variableness,  and  dampness; 
the  latter  being  emphasized  by  most  writers  as  of  predominating  influence. 
Yet  the  tables  to  which  I  am  directing  your  attention  show  that  the 
highest  ratio  of  prevalence  of  inflammatory  attacks  of  the  mucous  mem- 
brane of  the  respiratory  passages  in  the  northern  part  of  the  interior  valley, 
was  at  Fort  Snelling,  in  the  immediate  vicinity  of  !St.  Paul,  Minnesota, 
])eing  GOO  attacks  for  every  1,000  soldiers;  while  the  lowest  ratio  was  at 
Fort  Dearborn,  on  the  site  now  occupied  by  the  city  of  Chicago,  being 
only  102  for  every  1,000  soldiers.  Looking  at  the  posts  in  the  eastern 
part  of  the  northern  belt  of  country,  Madison  Barracks,  at  Sackett's  Harbor, 
at  the  eastern  end  of  I^ake  Ontario,  gives  a  ratio  of  637  attacks  for  every 
1,000  soldiers;  while  Fort  Niagara  at  the  mouth  of  Niagara  River  near 
the  western  end  of  the  same  lake,  gives  a  ratio  of  only  355.  Again 
turning  to  the  posts  in  the  southern  belt  of  country  the  tables  show  at 
Fort  Jessup  in  the  interior  of  western  Louisiana,  a  ratio  of  432.8;  wliile  at 
Fort  Jackson  the  ratio  was  only  47.5,  and  at  Fort  King  101.3.  As  Fort 
Snelling  is  on  the  high  rolling  prairie  of  the  interior  of  Minnesota,  noted 
for  its  cold  and  dry  air,  and  Fort  Jessup  on  the  elevated,  arid  plateau 
between  the  head  waters  of  the  Sabine  and  the  Red  river,  they  cannot  be 
noted  for  a  high  degree  of  atmospheric  moisture.  On  the  other  hand.  Fort 
Dearborn  was  located  near  the  mouth  of  the  Chicago  river,  on  the  site 
now  occupied  by  this  city  (C.icago),  which  was  then  a  low  and  wet 
prairie  with  a  sub-stratum  of  impervious  clay,  giving  all  the  conditions 
favorable  for  the  prevalence  of  a  high  degree  of  atmospheric  moisture. 
And  Forts  Jackson  and  King  were  both  on  low  alluvial  lands  only  fifty 
miles  from  the  Gulf.  Again,  Fort  Niagara  is  surrounded  by  all  the  con- 
ditions favoring  a  high  degree  of  atmospheric  moisture  certainly  equal  to 
those  surrounding  Madison  Barracks  in  nearly  the  same  latitude;  and  yet 
the  ratio  of  attacks  in  the  latter  was  nearly  double  those  in  the  former. 
It  will  be  evident  to  you,  therefore,  that  there  must  exist  some  important 
factor  in  the  climatic  relations  of  the  inflammatory  affections  of  the  res- 
piratory passages,  besides  temperature,  humidity,  and  changeableness. 
A  glance  at  the  topography  of  the  whole  country  will  show  you  that  each 
of  the  posts  giving  a  high  ratio  of  attacks,  namely,  Madison  Barracks  and 
Forts  Snelling  and  Jessup,  to  which  may  be  added  Forts  Gratiot,  Craw- 
ford, and  Wood,  are  so  located  as  to  be  exposed  to  the  prevalence  of  unu- 
sually severe  winds  or  atmospheric  currents  either  from  the  north-east  up 
the  valley  of  the  St.  Lawrence  to  Madison  Barracks,  or  the  north-west  and 
west  to  Forts  Snelling  and  Jessup,  with  certain  relations  to  high  mountain 
ranges  in  the  west  and  ocean  currents  in  the  east.  That  the  high  ratio  of 
attacks  of  catarrhal  affections  at  Madison  Barracks  is  largely  due  to  the 
influence  of  the  winds  I  have  alluded  to,  is  corroborated  by  the  fact  that 
the  same  diseases  are  much  more  prevalent  in  the  province  of  Quebec, 
through  which  the  valley  of  the  St.  Lawrence  extends,  than  in  the  province 
of  Ontario,  as  shown  by  the  Register  General's  report  in  reference  to  the 
several  military  posts  in  the  Canadas- 

And  it  is  equally  evident  that  the  high  ratio  of  prevalence  of  the  same 
diseases  at  Forts  Snelling,  Crawford  and  Jessup  is  also  largely  due  to  the  cold 
and  strong  atmos]iheric  currents  that  sweep  over  the  plains  from  the  north- 
west and  west  with  such  force  as  to  justify  the  popular  title  of  "blizzards." 
I  may  safely  say,  therefore,  that  the  force  and  direction  of  atmospheric 
currents  have  quite  as  much  to  do  with  the  development  of  inflammations  of 
the  air  passages,  as  either  temperature  or  humidity. 

Season  of  the  Year.  —  As  might  be  inferred  from  what  has  already  b^'en 


0/4  INFLAMMATION    OF    THE    AIR    PASSAGES. 

said  in  relation  to  the  influence  of  climatic  conditions,  those  parts  of  tlie 
year  characterized  by  low  temperature,  high  winds,  and  frequent  thermo- 
metric  changes  are  accompanied  by  the  highest  ratio  of  prevalence  of  inflam- 
mations of  the  respiratory  passages.  This  is  fully  sbown  both  by  the  sta- 
tistics compiled  from  the  records  of  all  the  military  posts  by  Dr.  Drake,* 
and  by  the  results  of  clinical  records  kept  under  my  own  observation 
through  a  series  of  years. 

Exciting  Causes. —  Exposure  to  sudden  and  extreme  changes  in  atmos- 
pheric temperatui'e  from  warm  to  cold,  is  almost  universally  regarded  as 
the  chief  exciting  cause  of  inflammation  in  any  part  of  the  mucous 
membrane  of  the  air  passages.  More  accurate  and  detailed  observations, 
however,  show  that  such  changes  of  teu,perature  are  seldo  -i  productive  of 
diseases  of  this  class  unless  accompanied  by  coincident  high  winds  and 
humidity.  My  own  studies  concerning  the  relations  between  special  me- 
teorological conditions,  and  the  prevalence  of  particular  diseases  have  led 
me  to  the  following  conclusions  in  regard  to  inflammation  of  the  mucous 
membrane  of  the  air  passages. 

First.  Many  sporadic  cases  are  caused  at  any  and  all  seasons  of  the  year 
by  exposure  of  limited  portions  of  the  cutaneous  surface  to  cool  or  cold 
currents  of  air,  while  the  rest  of  the  body  is  well  protected. 

Second.  The  sudden  transition  from  a  protracted  period  of  intense  dry 
cold,  to  a  higher  temperature  with  increased  atmospheric  humidity.  Almost 
every  winter  season  in  the  northern  belt  of  the  United  States  east  of  the 
Rocky  Mountains,  is  characterized  by  several  periods  of  steady  dry  cold  air, 
varying  from  one  to  three  weeks  in  duration,  during  which  the  mercury  in  the 
thermometer  often  descends  more  than  20'^  C.  (S"-'  to  10*^  F.)  below  zero,  and 
which  generally  end  in  a  sudden  change  in  the  direction  of  the  winds,  and  a 
marked  elevation  of  temperature,  constituting  what  is  popularly-  called 
"rt  thaio.''''  Such  changes  are  very  uniformly  accompanied  by  a  general 
prevalence  of  catarrhal  affections  of  the  air  passages. 

Third.  The  occurrence  of  those  cold  north-east  winds  that,  during  the 
latter  part  of  autumn  and  early  ])art  of  spring,  so  olten  sweep  over  the 
whole  extent  of  our  Atlantic  coast,  and  press  up  the  valley  of  the  St. 
Lawrence  to  the  great  interior  lakes;  and  the  still  more  severe  currents 
that  come  during  the  s- me  seasons  frcnn  the  north-west  and  west  over 
all  the  wide  plains  that  intervene  between  the  great  mountain  chains  to 
the  west,  and  the  u]jper  lakes  and  Mississippi  river  to  the  east,  are  also  ac- 
companied by  a  high  ratio  of  prevalence  of  the  diseases  now  ur.der  con- 
sideration. Most  of  these  severe  storms  of  wind  are  accompanied  by 
either  snow  or  rain,  and  a  marked  increase  of  ozone  or  active  oxydizers. 
In  some  of  the  severe  snow  storms  from  the  north-east  occurring  in  the 
latter  part  of  February  and  in  Maich  I  have  found  an  unusual  amount  of 
free  ammonia.  Whether  either  the  ozone  or  the  ammonia  has  aiiythii:g 
to  do  with  the  production  of  the  catarrhal  aft'ections  remains  to  be  determined 
by  more  exact  observations  and  records. 

Aci.ite  Ir\f<immation  in  the  Nasal  Passages. — Acute  and  subacute  in- 
fianimation  in  the  Schneiderian  membrane,  more  familiarly  known  as  acute 
nasal  catarrh,  is  a  disease  of  very  frequent  occurrence  in  all  the  northern 
part  of  our  country,  as  I  have  shown  while  speaking  of  the  etiological  re- 
lations of  climate. 

It  usually  commences  with  a  sense  of  heat,  dryness,  and  fullness,  in  the 

•  See  Drake  on  ihe  Principal  Diseases  of  the  Interior  Valley  of  North  America,  p.  792. 


SYMPTOMS.  375 

« 
nostrils  ;  a  watery  appearance  of  the  eyes;  frequent  sneezing  ;  dull  pain  in 
the  forehead  and  temples;  sometimes  rigors  or  chilliness  ;  followed  by 
slight  general  fever",  and  acceleration  of  pulse.  In  from  twelve  to  eighteen 
hours,  the  heat  and  dryness  in  the  nostrils  give  place  to  the  secretion  of  a 
thin  water  colored  mucus  that  increases  in  quantity  until  at  the  end  of 
twenty-four  hours  it  will  require  the  constant  use  of  a  handkerchief  to 
keep  it  from  dripping  from  the  nostrils.  The  Schneiderian  membrane  is 
red  and  tumefied  from  the  intense  injection  of  the  vessels,  and  this  redness 
often  extends  from  the  posterior  nares  over  a  part  of  the  pharynx  and  arch 
of  the  fauces,  while  the  tumefaction  of  the  membrane  over  the  turbinated 
bones  and  in  the  middle  part  of  the  nasal  passages  so  nearly  closes  them 
as  to  prevent  getting,'  the  breath  except  by  opeaing  the  mouth.  This  is 
particulaily  annoying  to  nvirsing  children  who  can  take  but  one  or  two  swal- 
lows of  milk  from  the  breast  before  they  are  obliged  to  let  go  the  nipple  to 
take  in  breath  through  the  mouth.  In  most  cases  in  from  twenty-four  to 
forty-eight  hours  after  the  commencement  of  the  attack,  the  heavy,  dull, 
feeling  in  the  forehead  begins  to  abate,  the  secretion  in  the  nostrils  begins 
to  be  thicker  and  flows  less  freely;  and  in  another  day  it  becomes  whitish, 
opaque,  or  muco-purulent.  At  the  same  time  the  tumefaction  of  the 
membrane  begins  to  abate,  and  there  is  less  trouble  in  breathing  through 
the  nostrils,  except  after  sleeping  when  the  accumulation  of  thick  muco- 
purulent matter  necessitates  free  blowing  of  the  hose  to  clear  it  away  be- 
fore the  breathing  can  go  on  well  in  the  morning.  In  most  of  the  acute 
cases  the  decline  of  the  inflammation  is  sufficiently  rapid  to  allow  the  pa- 
tient to  regain  free  use  of  the  nostrils  and  exemption  from  further  annoy- 
ance in  from  five  to  seven  days.  Such  is  the  most  common  course  of  acute 
inflammation  in  the  membrane  lining  the  nasal  passages,  as  it  occurs  in 
])ersons  of  all  ages,  from  infancy  to  old  age,  but  most  frequently  in  child- 
hood and  youth.  There  are,  however,  some  important  deviations  from  this 
simple  course.  Occasionally  a  case  is  met  with  in  which  the  inflammation 
extends  to  the  membranes  lining  the  antrums  or  the  frontal  sinuses  or 
both,  giving  rise  to  more  severe  pain  and  heaviness  both  in  the  cheek  bones 
and  frontal  region;  more  general  febrile  disturbance,  with  scanty  and  high 
colored  urine.  Such  cases  are  more  protracted,  but  pass  through  the 
same  stages  as  those  T  have  just  described.  When  the  discharge  from  the 
nostrils  begins  to  be  opaque  or  muco-purulent,  there  comes  along  with  it, 
or  sometimes  a  day  or  two  later,  a  consideraljle  quantity  of  a  yellow,  se- 
rous fluid,  which  makes  the  handkerchief  stiff'  and  sticky  as  if  it  had  been 
wet  with  starch.  This  comes  from  one  or  more  of  the  cavities  just  men- 
tioned, and  is  usually  followed  by  much  relief,  or  entire  recovery. 

In  other  cases,  however,  the  disease  having  reached  the  third  or  muco- 
purulent stage,  further  progress  in  the  direction  of  resolution  of  the  in- 
flammation ceases,  and  the  case  assumes  a  chronic  form,  in  which  condi- 
tion it  is  liable  to  remain  for  months  and  sometimes  years.  Another  class 
of  cases  commences  in  ail  respects  like  those  of  simple  acute  nasal  catarrh, 
and  in  three  or  four  days  the  irritation  declines  rapidly,  but  coincidently 
attacks  in  succession  the  membrane  lining  the  fauces,  pharynx,  trachea, 
and  bronchial  tubes,  causing  soreness  and  tightness  in  the  chest,  with  se- 
vere cough,  and  sometimes  much  dyspnoea.  There  is,  also,  still  another 
class  of  cases  in  which  the  inflammation  attacks  simultaneously  the  whole 
mucous  membrane  of  the  air  passages,  accompanied  by  rigors,  and  fol- 
lowed by  general  irritative  fever  of  considerable  severity.  These  are 
cases  of  influenza,  and  have  been  fully  considered  in  the  ninth  lecture  of  the 
present  course.* 

*  See  page  69  of  present  Vol. 


376  CHRONIC   INFLAMMATION. 

Chronic  Inflammation  of  the  Membrane  lining  the  JSfasal  Passages. — 
Some  degree  of  chronic  inflammation  in  the  mucous  membrane  lining  the 
nostrils  and  pharynx,  usually  called  chronic  catarrh,  is  one  of  the  most  com- 
mon diseases  met  with  in  all   cold  and  variable  climates. 

It  is  most  generally  the  result  of  repeated  acute  attacks,  but  sometimes 
originates  as  a  chronic  form  of  disease  without  having  been  preceded  by 
acute  symptoms.  It  may  occur  at  any  period  of  life,  although  attacks  are 
much  more  frequent  in  childhood  and  youth  than  later  in  life.  The  cases  as 
met  with  in  ordinary  practice  may  be  arranged  in  four  groups.  The  first 
group  includes  all  those  cases  characterized  by  a  simple  morbid  sensitive- 
ness of  the  Schneiderian  membrane,  which,  during  warm  dry  weather  gives 
the  patient  little  or  no  trouble,  but  responds  so  readily  to  the  influence  of 
cold  and  damp  air  that  the  membrane  becomes  congested  with  the  first 
recurrence  of  the  wet  and  cold  weather  of  autumn  and  remains  so  through 
the  winter  and  spring.  In  most  of  these  annually  recurring  cases,  the  pa- 
tient simply  sufi'ers  from  a  feeling  of  fullness  or  obstruction  in  the  nostrils, 
coupled  with  an  abundant  secretion  of  mucus,  mostly  of  a  water  color  and 
readily  dislodged  by  blowing  the  nostrils  freely. 

But  any  special  or  unusual  exposure  to  currents  of  cold  damp  air  gen  ■ 
erally  causes  a  temporary  increase  of  tumefaction  in  the  membrane  with 
greater  stenosis  or  obstruction  to  breathing  through  the  nose,  stopping  of 
the  tear  ducts  and  a  watery  appearance  of  the  eyes,  which  lasts  from  two 
to  four  days;  and  on  its  subsidence  the  secretion  presents  more  of  a  muco- 
purulent appearance  for  two  or  three  days  and  then  returns  to  the  state 
previously  described.  When  the  patient  lies  on  the  back,  more  or  less  of 
the  secretion  falls  into  the  pharnyx  and  may  be  either  swallowed,  or 
hawked  out  by  voluntary  efi'ort.  In  this  class  of  cases  there  is  usually  little 
or  no  deterioration  of  the  general  health  of  the  patient,  but  much  annoy- 
ing inconvenience  during  the  cold  part  of  every  year. 

The  second  group  embraces  such  cases  as  involve  chiefly  the  membrane 
lining  the  posterior  part  of  the  nostrils  and  covering  the  pharynx,  consti- 
tuting anaso-pharyngeal  disease  of  varying  degrees  of  severity,  butalwavs 
annoying  to  the  patient.  The  chief  sj'^mptoms  are  a  sense  of  fullness  in 
the  fauces  with  an  excess  of  mucus,  frequently  of  a  thick  viscid  character, 
requiring  much  snuffing  and  hawking  to  dislodge  it,  especially  in  the 
morning,  as  it  tends  to  accumulate  in  the  posterior  nasal  fossa  during 
sleep,  and  is  capable  of  only  an  imperfect  expulsion  by  blowing  through 
the  nostrils.  In  this  class  of  cases  there  is  little  appearance  of  disease  or 
discharge  from  the  anterior  part  of  the  nostrils  ;  but  the  whole  surface  of 
the  pharynx,  the  arch  of  the  fauces,  and  the  lining  of  the  posterior  nostrils 
as  far  as  it  can  be  seen,  are  red  and  tumefied  from  congestion  of  the  ves- 
sels and  more  or  less  hyperplasia  of  the  epithelium  and  connective  tissue 
of  the  mucous  membrane.  In  some  cases  the  follicles  are  large,  rounded, 
and  smooth,  looking  like  granulations.  The  discharge  varies  much  in 
quantity  and  quality,  being  sometimes  scanty  and  of  a  bluish  tenacious 
character,  and  at  others  abundant  and  of  a  yellowish  miico-purulent  appear- 
ance. These  cases,  though  often  greatly  aggravated  by  fresh  exposures  to 
the  ordinary  exciting  causes  in  the  changeable  seasons  of  spring  and 
autumn,  seldom  entirely  disappear  even  in  the  warmest  part  of  summer. 

The  cases  included  in  the  third  group,  are  in  some  deo;ree  a  modification 
of  those  just  described.  The  seat  of  the  disease  is  the  same,  occupying 
chiefly  the  posterior  part  of  the  nostrils  and  pharynx  ;  but  the  inflamed 
membrane  is  darker  red,  dry,  in  some  cases  smooth,  in  others  granular,  and 
looking  as  though  denuded  of  its  epithelium.  The  secretion  is  scanty  and 
of  a  gluey  tenacious  quality  ;  and  usually  dries  up  into  crusts,  like  scabs,  of 


SYMPTOMS.  377 

various  sizes  from  the  circumference  of  a  sm:ill  pea  to  that  of  a  nickel  half- 
dime.  The  larger  masses  accumulate  mostly  on  the  floor  of  the  posterior 
and  middle  part  of  the  nostrils,  but  the  smaller  ones  may  be  often  seen  ad- 
hering to  the  dry  surface  of  the  upper  part  of  the  pharynx.  In  many 
cases  these  dried  masses  or  crusts  are  dislodged  with  much  difficulty  and 
often  yield  an  unpleasant  odcr.  This  group  of  cases  is  less  influenced  by 
atmospheric  conditions  or  changes  of  the  seasons,  than  either  of  those  I 
have  just  previously  described  ;  and  are  almost  always  associated  with 
either  a  scrofulous  or  syphilitic  constitutional  condition. 

The  fourth  group  includes  those  cases  which  are  described  by  most 
authors  and  teachers  under  the  name  of  ozena.  In  these,  the  inflamma- 
tion is  located  in  the  membrane  covering  the  upper  and  lower  turbinated 
bones,  and  lining  the  middle  and  anterior  part  of  the  nasal  passages.  It 
is  met  with  mostly  in  childhood  and  youth,  though  sometimes  also  in  the 
early  part  of  adult  life.  It  may  be  limited  to  one  nostril  or  it  may  involve 
both  at  the  same  time.  The  most  prominent  and  characteristic  symptoms 
are  redness  and  tumefaction  of  the  membrane,  especially  where  it  covers 
the  lower  turbinated  bone  and  lines  the  vomer,  with  an  abundant  muco- 
purulent discharge  more  or  less  offensive  to  the  smell.  In  most  of  these 
cases  the  swelling  of  the  membrane  where  it  covers  the  lower  turbinated 
bone  presents  a  prominent  rounded  or  projecting  surface  somewhat  like 
the  appearance  of  a  polypoid  growth,  and  either  completely  closes  up  or 
greatly  narrows  the  passage  through  the  nostril.  In  some  children  the 
discharge  is  not  only  abundant  and  muco-purulent  but  sanicus  or  irritating, 
causing  excoriation  of  the  upper  lip  which  in  some  instances  becomes 
covered  with  a  thick  honey-comb  like  scab,  adding  much  to  the  bad  looks 
as  well  as  discomfort  of  the  child.  In  other  cases  the  inflamed  mambrane 
in  the  nostrils  becomes  ulcerated,  and  even  the  turbinated  bones  more  or 
less  carious  or  necrosed.  In  some,  the  ulcerative  process  extends  to  the 
cartilage  of  the  septum,  destroying  more  or  less  of  it  and  leaving  a  per- 
manent opening  from  one  nostril  into  the  other.  In  most  of  the  cases  in 
this  group,  there  is  some  degree  of  offensive  odor  to  the  discharge  and  to 
the  breath  that  comes  thrcmgh  the  nostrils  ;  and  in  suoh  as  are  accompa- 
nied by  caries  or  necrosis  of  the  bones  the  odor  is  almost  intolerabla. 

The  cases  belonging  in  this  group,  like  those  in  the  preceding  one, 
occur  almost  exclusively  in  persons  inheriting  a  syphilitic  or  scrofulous 
diathesis,  or  in  those  surrounded  by  such  sanitary  conditions  as  favor  the 
development  of  the  latter.  In  the  naso-pharvngeal  cases  conetituting  the 
second  and  third  groups,  it  often  happens  that  the  inflammation  extends 
along  the  Eustachian  tube  to  the  middle  ear  causing  sometimes  pain,  hut 
more  generally  ojnly  a  sense  of  fullness  with  hissing,  buzzing  or  other 
noises  in  the  ear,  and  more  or  less  impairment  of  hearing.  In  a  few  in- 
stances the  inflammatory  process  extends  into  the  lining  of  the  antrums 
or  frontal  sinuses.  In  the  former  it  may  reach  the  root  of  some  tooth  that 
has  penetrated  the  floor  of  the  antrum,  and  cause  it  to  become  necrosed 
and  the  antrum  filled  with  a  sero-purulent  fluid,  thereby  adding  to  the 
other  symptoms  much  sense  of  fullness  and  severe  pain  in  the  region  of 
the  upper  maxillary  bone. 

A  case  of  this  kind  came  under  my  observation  only  a  few  months 
since,  in  which  the  extraction  of  the  tooth  was  followed  by  the  discharge 
of  a  large  c{uantity  of  offensive  purulent  matter  from  the  antrum.  By 
rinsing  out  the  antrum  every  day  with  anti-septic  liquids,  the  suppurative 
process  was  arrested,  the  odor  removed,  and  the  patient  recovered  as  far 
as  the  antrum  was  concerned;  but  he  still  suffers  some  from  the  chronic 
naso-pharyiigeal  inflammation. 


378  CHRONIC  INFLAMMATION. 

Diagnosis. — I  have  o-iven  you  all  the  important  diagnostic  symptoms  in 
relating  the  clinical  history  of  each  group  of  cases,  rendering  it  unnecessary 
to  repeat  them  here.  I  wish  to  remind  you,  however,  that  the  habitual 
use  of  tobacco,  either  by  smoking  or  chewing,  causes,  in  many  persons,  a 
congested  and  slightly  swollen  condition  of  the  naso-pharyngeal  mem- 
brane, sufficient  to  cause  an  unpleasant  sense  of  fullness  and  a  disposition 
to  hawk  and  clear  the  throat  with  annoying  frequency.  If  you  regard 
these  as  cases  of  ordinary  mild  naso-pharyngeal  inflammation,  and  attempt 
to  treat  them  without  prohibiting  the  further  use  of  the  tobacco,  your 
treatment  will  be  found  to  exert  very  little  curative  influence. 

Prognosis.  —  It  is  probable  that  uncomplicated  cases  of  inflammation  of 
the  nostrils  and  pharynx  of  a  chronic  character  have  never  destroyed  life. 

The  prognosis,  therefore,  so  far  as  relates  to  a  continuance  of  life,  is 
favorable  in  all  grades  of  the  disease.  But  though  the  disease  does  not 
directly  endanger  the  loss  of  life,  it  is  always  troublesome  to  the  patient; 
in  some  of  its  forms  sufficiently  severe  to  impair  the  general  health;  and 
very  difficult  of  permanent  cure,  more  especially  while  the  patient  remains 
in  a  cold  and  variable  climate. 

Treatment.  —  There  are  very  few  of  the  more  common  diseases  met  with 
in  the  ordinary  routine  of  medical  practice,  that  have  been  treated  more 
empirically,  or  have  prompted  the  invention  of  a  larger  number  of  specific 
cures,  than  the  various  grades  of  inflammation  of  the  mucous  membrane 
of  the  nostrils  and  pharynx.  Catarrh  snuff's,  nasal  douches,  sprays,  and 
inhalations,  have  been  invented  and  used  with  but  little  discrimination  in 
all  varieties  and  stages  of  the  disease.  Many  of  them  have  been  useless, 
and  some  productive  of  positive  harm  instead  of  benefit. 

This  is  especially  true  of  the  too  free  and  indiscriminate  use  of  the  nasal 
douche,  by  which  inflammations  and  injuries  have  been  caused  in  the 
middle  ear,  of  more  importance  than  the  original  catarrhal  affection  of  the 
nostrils.  I  need  hardly  remind  you,  gentlemen,  that  there  are  no  real 
specifics  for  the  cure  of  any  stage  of  inflammation  of  the  mucous  mem- 
branes, in  the  nostrils  or  elsewhere.  And  if  you  would  give  your  patients 
suffering  frum  any  form  of  the  annoying  maladies  now  under  consideration, 
the  greatest  possible  degree  of  relief,  you  must  in  each  case  give  due  at- 
tention to  the  causes  that  may  have  induced  the  disease  and  maybe  still 
active  in  perpetuating  it;  to  the  extent  and  stage  of  advancement  of  the 
disease  itself;  and  to  the  coincident  cons  itutional  condition  of  the 
patient.  There  are  very  many  cases  of  the  acute  and  subacute  forms  of 
inflammation  in  the  Schneiderian  membrane,  called  coryza,  which  arise 
from  temporary  exposures  to  severe  atmospheric  changes  by  persons  in 
other  respects  in  good  health,  that  get  well  in  a  few  days  without  coming 
under  the  care  of  the  physician. 

There  are  many  other  cases  of  the  same  class  for  which  the  physician  is 
consulted,  that  need  no  other  treatment  than  the  restriction  of  the  patient 
to  a  light  plain  diet  with  a  limited  use  of  liquids  of  any  kind,  and  the 
taking  of  some  laxative  and  diuretic  medicine  sufficient  to  gently  increase 
the  action  of  the  bowels  and  kidneys.  For  this  purpose  a  saturated  solu- 
tion of  the  bi-tartrate  of  potassium  in  sweetened  water,  may  be  given  in 
d  ses  of  ten  or  fifteen  cubic  centimeters  (fl.  3iiss  or  3iv)  three  or  four 
times  during  the  day.  Or  if  you  are  called  early  to  a  case  of  more  than 
prdinary  severity,  just  as  the  first  stage  ol  intense  congestion  of  the  mem- 
brane is  beginning  to  give  place  to  the  copious  thin  discharge  that  usually 
follows,  you  may  giv(^  the  patient  a  full  dose  of  the  compound  powder  of 
opium  and  ipecacuanha,  cover  him  up  in  bed  for  a  sleep  of  six  or  eight  hours, 
after  which  the  bow  ils  may  be  opened  by  a  saline  laxative,  and  if  he  takes 


TREATMENT.  379 

only  lig-ht  food  and  a  limited  amount  of  liquids,  it  will  in  a  large  propor- 
tion of  cases  cut  short  the  attack  with  but  little  nasal  discharge.  If  any 
local  applications  are  used  in  the  first  and  second  stag-es  of  such  cases  they 
should  be  simply  of  a  soothing  or  anodyne  quality,  and  in  the  form  of 
vapor.  It  is  doubtful,  however,  whether  in  ordinary  cases  they  do  enough 
good  to  compensate  for  the  trouble  of  using  them.  You  ma}^  be  some- 
times called  to  cases  in  which  the  stage  of  congestion  and  that  of  thin 
mucous  secretion  have  both  passed  by,  and  you  find  the  patient  with  a 
copious  muco-purulent  discharge,  ami  considerable  tumefaction  of  the 
nasal  membrane;  some  dull  frontal  pains;  slight  acceleration  of  pulse  and 
increase  of  temperature  in  the  afternoon  and  evening,  followed  by  some 
sweating  in  the  latter  part  of  the  night;  and  a  general  feeling  of  weak- 
ness, with  impairment  of  appetite.  Such  cases  if  neglected,  are  liable  to 
be  protracted  in  duration  or  end  in  the  development  of  a  chronic  form  of 
the  disease. 

This  result  can  be  prevented  in  most  cases,  and  the  patient  relieved  in 
a  few  days,  if  you  will  give  him  from  two  to  three  decigrams  (gr.  iii  to  v) 
of  sulphate  of  quinia  each  morning,  noon,  and  evening;  see  that  the 
bowels  are  simply  kept  regular  by  mild  means;  the  diet  plain  but  suf- 
ficiently nourishing;  and  the  nostrils  carefully  washed  out  e-ach  morning 
and  evening  with  some  mild  antiseptic  and  slightly  astringent  wash.  I 
have  used  none  that  had  a  better  eftect  than  the  solution  of  carbolic  acid 
and  sulphate  of  zinc,  each  six  centigram  (gr.  i)  to  thirty  cubic  centi- 
meters (fl.  §1)  of  water.  The  solution  miy  be  used  with  a  suitable  syringe, 
or  if  the  patient  can  exercise  good  judginent,  he  may  be  instructed  to 
snuff  or  draw  it  up  gently  from  the  palm  of  his  hand,  until  he  feels  it  pass 
into  his  pharynx  from  which  he  can  readily  hawk  it  forward,  and  spit  it 
out. 

In  the  treatment  of  chronic  naso  pharyngeal  inflammations,  the  benefit 
you  confer  upon  your  patients  will  depend  very  much  upon  the  amount 
of  attention  you  give  to  the  removal  of  such  co-existing  functional  and 
constitutional  derangements  as  often  exert  much  influence  in  perpetuatino- 
the  local  catarrhal  aifection,  and  on  the  skill  with  which  you  adjust  the 
remedies  addressed  <lirectly  to  the  latter,  to  the  particular  grade  of  inflam- 
mation in  each  case.  A  large  proportion  of  all  the  varieties  of  chronic 
cases  have  for  their  predisposing  cause  habitual  failure  or  inefficiency  of 
one  or  more  of  the  excretory  functions  by  wliich  the  products  of  tissue 
change  and  :>ther  disturbing  elements,  are  separated  from  the  blood  and 
eliminated  from  the  system.  This  failure  may  be  in  the  lungs  and  skin 
through  want  of  regular  active  out  door  exercise,  or  in  the  bowels  from 
habitual  constipation;  or  in  the  failure  of  the  kidneys  to  promptly  in- 
crease the  activity  of  their  secretory  action  whenever  the  cutaneous 
surface  is  restricted  by  exposure  to  cold  and  dampness.  If  by  any  of 
these  modes  more  or  less  of  the  products  of  tissue  disintegration  and 
waste  are  retained  in  the  blood,  they  will  not  only  greatly  increase  the 
tendency  to  develop  disease  in  any  of  the  more  sensitive  structures  of  the 
body,  but  their  continuance  through  inattention  of  the  physician,  or 
neglect  on  the  p:art  of  the  patient,  will  render  a  cure  of  the  local  affection 
more  difficult,  and  relapses  more  certain  and  persistent. 

Long  and  careful  attention  to  this  subject  has  satisfied  me  that  a  \e.rj 
large  proportion  of  chronic  catarrhal  affections  of  the  respiratory  organs 
have  their  origin  in  the  failure  of  some  one  or  more  of  the  excretory 
functions  to  which  I  have  alluded;  and  especially  in  failure  to  maintain  the 
proper  sympathy  or  compensative  adjustment  of  action  between  the  skin 
and   kidneys  during  the   transition  of   the   seasons,  as  well   as  during  the 


3S0  CHRONIC    CATARRH. 

more  sudden  transition  from  protracted  periods  of  severe  cold  to  a  higher 
temperature. 

A  very  important  part  of  the  treatment  of  all  chronic  cases  therefore 
consists  in  carefully  correcting  whatever  functional  derangements  exist. 
The  judicious  use  of  baths  at  such  temperature  as  is  most  agreeable  to  the 
patient,  perhaps  twice  per  week,  followed  by  thorough  frictions  with  dry 
soft  flannel;  the  wearing  of  warm  flannel  underclotties;  and  daily  active 
out-door  exercise,  constitute  the  most  efficient  means  for  establishing  and 
maintaining  the  natural  eliminations  from  the  skin  and  lungs.  Constipa- 
tion may  be  obviated  and  digestion  improved  by  the  use  of  certain  tonics 
combined  with  just  enough  laxative  medicine  to  secure  a  regular  intesti- 
nal evacuation  once  in  the  twenty-four  hours.  For  this  purpose  I  have 
found  nothing  better  suited  to  most  cases,  than  the  following  combination: 

3      Ferri   Sulphatis  2.0  grams  gr.  xxx 

Extract i  Hyoscyami  2.0       "  "      " 

Pulv.>ris  Aloes  O.G       "  ^'      x 

Piluige   Hydrrirgyri  ().G        "•  "      '' 

Extracti  Nucis  Vomicae  O.G       "  "      " 

Mix.  Divide  into  pills  xxx;  of  which  one  may  be  taken  before  each 
meal-time,  or  before  breakfast  and  dinner,  as  is  found  necessary  to  secure 
an  easy,  natural  passage  from  the  bowels  once  a  day.  If  the  case  you 
have  in  hand  is  complicated  with  constitutional  syphilis  or  scrofula,  you 
must  call  to  the  aid  of  your  patient  all  those  hygienic  and  remedial 
measures  that  I  recommended  in  lectures  twenty-eight  and  thirty  of  the 
present  course.* 

Local  Treatment. — Remedies  addressed  directly  to  the  diseased  mem- 
brane, to  be  beneficial,  must  be  carefully  adjusted,  both  in  their  nature 
and  modes  of  application,  to  the  special  conditions  of  each  case.  In  the 
cases  belonging  to  the  first  and  second  groups,  as  I  have  described  them, 
the  solution  of  carbolic  acid  and  sulphate  of  zinc,  used  in  the  same  man- 
ner as  I  mentioned  when  speaking  of  the  treatment  of  the  more  advanced 
stage  of  acute  cases,  will  be  found  one  of  the  best  that  can  be  devised. 
In  maTiy  of  the  same  groups  of  cases,  the  frequent  inhalation  of  the  vapor 
of  the  oil  of  eucalyptus,  has  proved  beneficial.  This  may  be  taken  directly 
from  the  open  mouth  of  a  small  vial  containing  eight  or  ten  cubic  centi- 
meters (3ii  or  3iiss)  of  the  oil.  In  cases  of  long  standing,  in  which  there 
is  much  thickening  of  the  membrane  and  hypertrophy  of  the  follicles, 
remedies  capable  of  producing  a  degree  of  stimulating  and  alterative 
efi'ect  may  constitute  the  best  local  applications.  One  that  1  have  used  in 
such  cases  with  good  effect  is  a  solution  of  iodine  three  decigrams  (gr.  v) 
in  fifteen  cubic  centimeters  (fl.  3iv)  of  chloroform  in  a  little  vial  with  a 
glass  stopper.  One  or  two  slow,  full  bceaths  of  the  vapor  from  the  open 
mouth  of  the  vial  may  be  drawn  through  each  nostril  five  or  six  times  a 
day.  The  vial  should  be  kept  well  stoj^ped  except  while  in  actual  use. 
In  the  cases  I  described  as  belonging  to  the  third  and  fourth  groups,  one 
of  the  most  important  objects  to  be  accomplished  by  local  remedies  is  to 
maintain  cleat)liness  and  proper  disinfection  of  the  nasal  pass  ges.  For 
this  purpose  the  nostrils  should  be  carefully  but  efficiently  washed  out, 
once  or  twice  a  day,  with  a  solution  of  carbolic  acid  and  sulphate  of  zinc 
in  the  proportion  of  six  to  thirteen  centigrams  (gr  i  to  ii)  of  each,  in 
thirty  cubic  centimeters  (fi)  of  water.     Solutions  of  permanganate  of  po- 

*  See  pages  258  and  286  of  this  VoL 


TREATMENT.  381 

tassium,  benzoic  acid,  and  chloride  of  sodium  may  be  used  for  the  same 
purpose  and  of  the  same  strength.  The  best  and  safest  instrument  for 
using  these  solutions  to  cleanse  the  diseased  surfaces  is  the  post-nasal  snt- 
inge.  And  even  the  use  of  this  should  not  he  intrusted  to  entirely  un- 
skillful hands.  Their  use  with  the  ordinary  fountain  nasal  douche  is  so 
liable  to  be  followed  by  pains  and  inflammation  in  the  Eustachian  tubes, 
middle  ear,  and  antrums,  that  I  have  deemed  it  better  to  prohibit  this 
method  altogether.  In  several  cases  I  have  found  free  cleansing  of  the 
nasal  passages  with  the  syringe  once  in  three  days,  and  the  use,  each 
morning  and  evening  during  the  intervening  days,  of  inhalations  of  a 
mixture  of  ca  bolic  acid  two  grams  (gr.  xxx)  oil  of  Scotch  pine  four 
cubic  centimeters,  (fl.  3i)  and  camphorated  tincture  of  opium  sixty  cubic 
centimeters  (fl.  jii)  in  the  following  manner  to  keep  the  parts  in 
good  order:  Put  four  cubic  centimeters  of  the  mixture  into  half  a  pint  of 
hot  water  in  an  ordinary  inhaling  bottle,  and  instruct  the  patient  to  take 
in  a  full  inspiration  of  the  vapor  from  the  mouth-piece  and  force  it  back 
through  the  nostrils.  This  process  may  be  continued  from  three  to  five 
minutes  two  or  three  times  a  day.  If  proper  attention  is  given  to  such 
internal  treatment  as  the  general  health  and  special  constitutional  condi- 
tion of  the  patients  require,  on  the  principles  I  have  indicated,  with  the 
aid  of  the  local  applications  I  have  now  mentioned,  almost  all  the  cases  of 
chronic  nasal  and  naso-pharyngeal  inflammations  will  be  greatly  im- 
proved and  many  of  them  will  be  cured.  But  those  cases  which  have  be- 
come complicated  with  extensive  ulceration  of  the  membrane  and  either 
caries  or  necrosis  of  the  turbinated  or  other  bony  or  cartilaginous  struct- 
ures, will  make  no  marked  progress  toward  recovery  until  the  diseased 
portions  of  bone  are  removed  either  spontaneously,  by  exfoliation,  or  by 
surgical  interference.  When  foul  and  ill-conditioned  ulcerated  places  are 
so  located  that  they  can  be  reached  with  the  aid  of  the  rhinoscope  and 
other  instruments,  much  improvement  may  be  produced  by  applying  to 
the  ulcerated  surface  daily  a  small  quantity  of  a  powder  composed  of 
finely  pulverized  white  sugar  two  parts  and  iodoform  one  part.  Having 
given  you  the  results  of  my  own  observations  and  clinical  experience  in 
the  management  of  the  various  grades  of  the  disease  under  consideration, 
I  will  detain  you  for  only  one  further  remark,  namely,  that  a  very  large 
proportion  of  patients  sufi'ering  from  chronic  naso-pharyngeal  inflamma- 
tion can  be  ^:)erma7?e?i;;^y  relieved  only  by  changing  their  residence  from  a 
cold,  variable  climate,  to  one  mild  and  dry;  and  at  the  same  time  abstain- 
ing altogether  from  the  use  of  alcoholic  drinks  and  tobacco. 


LECTURE   XL, 

>    Inflammations  of  the  Larynx  and    Trachea— Croup  :    Their  Varieties,  Causes,  Anatomical  Char- 
acteristics, Symptoms,  Diagnosis,  Prognosis  and  Treatment. 

GENTLEMEN:  Although  the  larynx  and  trachea  are  anatomically 
distinct  divisions  of  the  respiratory  passage,  and  the  mucous  mem- 
brane in  each  capable  of  being  ii  flamed  to  some  extent  without  extending 
into  the  other,  yet  in  all  the  more  serious  attacks  the  membrane  in  both  sec- 
tions is  involved,  constituting  a  true  laryngo-tracheitis.    Practically,  there* 


382  LAHYNGO-TRACHErTIS. 

fore,  they  constitute  but  one  section  in  their  relations  to  the  inflammatory 
affections,  and  I  shall  so  regard  them  during  the  remainder  of  the  present 
lecture. 

Varieties. — Laryngitis,  or  laryngo-tracheitis,  may  be  met  with  in  all  de- 
grees of  intensity,  from  simple  hyperfemia,  with  increased  irritalnlity  of  the 
texture,  to  the  most  intense  plastic  or  pseudo-membranous  inflammation. 
It  may  be  acute,  running  its  course  in  a  few  days,  or  it  may  be  so  chronic  as 
to  continue  as  many  months,  or  even  years.  Anatomically,  the  inflammatory 
process  may  be  limited  to  the  epithelial  or  free  surface  of  the  membrane, 
causing  hj^perjemia,  with  increased  mucous  exudation;  or  it  may  extend  to 
the  sub-mucous  tissue,  causing  inflammatory  exudations  beneath  the  lining- 
membrane  as  well  as  upon  its  surface  and  consequently  greater  tumefaction 
of  the  parts;  or  it  may  be  of  such  grade  as  to  cause  the  exudations  upon 
the  surface  to  be  highly  plastic,  and  to  undergo  rapid  organization  into  a 
layer  of  false  membrane  closely  adherent  to  the  inflamed  surface.  On  the 
other  hand,  cases  more  rarely  occur  involving  the  sub-mucous  tissue,  and 
causing  a  serous  exudation  by  which  the  parts  are  rendered  oedematous  and 
much  tumefied.  Hence,  for  convenience  of  description,  the  cases  liable  to 
be  seen  in  general  practice  maybe  arranged  into  four  groups,  namely,  the 
mucous  or  superficial  laryngitis;  the  sub-mucous;  the  pseudo-membranous; 
and  the  oedematous.  Either  of  these  varieties  may  be  acute,  subacute  or 
chronic,  in  their  grade  and  rate  of  ]Drogress. 

Causes. — The  causes  of  the  different  varieties  of  laryngitis  are  the  same 
as  I  mentioned,  more  in  detail,  when  discussing  the  etiology  of  inflamma- 
tions of  the  mucous  membrane  of  the  respiratory  passages  generalh^,  in 
the  preceding  lecture.  The  first  or  superficial  variety  is  of  frequent  oc- 
currence at  all  periods  of  life;  and  may  be  produced  by  exposures  to  cold 
and  damp  air  especially  when  accompanied  by  high  winds;  by  excessive 
use  of  the  voice;  and  as  a  result  of  eruptive  fevers  and  tuberculosis.  The 
sec;)nd  and  third  varieties  occur  much  more  frecjuently  in  childhood;  while 
the  fourth,  or  oedematous  larvngitis  is  mostly  limited  to  the  adult  period 
of  life. 

Pathological  Anatomy. — The  anatomical  changes  which  take  place 
during  the  progress  of  inflammation  in  the  membrane  lining  the  larynx 
and  trachea  do  not  difi'er  essentially  from  those  which  characterize  the 
same  grade  of  inflammatory  action  in  other  parts  of  the  respiratory  mu- 
cous membrane.  In  the  simple  superficial  inflammation  there  is  intense 
redness  from  congestion  of  blood  in  the  vessels  and  slight  tumefaction, 
with  temporary  dryness,  followed  speedily,  however,  by  an  increased  secre- 
tion of  mucus,  at  first  transparent  and  tenacious,  but  subsequently 
changing  to  a  white,  opaque,  or  slightly  yellowish  appearance,  and  con- 
taining more  or  less  epithelium  and  pus  corpuscles.  If  the  inflammation 
is  more  severe,  extending  to  the  sub-mucous  tissue,  there  is  added  to 
these  superficial  changes,  more  or  less  exudation  of  serum  with  white  and 
red  blood  corpuscles,  into  the  texture  of  the  membrane  and  into  the  con- 
nective tissue  beneath  it,  adding  much  to  the  tumefaction  of  the  parts. 
In  the  middle  and  later  stages  of  the  case  pus  cells  become  freely  min- 
gled with  the  other  exudative  materials,  and  in  some  instances  the  base- 
ment membrane  becomes  denuded  of  its  epithelium  in  patches,  giving  it  the 
appenrance  of  abrasions  or  slight  ulcerations.  In  the  third,  or  pseudo- 
membranous grade  of  the  inflammation  you  find  all  the  changes  I  have 
mentioned  as  belonging  to  the  simple  mucous  and  sub-mucous  varieties, 
with  the  important  addition  of  a  large  proportion  of  fibrin  and  lymphoid 
cells  in  the  exudative  materials. 

The  addition  of  these  plastic   elements  causes   the  exudative  materials 


SYMPTOMS.  383 

upon  the  surface  of  the  membrane  to  rapidly  solidify  or  organize  into  a 
firm,  white,  adherent  hiyer  of  false  membrane;  generally  thickest  and 
most  adherent  over  the  vocal  cords  and  the  rima  glottis,  but  often  extond- 
ino-  upward  over  the  lower  part  of  the  pharynx  and  downward  through 
the  whole  extent  of  the  larynx  and  trachea  to  the  larger  bronchi.  The 
rapid  exudation  upon  the  surface  of  the  membrane  in  this  class  of  cases 
detaches  much  of  the  epithelium,  and  henco  on  close  examination  you  find 
in  many  places  the  layer  of  false  membrane  resting  directly  on  the  sur- 
face of  the  basement  membrane,  but  not  permeating  it,  as  is  the  case  in 
the  membranous  formations  of  true  diphtheria.  More  or  less  of  epithelial 
and  pus  cells,  and  red  blood  corpuscles  may  be  seen  in  the  meshes  of  the 
fibrillated  fibrin  constituting  the  basis  of  the  false  membrane.  As  the 
disease  advances  beyond  the  first  stage,  the  proportion  of  pus  cells  and 
necrosed  epithelium  cells  increase,  with  an  increased  exudation  of  mucus, 
lessening  the  tenacity  of  the  plastic  or  organized  false  membrane  and 
causing  it  to  be  detached  in  shreds  or  patches,  and  sometimes  in  whole 
tubes  of  considerable  length.  At  first,  new  layers  of  false  membrane  form 
on  those  surfaces  from  which  the  first  layer  had  been  detached,  but  in 
acute  cases  this  tendency  ceases  after  the  fourth  or  fifth  day,  and  the  in- 
flammatory process  rapidly  declines.  In  the  fourth  gi'oup  of  cases,  called 
oedematous  laryngitis,  a  large  part  of  the  exudation  is  into  and  beneath 
the  membrane,  and  is  composed  of  serum  or  the  watery  element  of  the 
blood.  Consequently  it  is  a  true  cedema  of  the  parts,  especially  over  the 
vocal  cords  and  at  the  base  of  the  epiglottis.  Occasionally  colonies  of 
bacteria  have  been  found  in  the  meshes  of  the  pseudo-membranous  forma- 
tion, but  with  no  uniformity,  and  no  evidence  that  they  exert  a.ny  causa- 
tive influence. 

Symjytoms. — The  circumstances  connected  with  the  natural  structure  of 
the  larynx,  exert  much  influence  over  the  character  of  the  symptoms  which 
accompanv  inflammation  of  its  lining  membrane,  as  well  as  over  the  results 
of  such  inflammation.  These  are,  the  narrowiiess  of  the  rima  glottidis,  or 
opening  into  the  larynx;  the  firm,  unyielding  condition  of  its  walls;  and  the 
special  sensitiveness  of  the  nerves  of  the  part.  The  narrowness  of  the  en- 
trance I'rom  above  into  the  larynx  is  such,  that  a  very  moderate  swelling  of 
the  lining  membrane  is  ciipable  of  creating  marked  dyspnoea  or  obstruction 
to  the  breathing,  while  the  firmness  of  the  laryngeal  wads  prevents  disten- 
sion, and  thereby  causes  the  whole  of  the  congestion  and  tumefaction  to 
crowd  inward,  still  further  diminishing  the  space  for  the  ingress  and  egress 
of  air  in  breathing.  The  sensitiveness  of  the  nerves  and  their  relation  to 
the  muscles  of  the  larynx,  and,  in  some  degree,  to  the  muscles  of  respiration 
generally,  cause  the  presence  of  inflammatory  action  to  readily  excite  severe 
spasmodic  contractions  in  the  muscles  and  to  impart  to  the  cough  a  spas- 
modic and  paroxysmal  quality,  both  distressing  and,  in  some  cases,  danger- 
ous to  the  patient.  The  milder  cases  of  superficial  inflammation  of  the  lar- 
ynx in  the  adult  are  characterized  at  first  by  a  sense  of  fullness,  soreness 
and  heat  in  the  larynx;  hoarseness  or  roughness  of  voice;  a  dry  and  rough 
or  ringing   cough;  and  slight  sense  of  difficulty  in  breathing. 

The  general  febrile  symptoms  in  such  cases  are  very  slight,  and  in  some, 
absent  altogether.  In  the  same  class  of  cases  in  children  under  five  years 
of  age,  there  is  more  uniformly  sufficient  fever  to  cause  a  little  accel- 
eration of  pulse,  a  rise  of  one  or  two  degrees  of  temperature,  and  the  ad- 
dition of  more  distinct  paroxysms  of  dyspnoea  from  constriction  of  the  lar- 
ynx, with  a  more  spasmodic  quality  of  cough.  After  the  first  twenty-four 
hours,  the  increased  secretion  or  exudation  of  mucus  upon  the  surface  of  the 
inflamed  membrane  renders  the  cough  less  dry  and  ringing,  and  causes  some 


384  LARYNGO-TKACHEITIS. 

coarse  moist  rales  as  the  air  passes  through  the  larynx.  In  most  cases  during 
the  third  day,  whatever  of  general  febrile  symptoms  hadex.sted,  disappear; 
the  cough  is  less  spasmodic  ar^d  accompanied  by  more  free  mucous  expecto- 
ration; and  the  paroxysms  of  dyspnoea  less  frequent.  During  the  next  two 
or  three  days  the  hoarseness  and  all  other  symptoms  of  disease  disappear; 
making  the  whole  duration  of  the  laryngeal  symptoms  from  five  to  seven 
days.  In  the  second  or  sub-mucous  grade  of  inflammation,  the  svmptoms 
are  the  same  in  kind  but  much  more  severe.  There  is  usually  some  chilli- 
ness at  the  beginning,  followed  by  more  decided  fever;  more  frequency  and 
fullness  of  pulse;  more  sense  of  constriction  in  the  larynx;  more  frequent 
and  severe  paroxysms  of  dyspnoea  with  dry  whistling  sounds  in  the  larynx 
at  first,  subsequently  replaced  by  coarse  mucous  rattles;  a  more  severe  spas- 
modic or  suffocating  cough  with  increased  hoarseness  and,  in  some  cases,  en- 
tire suppression  of  voice.  In  the  more  severe  examples  of  this  class  during 
the  second  and  third  days,  the  opening  of  the  larvnx  becomes  so  narrowed 
by  the  exudation  into  and  beneath  the  membrane,  and  the  constant  accumu- 
lation of  mucus  upon  its  surface,  that  the  difficulty  of  breathing  is  con- 
stant and  noisy,  with  paroxysms  of  coughing  that  seem  to  threaten  the  act- 
ual suffocation  of  the  patient.  The  mucus  is  tenacious  and  difficult  to  dis- 
lodge, esp'?cially  in  young  children,  and  yet  accumulates  so  rapidly  as  to 
compel  frequent  and  tiresome  efforts  at  coughing,  during  some  of  which 
the  stomach  turns  and  brings  an  effort  to  vomit,  by  which  considerable  quan- 
tities of  mucus  are  expelled  from  the  larynx  and  throat,  wnth  much  temporary 
relief  to  the  little  sufferer.  But  the  constant  obstruction  to  the  ingress  and 
egress  of  air,  coupled  with  the  frequent  struggles  in  the  paroxysms  of  cough- 
ing, soon  begin  seriously  to  impair  the  oxygenation  and  decarbonization 
of  the  blood  and  to  exhaust  the  strength  of  the  patient.  The  flush  of  the 
face  gives  place  to  a  bloated  and  pale  appearance  with  a  leaden  or  purplish 
hue  of  the  prolabia;  the  extremities  become  cool  and  bluish;  pulse,  frequent 
and  small;  the  mind  dull,  with  inclination  to  lie  with  the  head  thrown  a  lit- 
tle back  to  straighten  the  larynx;  the  eyelids  only  partly  closed,  and  the 
larynx  moving  up  and  down  with  every  inspiration  and  expiration,  accom- 
panied by  laryngo-tracheal  rales  loud  enough  to  be  heard  over  the  whole 
room.  Tliis,  to  the  patient,  half  unconscious  quiet,  is  disturbed  every  five 
to  fifteen  minutes  by  sudden  and  severe  paroxysms  of  coughing,  and  strug- 
gling to  clear  away  the  laryngeal   obstruction. 

In  the  worst  cases  of  this  class,  at  this  stage  of  their  progress,  the  strength 
of  the  patient  fails  rapidly;  the  extremities  become  cold;  pulse  a  mere 
thread;  discharges  of  urine  and  i'?eces  involuntary;  the  face  more  pale,  eye- 
balls turned  upward,  with  the  lids  half-closed;  the  mind  too  dull  to  be 
aroused;  the  head  further  back;  the  larynx  still  more  strongly  moved  up 
and  down  with  the  efforts  to  force  air  through  it;  until,  at  length,  the  chin 
drops  and,  with  a  few  more  gasps  for  breath,  the  struggle  for  life  ceases. 
Such,  gentlemen,  is  an  outline  of  the  phenomena  accompanying  the  progress 
of  a  fatal  case  of  sub-mucous  laryngitis,  or  croup;  and  j^ou  will  only  need 
to  witness  it  once  to  have  its  vivid  and  distressing  features  indelibly  fixed 
in  your  minds.  When  death  occurs  in  this  class  of  cases,  it  is  usually  be- 
tween the  third  and  fifth  days  from  the  beginning  of  the  attack.  But  in 
most  of  this  class  of  cases,  the  tumefaction  of  the  membrane  and  the  ac- 
cumulated inflamatory  products  are  not  sufficient  to  fatally  interfere  with 
the  respiratory  function,  and  after  the  second  day,  the  sub-mucons  exuda- 
tion begins  to  diminish,  the  mucus  on  the  surface  becomes  more  abundant, 
less  tenacious  and  a  little  opaque;  the  paroxysms  of  coughing  are  less  suf- 
focating and  dislodge  the  mucus  more  readily,  and  the  general  febrile 
symptoms  also  begin   to  abate.       The  crisis  of   the  inflammatory  process 


SYMPTOMS.  385 

having  passed,  the  symptoms  continue  to  improve  from  day  to  day,  and 
leave  the  patient  convalescent  in  from  five  to  nine  days  from  tiie  com- 
mencement of  the  symptoms. 

In  the  pseudo-membranous  class  of  cases,  called  by  some  writers  true 
croup^  the  essential  symptoms  and  progress  correspond  closely  with  those 
of  the  most  severe  cases  belonging  to  the  sub  mucous  class  as  just  described. 
The  attacks  are  limited  mostly  to  children  under  ten  years  of  age.  They 
differ  from  the  severe  cases  just  fully  described  chiefly  in  three  particulars. 
(«)  The  stage  duriqg  which  the  laryngeal  sounds  remain  dry  and  whistling, 
is  more  marked  and  protracted,  with  apparently  greater  constriction  of  the 
tube,  (b)  The  voice  is  more  hoarse  or  more  completely  suppressed,  and 
the  paroxysms  of  coughing  are  characterized  at  first  by  greater  spasmodic 
violence  and  loud  stridulous  sounds,  and  subsequently  by  a  muiBing  or 
suppression  of  the  sounds,  corresponding  with  the  suppression  of  the  voice, 
(c)  There  appears  early  upon  the  surface  of  the  rima  glottidis,  epiglottis,  and 
sometimes  up  over  the  lower  part  of  the  pharynx  a  layer  of  white,  fibrin- 
ous and  plastic  exudation  which  constitutes  the  pseudo-membrane,  that  has 
given  the  name  of  pseudo-membranous  laryngitis  or  membranous  crouD  to 
this  variety  of  the  disease.  At  the  same  time  the  secretion  of  mucus  is 
much  more  scanty  than  in  the  other  varieties,  and  when  the  patient  begins 
to  dislodge  and  expectorate  some  in  his  paroxysms  of  coughing,  close  ex- 
amination will  generally  discover  in  it  small  shreds  of  the  solidified  or  fibril- 
lated  fibrin  torn  from  the  layer  of  adherent  pseudo-membrane.  If  the 
patient  does  not  suffer  so  rapid  an  accumulation  of  the  inflammatory  prod- 
ucts as  to  induce  death  by  suffocation  within  thirty-six  hours,  the  mucous 
secretion  increases,  adding  more  of  the  rattling  moist  sounds  to  the  breath- 
ing, and  in  the  severer  paroxysms  of  coughing  dislodging  larger  pieces  of 
the  false  membrane.  From  this  stage  of  progress,  in  the  milder  examples 
of  this  class,  the  mucous  secretion  continues  to  increase  and  becomes  more 
opaque;  the  false  membrane  gradually  loosens  and  is  dislodged  more  and 
more  freely  in  shreds  and  patches  by  the  violent  paroxysms  of  coughino-, 
aided  sometimes  by  vomiting;  and  in  some  rare  instances,  the  whole  mem- 
brane is  expelled  at  once,  presenting  when  distended  in  water  a  complete 
representation  of  the  interior  of  the  larynx.  With  the  breaking  up  and  ex- 
pulsion of  the  false  membrane,  all  the  essential  symptoms  improve  and  the 
patient  reaches  the  stage  of  convalescence  in  from  one  to  two  weeks.  In 
a  large  proportion  of  this  class  of  cases,  however,  the  plastic  exudations 
continue  to  accumulate,  the  laryngeal  obstruction  becomes  hourly  more  se- 
vere until  some  time  between  the  second  and  fifth  days  death  ensues,  pre- 
ceded and  accompanied  by  essentially  the  same  symptoms  I  have  already 
described. 

The  fourth  group  of  cases  which  includes  those  affected  with  true  oedema 
of  the  glottis,  occurs  almost  exclusively  in  adults,  in  connection  with  a  debil- 
itated, depraved  or  anaemic  condition  of  the  system  caused  by  some  prior  dis- 
ease. It  has  occurred  during  the  convalescing  stage  of  typhoid  and  typhus 
fevers.  Only  a  few  months  since  a  fatal  case  of  this  kind  occurred  in  the 
Mercy  Hospital,  in  an  adult  male,  who  had  begun  to  convalesce  from  a  se- 
vere attack  of  typhoid  fever  complicated  with  severe  broncho-pneumonia. 
The  attacks  generally  supervene  suddenly  and  the  serous  exudation  or  in- 
filtration accumulates  rapidly  in  the  areolar  or  connective  tissue  at  the  base 
of  the  epiglottis  and  above  the  vocal  cords,  quickly  suppressing  the  voice 
and  causing  such  a  degree  of  tumefaction  as  to  obstruct  the  free  ingress  but 
not  the  egress  of  air,  and  giving  rise  to  laryngeal  dyspnoea,  suffocating 
paroxysms  of  coughing,  imperfect  oxygenation  and  decarbonization  of  the 

25 


386  CHRONIC    LAEYNGITIS. 

blood,  and  in  most  cases  death  from  apnoea,  or  exclusion  of  air  from  the 
lungs,  in  from  twelve  to  thirty-six  hours.  A  few  of  the  less  severe  cases 
recover. 

Chronic  Laryngo- Tracheitis. — Chronic  inflammation  may  exist  in  any 
part  of  the  lining  membrane  of  the  larynx  and  trachea,  and  maybe  either 
the  sequel  of  an  acute  attack  or  may  have  originated  de  novo.  A  very  large 
proportion  of  the  cases  met  with  in  practice  are  the  result  of  tubercular  de- 
posits in  the  folliclesof  the  laryngeal  membrane,  and  are  uniformly  assoc'ated 
with  more  or  less  tubercular  disease  in  the  lungs.  I  have  met  with  no  ex- 
ceptions to  this  rule.  Another,  though  less  numerous  class  of  cases,  are  the 
result  of  constitutional  syphilis.  Chronic  laryngitis  not  dependent  on  either 
tuberculosis  or  syphilis  is  rarely  met  with  in  ordinary  practice. 

Biimptoms. — The  two  most  prominent  and  characteristic  symptoms  are 
alterations  of  the  voice  and  cough.  The  first  may  be  simply  hoarse,  rough 
or  squeaking,  presenting  different  degrees  of  dysphonia,  or  it  may  be  sup- 
pressed, aphonia.  The  latter,  which  is  always  present  in  some  degree  but 
varying  much  in  frequency  and  severity,  presents  the  same  characteristics 
as  the  voice,  being  in  some  cases  simply  harsh  or  rough,  in  others  ringing 
or  stridulous,  and  in  still  other  cases  so  muffled  as  to  be  without  vibratory 
sounds.  In  cases  not  complicated  by  either  tuberculosis  or  syphilis,  there 
is  usually  only  a  moderate  sense  of  uneasinessor  slight  soreness  in  the  lar- 
vnx,  but  rather  a  tickling  or  sense  of  something  present  that  ought  to  be 
cleared  away,  prompting  the  patient  to  cough  or  hawk,  as  if  to  clear  the 
throat;  yet  in  such  cases,  there  is  only  a  scanty  secretion  of  mucus,  which 
presents  a  white  and  rather  frothy  appearance  when  expectorated.  On 
the  other  hand,  when  the  case  is  complicated  with  tubercu'ar  deposits,  the 
cough  generally  becomes  much  more  troublesome  and  severe,  harassing 
the  patient  much,  especially  during  the  last  part  of  the  night  and  early  in 
the  morning,  accompanied  in  the  early  stage  by  the  expectoration  of  a  vis- 
cid water-colored  mucus,  which  gradually  becomes  opaque,  and  finally 
,  purulent. 

There  is  in  these  cases  also  much  greater  sense  of  soreness  and  constric- 
'tion,  with  frequent  pains  in  the  larynx  and  trachea;  and  in  the  later  stages 
of  their  progress,  some  general  fever  every  afternoon  and  evening,  disappear- 
ing with  some  sweating  in  the  last  part  of  the  night,  leaving  the  patient 
■cool,  pale,  and  weak  in  the  morning,  when  the  paroxysms  of  coughing  are 
most  severe  and  strangulating,  and  often  accompanied  by  efforts  to  vomit. 
There  is  also  a  pretty  constant  loss  of  flesh  and  strength  until  the  patient 
presents  all  the  symptoms  of  the  advanced  stage  of  pulmonary  phthisis, 
including  copious  purulent  expectoration,  hectic  fever,  night  sweats  and 
the  physical  signs  of  suppurative  cavities  in  the  upper  part  of  one  or  both 
lungs.  And  yet,  owing  to  the  constant  annoying  sensations,  such  as  tick- 
ling, soreness  and  sense  of  constriction  in  the  larynx,  which  appear  to  be 
the  immediate  cause  of  the  cough,  the  patient  will  persist  in  attributing 
all  his  sickness  to  the  affection  of  the  larynx,  and  often  firmly  deny  that 
there  is  anything  the  matter  with  his  lungs  or  parts  within  the  chest.  And 
[  have  met  with  some  cases  in  which  the  attending  physician  had  allowed 
himself  to  be  so  far  misled  by  the  positive  assertions  of  the  patient  as  to 
Dverlook  the  coincident  pulmonary  lesions  entirely,  until  within  a  few  weeks 
Df  the  fatal  termination.  Let  me  caution  you,  gentlemen,  against  the  com- 
mittal of  any  such  blunders.  In  every  case  of  chronic  laryngitis  it  will 
be  your  duty  to  examine  the  chest  carefully  and  repeatedly  for  the  physical 
signs  of  pulmonary  tuberculosis,  without  regard  to  the  sensations  or  opin- 
ions of  the  patient.  When  chronic  laryngitis  arises  from  syphilitic  influ- 
ence, the  local  symptoms  differ  from  those    of  the  tuberculous    var.ety, 


PATHOLOGICAL    ANATOMY.  387 

chiefly  in  the  f^reater  degree  of  pain  and  soreness,  more  distinct  tenderness 
to  pressure  and  sometimes  slight  swelling  over  some  of  the  cartilages,  and 
more  rapid  ulceration  particularly  of  the  epiglottis  and  parts  above  the  vo- 
cal cords.  When  the  epiglottis  and  lower  posterior  part  of  the  rima  glot- 
tidis  is  the  seat  of  ulceration,  whether  connected  with  syphilis  or  tubercu- 
losis, the  swallowing  of  food  becomes  acutely  painful;  and  when  the  epi- 
glottis is  largely  destroyed,  as  happens  in  some  cases,  the  taking  of  food 
is  not  only  painful,  but  it  so  frequently  enters  the  larynx,  causing  the  most 
violent  coughing  and  choking,  that  the  patient  can  not  be  persuaded  to  take 
sufficient  to  prevent  ultimate  starvation. 

.Pathological  Anatomy. — In  simple  uncomplicated  chronic  inflammation 
of  the  larynx  and  trachea,  instead  of  intense  redness  as  in  the  acute  grade 
of  the  disease,  the  mucous  membrane  has  a  grayish  color,  and  more  or 
less  of  a  granular  appearance  from  hypertrophy  of  the  mucous  follicles, 
and  is  partially  covered  with  a  layer  of  mucus  or  muco-purulent  matter. 
The  epithelium  covering  the  vocal  cords  is  generally  thickened  and  more 
opaque;  and  in  most  of  the  cases  the  whole  inflamed  part  of  the  mem- 
brane is  thicker  and  harder  than  natural  from  hyperplasia  or  increased 
growth  of  the  connective  tissue  elements.  Ulcerations  are  rarely  seen  in 
this  class  of  cases;  but  in  a  few  instances  some  of  the  mucous  glands 
have  become  so  much  enlarged  as  to  project  like  papillomatous  growths 
from  the  surface  of  the  membrane.  A  few  cases  have  been  reported  in 
which  the  laryngeal  membrane  was  atrophied  or  thinner  than  natural.  In 
cases  arising  from  primary  tubercular  deposits,  ulcerations  constitute  a 
prominent  part  of  the  pathological  changes,  in  addition  to  those  I  have 
mentioned.  They  are  more  frequently  located  at  or  near  the  posterior 
commissure  of  the  vocal  cords,  but  may  be  seen  in  different  cases  in  all 
parts  of  the  membrane. 

You  may  find  in  one  case  but  a  single  ulcer,  and  in  another  several, 
varying  much  in  their  size  and  progress.  In  the  syphilitic  cases,  ulcera- 
tion commences  early  and  in  most  cases  extends  from  the  pharynx  to  the 
epiglottis  first,  and  then  downward  into  the  glottis  and  over  the  vocal 
cords.  In  some  rare  instances  the  inflammation  and  suppuration  extend 
to  one  or  more  of  the  cartilages,  forming  abscesses  that  may  break,  either 
into  the  larynx  adding  to  the  necessity  for  frequent  coughing,  and  expec- 
toration of  pus  generally  more  or  less  offensive  to  the  smell;  or  externally 
through  the  integuments,  where  it  will  result  in  a  protracted  fistulous  dis- 
charge, or  extend  into  an  open  indolent  ulcer;  and  in  some  instances  in- 
volving necrosis  of  the  cartilage  itself. 

Diacpiosis. — The  diagnosis  of  all  grades  of  inflammation  affecting  the 
mucous  membrane  of  the  larynx,  is  not  difficult.  The  interference  with 
the  function  of  the  vocal  cords  and  the  access  of  air  to  the  lungs,  necessi- 
tates such  changes  in  the  voice,  the  cough,  the  mucous  secretion,  and  the 
passage  of  air,  as  point  directly  to  the  seat  of  disease.  And  it  only  re- 
quires a  reasonable  degree  of  attention  on  the  part  of  the  practitioner  to 
distinguish  between  the  persistent  and  progressive  symptoms  of  inflam- 
mation, and  the  more  transient  and  changeable  phenomena  of  mere  nerv- 
ous and  functional  disturV)ances.  And  in  cases  involving  an};-  doubts  a 
careful  examination  with  the  laryngoscope  should  dispel  them. 

Proc/nosis. — On  account  of  the  narrowness  of  the  opening  into  the  larynx 
and  the  small  amount  of  swelling  in  the  parts  required  to  close  or  so  ob- 
struct it  as  to  deprive  the  lungs  of  sufficient  air  for  the  purposes  of  life,  all 
of  the  more  severe  grades  of  inflammation  affecting  its  interior  membrane 
are  highly  dangerous  and  result  in  a  large  ratio  of  mortality.  The  simple 
mucous  or  superficial  grade  of  laryngitis  seldom   terminates  fatally,  either 


388  LARYXGO-TEACHEITIS. 

in  cbildhoofl  or  adult  life.  The  sub-mueous  variety  is  necessarily  accom- 
panied by  greater  tumefaction,  and  consequently  more  danger,  especially 
in  young  children  ;  yet  a  large  majority  of  this  class  recover. 

But  the  pseudo-membranous  cases,  which  occur  chiefly  in  childhood, 
result  in  a  much  higher  ratio  of  mortality;  and  the  same  is  true  of  the 
oedematous  form  of  the  disease  as  it  occurs  in  adults.  It  is  probable  that 
consideral)ly  more  than  one  half  of  all  the  cases  of  either  of  these  varie- 
ties terminate  fatally.  The  simple  non-specific  form  of  chronic  laryngitis 
seldom  causes  sufficient  swelling  of  the  inflamed  structures  to  obstruct  the 
ingress  or  egress  of  air  in  such  degree  as  to  endanger  the  life  of  the  pa- 
tient; although  it  may  give  him  great  annoyance  for  an  indefinite  number 
of  years.  Chronic  cases,  dependent  on  constitutional  syphilis,  are  gener- 
ally curable  by  appropriate  treatment,  unless  the  cartiiages  have  become 
necrosed  with  extensive  suppuration;  or  so  large  a  part  of  the  epiglottis, 
rima  glottidis,  and  vocal  cords  have  been  destroyed  by  ulceration  as  to 
prevent  the  patient  from  taking  sufficient  food.  The  scrofulous  and  tu- 
berculous cases  of  chronic  laryngitis  very  seldom  recover,  but  the  ulti- 
mately fatal  termination  is  induced  more  by  the  progress  of  the  disease  in 
the  lungs,  than  in  that  affecting  the  larynx  or  trachea. 

Treatment. — The  treatment  of  all  forms  of  acute  and  sub-acute  laryn- 
gitis embrace  the  accomplishment  of  three  objects,  namely,  to  lessen  the 
morbid  sensitiveness  or  irritability  of  the  inflamed  structures;  to  lessen 
the  vascular  fullness  or  congestion  in  the  early  stages  and  thereby  limit  the 
amount  of  either  sub-mucous  or  plastic  exudation;  and  in  the  later  stage 
to  hasten  the  disintegration  and  removal  of  such  exudation  as  may  have 
occurred. 

In  the  mild  or  superficial  form  of  the  disease,  neither  of  the  pathological 
conditions  on  which  these  indications  are  founded,  are  sufficiently  devel- 
oped to  endanger  the  life  of  the  patient  or  to  require  very  active  remedial 
measures  for  relief.  Confinement  to  the  house,  or  protection  from  further 
exposures  to  cold  or  severe  currents  of  air,  the  inhalation  of  some  mild 
anodyne  vapor,  or  the  taking  of  a  mild  anodyne  expectorant,  is  usually 
sufficient  to  cause  the  disappearance  of  the  symptoms  in  a  few  days.  The 
following  is  a  prescription  I  have  long  used  in  this  class  of  cases  with 
benefit: 

5.      Syrupi  ScillfB  Compositi 
Syrupi  Ipecacuanhae 
Tincturee  Opii  Camphoratse 

Mix.  To  an  adult,  I  give  four  cubic  centimeters  (fl.  31)  in  a  little 
water  every  three,  four,  or  six  hours.  -To  children  less  in  proportion  to 
their  age.  If  the  skin  is  quite  hot  and  dry  and  the  urine  scanty  I  give  from 
six  to  twenty  centigrams  (gr.  i  to  iii)  of  calomel,  and  follow  it  with  a 
saline  laxative  sufficient  to  procure  two  or  three  intestinal  evacuations. 

These  measures,  with  a  continuance  of  moderate  doses  of  the  anodyne 
ex])ectorant  mixture  for  three  or  four  days,  usually  constitute  all  the  treat- 
ment needed  in  such  cases.  In  the  second  group  of  cases,  in  which  the 
inflammation  involves  the  membrane  more  deeply,  and  if  not  checked  in 
its  incipiency,  causes  the  accumulation  of  exudative  material  both  in  the 
texture  of  the  membrane  and  in  the  sub-mucous  areolar  structure,  the 
tumefaction  or  swelling  is  sufficient  to  cause  more  or  less  danger  from  its 
obstruction  to  the  ingress  and  egress  of  air.  Consequ.ently  this  class  of 
cases  need  prompt  and  efficient  treatment.  As  this  form  of  the  disease  is 
met  with  most  frequently  in  children,  if  I  am  called  early  to  a  child  be- 
tween   three  and  five  years  of  age,  presenting  the  symptoms  1  have  men- 


45.0  0.  c. 

fiss 

15.0     " 

3SS 

60.0     " 

3ii 

TREATMENT.  389 

tioned  as  cnaracterizing  well'  marked  cases  of  sub-mucous  laryngitis,  I 
order  a  powder  containing  fifteen  to  twenty  centigrams  (gr.  iiss  to  iii)  of 
the  sub-sulphate  of  mercury  (turpeth  mineral)  to  be  given  at  once,  which 
seldom  fails  to  produce  free  vomiting  in  from  fifteen  to  forty-five  minutes. 
If  it  fails  to  do  this  1  have  the  dose  repeated  at  the  end  of  forty-five  minutes. 
Directly  after  the  vomiting  I  commence  giving  the  saoie  anodyne  expec- 
torant mixture,  the  formula  for  which  I  gave  you  only  a  few  minutes  since, 
in  doses  of  from  one  to  two  cubic  centimeters  (min.  xv  to  xxx)  every  two 
or  three  hours.  If  the  bowels  are  not  already  loose,  I  give,  also,  thirteen 
centigrams  each  of  calomel  and  bicarbonate  of  sodium,  in  one  dose,  which 
usually  induces  a  moderately  free  evacuation  fro'ai  the  bowels  in  three  or 
four  hours. 

These  measures  are  usually  followed  by  much  relief  to  the  breathing; 
more  free  secretion  from  the  mucous  membrane  of  the  air  passage;  and 
less  fever.  If  such  relief  continues  for  twenty-four  or  thirty-six  hours, 
the  crisis  of  the  disease  will  have  passed,  and  the  case  will  require  only 
the  moderate  continuance  of  the  anodyne  expectorant  mixture  for  two  or 
three  days  or  until  convalescence  is  fully  established.  But  in  many  cases 
the  relief  following  the  first  vomiting  proves  only  temporary,  and  in  from 
three  to  six  hours  the  paroxysms  of  dyspnoea  and  coughirig  again  become 
severe.  When  this  is  the  case  I  promptly  repeat  the  emetic  dose  of  the 
sub  sulphate  of  mercury,  after  the  action  of  which  the  same  internal  rem- 
edies are  continued  as  before,  while  externally  I  keep  the  front  part  of  the 
neck  covered  with  cloths  wet  in  an  infusion  of  hops  or  aconite  leaves  hold- 
ing in  solution  muriate  of  ammonia.  In  the  more  sanguine  and  robust 
class  of  children,  I  have  applied  leeches  in  sufficient  number  to  cause  a 
pretty  free  local  bleeding,  in  the  early  stage  of  the  disease,  with  the  most 
decided  benefit.  You  may  occasionally  meet  with  a  case  in  which  after 
the  acute  stage  has  passed  by,  there  remains  a  harsh  croupy  cough,  with 
suflficient  tightness  in  the  larj'nx  to  indicate  that  the  tumefaction  of  the 
mucous  membrane  is  subsiding  very  slowly.  If  you  do,  the  substitution 
of  the  same  quantity  of  the  tincture  of  sanguinaria  in  place  of  the  syrup 
of  ipecacuanha  in  the  formula  I  have  given  you,  and  the  addition  to  the 
same  of  ten  grams  (3iiss)  of  the  iodide  of  potassium,  will  add  much  to  its 
alterative  properties  and  render  it  more  efficient  in  promoting  the  removal 
of  the  remaining  infldmmatory  products.  In  locations  where  malarious  or 
periodical  fevers  prevail,  sulphate  of  quinia,  in  doses  of  thirteen  centi- 
grams (gr.  ii)  may  be  given  between  the  doses  of  the  expectorant  mixture, 
to  a  child  five  years  of  age,  with  much  benefit. 

In  the  pseudo-membranous  variety  of  laryngitis,  the  treatment  must  be 
guided  by  the  same  principles  as  in  the  sub-mucous  variety',  but  pursued 
more  energetically,  especially  iu  the  early  stage.  A  prompt  local  bleeding 
by  leeches,  and  free  vomiting  by  the  sub-sulphate  of  mercury  should  com- 
mence the  treatment,  and  be  followed  by  a  cathartic  dose  of  calomel  and 
bicarbonate  of  sodium.  Then  the  anodyne  expectorant  mixture  already 
mentioned  should  be  given  alternately  with  alterative  doses  of  the  calomel 
and  nitrate  of  potassium,  from  one  to  two  hours  apart.  The  emetic  should 
be  repeated  in  from  three  to  six  hours  according;  to  tiie  degree  of  dyspnoea 
and  whistling  sounds  in  the  larj-nx.  If  possible,  the  spray  of  dilute  lactic 
acid,  one  cubic  centimeter  (min.  xv)  to  forty-five  cubic  centimeters 
(fl.  Iiss)  of  water,  should  be  thrown  into  the  pharynx  freely  every  hour.  If, 
under  the  combined  influence  of  these  remedies,  the  progress  ol  the  disease 
appears  checked,  as  indicated  by  less  dyspnoea,  more  free  expectoration  of 
opaque  mucous  with  numerous  shreds  of  the  pseudo-membrane,  less 
spasmodic  violence  iu  the  paroxysms  of  coughing,  and  less  general  fever, 


390  LAEYNGO-TRACHEITIS. 

the  further  use  of  emetics  ma\  be  dispensed  with,  and  the  other  remedies 
g-iven  at  longer  intervals.  If  the  improvement  continues  after  the  first 
thirty-six  or  forty-eight  hours,  the  calomel  and  nitrate  of  potassium  mav 
be  discontinued,  and  moderate  doses  of  sulphate  of  quinia  given  in  their 
place.  If  instead  of  improvement,  h(  vrever,  you  find  your  patient  on  the 
second  or  third  day  showing  signs  of  exhaustion,  such  as  paleness  of  the 
face  with  a  leaden  hue  of  the  prolahia;  cool  extremities,  feeble  pulse, 
more  constant  difficulty  of  breathing,  and  drowsiness  between  the  parox- 
vsms  of  coughing,  you  had  better  omit  both  the  anod3^ne  expectorant 
mixture  and  tlie  powders  of  nitrate  of  potassium  and  calomel,  and  give  in- 
stead, a  solution  of  lactate  of  iron  in  water  alternately  with  moderate 
doses  of  the  sulphate  of  quinia. 

To  a  child  five  years  of  age  you  can  give  from  three  to  si's  centigrams 
(o-r.  ss  to  i)  of  the  lactate  of  iron  in  solution  every  two  or  three  hours,  ' 
and  from  six  to  nine  centigrams  (gr.  i  to  iss)  of  quinine  between.  Once 
or  twice  in  the  twenty-four  hours,  if  the  larynx  becomes  very  much  ob- 
structed by  the  exudation,  a  quick  free  vomiting  may  be  induced  by  giving 
a  full  dose  of  powdered  alum  and  ipecac,  with  the  hope  that  much  of  the 
accumulation  has  become  loosened  and  may  be  expelled  during  the  effort 
of  vomiting.  It  is  true  that  most  of  the  patients  who  reach  the  condition 
I  have  described  will  die.  But  none  should  be  given  up  or  abandoned 
until  life  has  actualh'  ceased,  for  I  have  seen  several  recover  from  a  con- 
dition apparently  hopeless.  In  the  first  stage  of  these  severe  cases  but 
little  attention  need  be  paid  to  nourishment;  but  in  the  more  advanced 
stage  when  the  strength  begins  to  fail,  milk,  beef  tea,  etc.,  should  be 
given  as  regularly  as  the  doses  of  medicine.  In  cases  where  the  relief  is 
partial,  and  there  appears  to  be  a  tendency  to  run  a  protracted  course,  one  or 
more  small  blisters  in  the  vicinity  of  the  larynx  may  do  good.  Through- 
out the  whole  course  of  the  disease  the  temperature  of  the  air  in  the 
room  should  be  kept  uniform  as  possible  varying  from  20°  to  'Zl"^  C. 
(68°  to  70°  F.),  and  rather  moist.  Some  direct  the  air  of  the  room  to  be 
kept  at  a  much  higher  temperature  and  constantly  saturated  with  aqueous 
vapor.  But  my  own  observations  have  led  me  to  think  such  an  atmosphere 
strono-ly  calculat-'d  to  lessen  the  exhalations  from  the  lungs,  ar>d  to  in- 
crease the  danger  of  early  and  excessive  prostration.  A  large  number  of 
other  remedies,  besides  those  I  have  mentioned,  have  been  strongly  rec- 
ommended by  different  writers,  most  of  which  I  have  either  tried  or  had 
ample  opportunities  of  seeing  tried  by  others.  In  the  list  of  emetics  you 
may  find  lobelia  inflata,  tartar  emetic,  alum,  sulphate  of  zinc,  sulphate  of 
copper,  ipecacuanha,  and  apomorphia;  Avhile  as  local  remedies  you  will 
find  the  inhalation  of  the  vapor  of  water  containing  freshly  slacked  lime, 
the  spray  of  chlorate  of  potassium,  iodide  of  potassium,  nitrate  potassium 
and  benzoate  of  sodium,  with  and  without  the  addition  of  belladonna  or 
conium  to  the  solution;  and  the  direct  application  of  strong  solutions  of 
nitrate  of  silver,  iodine,  and  tincture  of  chloride  of  iron.  But  from 
none  of  them  have  T  seen  as  good  results  as  from  the  course  I  have  directly 
recommended  to  you.  As  the  great  points  to  be  gained  in  the  manage- 
ment of  the  pseudo-membranous  form  of  the  disease,  are  to  lessen  the 
amount  and  plasticity  of  the  exudative  material,  and  to  hasten  the  loosen- 
ino-  or  disintegration  of  such  plastic  material  as  does  accumulate  on  the 
surface  of  the  inflamed  membrane,  it  will  be  difficult  to  find  any  agents 
better  calculated  to  produce  these  effects  than  the  local  bleeding  aided  by 
the  relaxing  and  expulsive  effects  of  the  sub-sulphate  in  emetic  doses,  fol- 
lowed by  the  alterant  and  aplastic  influence  of  the  calomel  and  sodium  or 
potassium  salts,  with  such  adjuncts  as  I  have  already  named.     In  applying 


TKACHEOTOMY.  6\)1 

leeches  to  young  children  care  should  be  exercised  that  the  number  be  ad- 
justed to  the  age  and  condition  of  the  patient.  In  infants  of  one  year  or 
less  not  more  than  two  leeches  should  be  applied  at  once,  and  the  bleeding 
may  be  promoted  from  the  bites  by  applications  of  warm  wet  cloths,  or 
stopped  by  styptic  applications  according  as  the  effects  produced  may  in- 
dicate. At  the  time  I  commenced  the  practice  of  medicine  much  reliance 
was  placed  upon  the  emetic  and  sedative  effects  of  tartar  emetic  in  the 
treatment  of  all  grades  of  laryngitis  or  croup.  But  as  early  as  1840,  or 
near  that  time,  my  attention  was  directed  to  the  use  of  the  yellow  sub- 
sulphate  of  mercury  as  an  emetic  in  this  form  of  disease,  by  the  report  of 
several  cases  treated  successfully,  in  which  it  was  used  by  Dr.  Hubbard, 
of  New  Hampshire.  And  from  that  time  to  the  present  I  have  certainly 
obtained  better  results  from  its  use  as  an  emetic,  than  from  any  other  rem- 
edy given  for  the  same  purpose. 

Tracheotomy. —  When,  in  the  more  severe  class  of  cases  of  laryngitis, 
ordinary  methods  of  treatment  fail  to  make  any  favorable  impression  on 
the  progress  of  the  disease,  the  question  whether  the  operation  of  trache- 
otomy ought  to  be  resorted  to,  always  comes  up  for  consideration.  Most 
of  the  writers  on  practical  medicine  recommend  a  resort  to  it  in  such  cases 
as  persist  in  the  increase  of  dyspnoea  notwithstanding  the  use  of  the  most 
active  internal  and  local  remedies,  and  caution  the  practitioner  against 
delaying  its  employment  until  the  patient  is  too  much  exhausted.  This 
subject  was  very  fully  and  ably  considered  by  Dr.  H.  Z.  Gill  of  Jersey- 
ville,  Illinois,  in  two  reports  to  the  Illinois  State  Medical  Society,  the  first 
in  1879,  and  the  other  in  1880.*  His  tables  include  129  cases  in  which 
the  operation  was  performed,  resulting  in  93  deaths  and  36  recoveries.  A 
majority  of  the  patients  operated  on  were  laboring  under  well  marked 
diphtheria,  the  inflammation  having  invaded  the  larynx.  The  remainder 
of  the  cases  are  designated  in  the  tables  either  as  croup,  true  croup,  or 
pseu do- membranous  croup.  But  no  attempt  is  made  by  the  writer  to 
establish  a  clear  line  of  distinction  between  these  several  grades  of 
disease.  As  the  operation  was  performed  in  some  of  the  cases  at  an  early 
period,  while  the  patient's  strength  was  good,  it  is  impossible  to  know 
whether  they  would  not  have  lived  if  the  operation  had  not  been  performed. 
In  all  the  cases  of  true  pseudo-membranous  laryngitis  coming  under  my 
own  observation,  in  which  the  operation  was  performed  by  some  one  of 
our  best  surgeons,  death  has  been  the  result.  Not  directly  on  the  operat- 
ing table,  but  in  from  six  to  seventy-two  hours  after;  and  pretty  uniformly 
from  the  development  of  inflammation  and  exudation  in  the  trachea  and 
larger  bronchi. 

It  is  well  known  that  cases  occur  in  which  patients  recover  from  this 
variety  of  disease  after  their  condition  appears  to  be  hopeless.  Therefore,  the 
question  whether  the  operation  for  tracheotomy  shall  be  performed  in  any 
given  case  or  not,  will  always  be  an  embarrassing  one  for  the  practitioner 
to  decide.  I  know  of  no  better  rule  than  to  try  diligently  all  the 
measures  of  treatment  affording  any  prospect  of  relief  until  it  becomes 
apparent  that  there  is  very  little  chance  left  for  success,  yet  not  carry  the 
delay  to  the  extreme  of  csanoses  or  the  commencement  of  a  death  struggle, 
but  with  everything  in  readiness  beforehand,  let  the  oper  ition  be  resorted 
to,  just  as  these  extreme  conditions  are  approaching,  instead  of  waiting  for 
their  full  development. 

In  such  cases  as  I  have  described  under  the  head  of  oedematous  laryn- 
gitis, consisting  of  a  rapid  infiltration  of  serum   into  the  areolar  or   con- 

*  See  Transactions  of  the  Illinois  State  Medical  Society  for  1879  and  1880. 


392  LARYNGO -TRACHEITIS. 

nective  tissue  at  the  base  of  the  epiglottis  and  between  it  and  the  vocal 
cords,  in  patients  previously  debilitated  or  anasmic,  the  danger  of  com- 
pletely shutting  out  the  entrance  of  air  at  almost  any  inspiration  usually 
makes  the  delay  necessary  for  obtaining  the  effects  of  medical  treatment 
extremely  dangerous  to  the  patient,  and  justifies  an  almost  immediate  re- 
sort to  surgical  interference.  This  interference  may  be  by  direct  scarifica- 
tion of  the  oedematous  part,  as  recommended  and  practiced  by  Dr.  Gurdon 
Buck  of  New  York,  in  1847,*  and  by  M.  Lisfranc,  at  a  much  earlier 
period;  or  by  opening  of  the  larynx  or  trachea,  as  in  the  ordinary  opera- 
tions for  laryngotomy  and  tracheotomy.  By  passing  the  index  finger  ol 
the  left  hand  back  over  the  tongue  to  the  base  of  the  epiglottis,  the  oedem- 
atous parts  maybe  felt  as  rounded  prominences,  and  maybe  freely  incised 
or  scarified  by  passing  a  properly  guarded  bistoury  along  the  finger  to  the 
proper  place  and  makinr  two  or  three  incisions  into  the  most  prominent 
part  of  the  swollen  tissues. 

By  the  surgeon  possessing  the  extraordinary  skill  and  tact  of  the  late 
Dr.  Buck,  such  scarifications  may  be  readily  and  safely  made.  But  those 
of  less  experience  will  find  the  struggle  of  the  patient  for  breath,  so  in- 
creased by  the  presence  of  the  finger  which  is  to  guide  the  bistoury,  that 
it  becomes  extremely  difficult  to  execute  the  necessary  incisions  without 
danger  of  injury  to  other  parts.  Practically,  therefore,  it  is  better  and 
more  certain  to  give  relief  to  the  patient,  if  the  larynx  or  trachea  is  opened 
at  once  by  the  ordinary  method.  If  the  immediate  danger  of  suffocation 
is  obviated  by  the  operation,  the  subsequent  treatment  will  depend  mostly 
on  the  nature  of  the  patient's  previous  sickness  and  the  causes  that  may 
have  provoked  the  attack. 

The  treatment  of  chronic  laryngitis,  which  occurs  mostly  in  adult  life 
and  largely  in  connection  with  tubercular  phthisis  or  syphilis,  must  be 
guided  m  a  great  degree  by  the  nature  of  the  constitutional  affections 
with  which  it  may  be  associated.  If  it  is  associated  with  tuberculosis  the 
patient  will  need  the  same  conditions  of  climate,  hygienic  relations,  and 
general  remedies  for  correcting  the  defects  in  nutrition  as  in  any  other 
case  of  phthisis  ;  while  if  it  has  a  syphilitic  origin  the  use  of  mercurials 
and  iodides  with  proper  attention  to  diet  and  drinks  must  be  your  chief 
reliance.  Non-specific  catarrhal  cases  may  be  treated  on  the  same  princi- 
ples and  with  the  same  remedies  as  I  recommended  to  you  in  the  preceding 
lecture  on  corresponding  grades  of  inflammation  in  the  nasal  passages  and 
pharynx.  So  long  as  no  ulceration  exists  the  local  treatment  should  con- 
sist of  moderate  external  counter-irritation  by  stimulating  liniments  or 
croton  oil;  and  within  the  larynx,  inhalations  of  a  soothing  anodyne  and 
antiseptic  nature  will  produce  the  best  results.  The  frequent  attempts  to 
apply  strong  astringent  and  cauterizing  remedies  by  means  of  the  probang 
or  sponge  in  such  cases,  are  productive  of  more  harm  than  good. 

In  cases  presenting  well  marked  ulcerations  so  located  that  with  the  use 
of  the  laryngoscope  you  can  make  an  application  of  nitrate  of  silver,  sul- 
phate of  copper,  or  iodoform,  directly  to  the  ulcerated  surface,  it  will  in 
many  cases  afford  much  relief.  If  it  does,  the  application  may  be  repeated 
every  second  or  third  day.  But  if  after  two  or  three  applications  the  re- 
sult is  an  increase  rather  than  a  diminution  of  the  patient's  suffering,  they 
should  be  discontinued. 

In  the  tuberculous  cases  all  treatment  will  prove  only  palliative,  but  in 
those  of  syphilitic  origin,  even  when  the  ulcerations  are  extensive,  proper 
constitutional  treatment  aided  by  the   local   applications  to  which  I  have 

*See  Transactions  of  the  American  Medical  Association  Vol.  1,  Page  135 


BRONCHITIS.  39  > 

alluded,  will  result  in  recoveries.  In  some  of  these,  however,  the  cicatrices 
in  the  larynx  cause  so  much  contraction  as  to  permanently  destroy  the 
action  of  the  vocal  cords,  causing  incurable  aphonia,  and  in  some  a  degree 
of  dyspnoea.  Cases  have  also  occurred  in  which  the  epiglottis  was  so  far 
destroyed  by  the  ulceration  as  to  leave  the  glottis  imperfectly  guarded 
from  the  entrance  of  food  and  drink  durino;  deglutition. 


LECTURE    XLI. 


Bronchitis— Acute  and  Chronic ;  Catarrhal,  Mechanical,  Capillary,  Rheumatic,  and  Pseudo-mem- 
branous—Their  Etiology,  Clinical  History,  Pathological  Anatomy  and  Diagnosis. 

GENTLEMEN:  By  the  term  bronchitis,  I  mean  inflammation  of  some 
part  or  all  of  the  membrane  lining  the  bronchial  tubes,  from  the 
bifurcation  of  the  trachea  to  the  air-oells,  or  alveoli,  of  the  lungs.  When 
the  inflammation  is  produced  by  atmospheric  or  climatic  influences,  it  is 
generally  called  catarrhal;  when  from  the  contact  of  dust  or  any  irritating 
particles  in  the  air,  it  is  called  mechanical;  when  it  is  located  mostly  in 
the  fibrous  structures  of  the  air-tubes,  it  is  called  rheumatic;  if  accompanied 
l)y  plastic  exudation,  it  is  called  pseudo-membranous;  and  when  the  in- 
flammation occupies  principally  the  smaller  bronchial  tubes,  it  is  called 
capillary  bronchitis.  You  may  meet  with  these  several  varieties  of 
bronchitis  in  all  grades  of  activity,  from  the  most  acute  to  the  most 
chronic  grade  of  inflammatory  action. 

History. — Bronchitis  has  been  prevalent,  especially  in  cold  and  variable 
climates,  fiom  the  earliest  records  of  human  history;  though  not  differen- 
tiated from  inflammations  of  the  larynx  and  tracliea  on  the  one  side,  or 
from  those  of  the  lungs  and  pleura  on  the  other,  until  after  the  commence- 
ment of  the  nineteenth  century.  Although  pretty  accurate  descriptions 
of  bronchitis  as  a  separate  disease  were  given  at  an  earlier  period  by 
Drs.  Badham,  Frank  and  Broussais,  yet  full  and  accurate  descriptions  of 
the  disease,  differentiating  it  from  inflammation  of  other  parts  of  the 
respiratory  organs  were  not  given  until  the  discovery  of  auscultation  by 
Ltennec,  and  its  practical  application  to  the  physical  examination  of  the 
3hest.  This  important  addition  to  the  previous  means  for  studying  the 
exact  location  and  extent  of  all  diseases  within  the  chest,  and  the  largely 
increased  attention  given,  about  the  same  time,  to  the  study  of  morbid 
anatomy,  soon  led  to  as  accurate  an  appreciation  of  the  existence  and  ex- 
cent  of  disease  in  any  part  of  the  organs  of  respiration  and  circulation  as 
.n  any  of  the  structures  of  the  human  body. 

Etiologij. — The  causes  of  bronchitis,  like  those  of  all  other  acute 
diseases,  may  be  divided  into  two  classes,  namely,  predisposing  and  ex- 
citing. Among  the  most  common  predisposing  causes  may  be  mentioned 
ige,  sex,  occupation  or  modes  of  life,  and  climatic  influences.  As  a  gen- 
eral rule,  the  several  grades  of  bronchitis  are  more  prevalent  during  child- 
hood and  old  age  than  during  the  active  period  of  adult  life.  The  British 
Ri'gistrar-General's  report  for  1868  contained  33,258  deaths  attributed  to 
bronchitis,  being   1,34:4   for  every  million   of  inhabitants.     Of  the   whole 


394  BRONCHITIS. 

number  10,550  died  during  the  first  thr'ie  years  of  life,  and  18,485  ovei 
forty-five  years  of  age,  leaving  only  4,223  to  occur  between  the  ages  of 
three  and  forty-five  years.  This,  however,  is  very  far  from  indicating  cor- 
rectly the  relative  prevalence  of  the  disease  at  the  different  periods  of 
life,  for  the  reason  that  the  disease  is  far  more  fatal  both  in  early  child- 
hood and  in  old  age  than  in  the  early  and  middle  periods  of  adult  life."* 
During  the  months  of  February,  March  and  April,  1882,  in  San  Fran- 
cisco there  were  65  deaths  reported  from  bronchitis,  of  which  37  were  of 
children  under  five  years  of  age,  25  of  adults  over  forty  years,  and  only  3 
of  persons  between  five  and  forty  years.  During  the  same  months  there 
were  reported  154  deaths  from  bronchitis  in  the  city  of  Chicago,  with 
about  the  same  ratio  in  regard  to  age.  In  the  city  of  Philadelphia  during 
the  seven  yeais  from  1862  to  1869,  the  deaths  from  bronchitis  at  all  periods 
of  life  aggregated  969,  of  which  495  were  of  children  under  five  years  of 
age;  14  over  five  and  under  fifteen  years,  and  460  of  persons  over  fifteen 
years  of  age.f 

These  and  similar  mortuary  statistics  have  led  to  the  very  general 
adoption  of  the  opinion  that  early  childhood  and  old  age  are  pre-eminently 
susceptible  to  attacks  of  bronchitis.  Yet  my  own  clinical  observations 
and  records  relating  to  the  time  and  number  of  acute  and  subacute  cases 
of  bronchitis  coming  under  my  own  care  lead  to  a  very  different  con- 
clusion. By  reference  to  those  records  I  find  a  larger  number  of  cases 
occurring  between  the  ages  of  ten  and  thirty  years  than  at  any  other 
period  of  life.  Thus,  during  the  first  six  months  of  the  present  year 
(1882)  I  recorded  59  cases  of  primary  bronchitis,  that  is,  cases  not  arising 
secondarily  as  complications  of  other  diseases.  Of  this  number  only  5 
were  children  under  ten  years  of  age;  38  between  ten  and  fortv  years, 
and  16  over  forty.  It  is  probable  that  similar  results  will  be  obtained  by 
all  who  will  take  the  trouble  to  record  the  whole  number  of  cases,  instead 
of  simply  the  numbsr  of  deaths.  The  statistics  of  mortality  in  relation 
to  this  disease  are  deceptive,  not  only  in  regard  to  relative  susceptibility 
of  the  human  system  to  attack  at  the  different  periods  of  life,  but  also  in 
regard  to  the  ratio  of  mortality  of  the  disease  itself.  It  is  generally  con- 
ceded that  the  chief  mortality  from  this  disease  occurs  during  infancy  or 
early  childhood  and  in  old  age,  cases  rarely  terminating  fatally  in  youth  or 
the  more  active  period  of  adult  life.  Careful  examination  of  cases  will 
show  that  this  fatality  at  the  extremes  of  life  is  owing  mainly  to  the 
greater  tendency  of  the  inflammation  at  those  periods  to  extend  directly 
from  the  bronchioles  into  the  lobules  of  the  lungs,  thereby  complicating 
the  bronchitis  with  lobular  pneumonia.  And  in  more  than  half  the  cases 
reported  under  the  head  of  bronchitis,  the  fatal  result  was  caused  by  the 
pneumonia,  instead  of  the  bronchitis. 

Sex. — Neither  recorded  facts  nor  my  own  clinical  observations  show 
any  decided  difference  in  the  susceptibility  of  the  sexes  to  attacks  of 
bronchial  inflammation. 

The  influence  of  occupations,  personal  habits,  and  climatic  conditions, 
as  predisposing  and  exciting  causes  of  inflammation  in  any  amt  all  parts 
of  the  respiratory  mucous  membrane,  I  explained  to  you  sufficiently  in 
the  thirty-ninth  lecture  of  the  present  course.  What  I  then  stated  in 
regard  to  the  causes  of  inflammation  in  the  respiratory  passages  generallv, 
is  especially  .•  pplicable  to  the  bronchial  part  of  those  passages,  and  con- 
sequently need  not  be  repeated  here.     I  will  therefore  ask  your  attention 

*  See  Reynolds'  System  of  Medicine,  Amer.  Edi'ion.  Vol.  II  p.  318. 

t  See  A  Practical  Treatise  on   the  Diseases  of  Children,  by  J.  F.   Meigs,  M.  D.,  and  William 
Pepper,  M.  D.;  Fourth  Edition,  page  1S9. 


SYMPTOMS.  395 

chioflv  to  the  clinical  history  of  the  dilTerent  grades  of  lironchial  in- 
llainiiiatioii. 

Acute  lironal litis. — The  most  comiaon  form  of  acute  brc^nchitis,  by 
many  writers  styled  catarrhal  bronchitis,  acute  bronchial  catarrh,  etc., 
presents  considerable  variety  of  symptoms  according  to  the  extent  of  the 
membrane  involved  and  the  intensity  of  the  iidlammatory  process.  As  a 
general  rule  the  disease  commences  with  slight  chilliness  or  unusual 
sensitiveness  to  slight  changes  of  temjierature,  accompanied  by  a  sense 
of  soreness  and  oppression  behind  the  sternum  and  sometimes  across  the 
whole  chest,  witli  a  frequent  and  rather  dry,  harsh  cough.  In  many  cases 
there  is  during  the  first  day  or  two  coincident  congestion  of  the  mem- 
brane lining  the  nostrils,  fauces  and  larynx,  causing  sneezing,  with  some 
feeling  of  soreness  in  the  throat  and  hoarseness;  also  a  heavy  dull  pain  in 
the  head,  much  increased  by  coughing.  By  the  second  day  a  moderate 
general  fever  has  supervened,  oiiaracterized  by  dryness  and  moderate 
heat  of  the  skin,  flushed  face,  slight  increased  frequ(mcy  and  fullness  of 
the  pulse,  more  sense  of  oppression  and  soreness  in  the  chest,  with  a  con- 
tinuance of  harsh  dry  cough,  which  often  causes  soreness  in  the  epigas- 
trium radiating  laterally  in  the  direction  of  the  attachments  of  the  dia- 
phragm to  the  inner  surfa-re  of  the  ribs.  On  the  second  or  third  day  the 
inflamed  membranes  begin  to  l)e  less  dry,  and  the  paroxysms  of  coughing 
bring  up  a  scanty  expectoration  of  a  tenacious,  somewhat  frothy  mucus, 
which  gradually  increases  until  about  the  fourth  or  fifth  day,  when  it 
becomes  more  opaque,  sometimes  yellowish,  and  much  more  easily  ex- 
pectorated. At  the  same  time  that  the  expectoration  changes  to  a  more 
opaque  condition,  the  general  febrile  symptoms  begin  gradually  to  abate, 
and  the  cough  is  accompanied  by  less  sore  pain,  both  in  the  chest  and  head. 

In  the  milder  class  of  cases  the  decline  in  all  the  general  symptoms  is 
so  rapid  that  by  the  seventh  or  ninth  day  convalpscence  is  established. 
But  in  the  more  severe  cases  the  more  important  symptoms  may  continue 
through  two  weeks  and  convalescence  not  be  complete  until  the  end  of 
the  third  week.  And  in  some  of  these  cases  the  inflammation  does  not  dis- 
appear on  the  subsidence  of  the  febrile  symptoms,  but  degenerates  into  a 
chronic  form,  causing  a  continuance  of  cough,  with  some  muco-purulent 
expectoration  and  slight  soreness  in  the  chest,  through  an  indefinite  period 
of  time.  The  disease  is  most  likely  to  take  this  course  when  it  occurs  in 
young  persons  having  a  scrofulous  diathesis;  or  in  connection  with 
eruptive  fevers  or  pertussis;  or  in  the  aged  nfflicted  with  rheumatism. 
During  the  active  stage  of  ordinary  cases  of  bronchitis  the  urinary  secre- 
tion is  diminished  in  quantity,  redder  than  natural,  aiid  deficient  in  chloride 
of  sodium;  and  the  bowels  inactive. 

But  after  the  crisis  of  the  disease  is  passed,  as  indicated  by  the  character 
of  the  expectoration,  the  renal  and  intestinal  discharges  soon  return  to 
their  natural  condition.  The  results  of  auscultation  and  percussion  in 
ordinary  bronchitis,  limited  to  the  membrane  lining  the  larger  bronchial 
tubes,  are  mostly  negative.  In  some  instances  during  the  first,  or  dry 
stage,  the  respiratory  or  vesicular  murmur  may  be  slightly  harsher  or  more 
dry  than  natural;  and  after  exudation  or  secretion  of  mucus,  as  indicated 
by  expectoration,  there  may  be  some  coarse  moist  rales,  which  are  re- 
moved temporarily  by  coughing,  but  return  again  in  a  little  time.  These 
rales  are  heard  much  more  in  cases  occurring  either  in  infancy  or  in  old  age, 
than  in  youth  or  the  middle  period  of  adult  life.  Percussion  elicits  only 
the  natural  degree  of  resonance  throughout  the  whole  course  of  the 
disease,  except  in  those  rare  cases  in  which  complete  occlusion  of  a 
bronchial    tube  has  taken   place,  causing   exclusion    of   air    from  certain 


396  BRONCHITIS. 

lobules  of  the  lungs,  and  consequently  a  shade  of  dullness  on  percussion 
over  such  lobules. 

31echaiiical  J3r07ichitis. — By  mechanical  bronchitis  is  meant  those  cases 
in  which  the  inflammation-  is  caused  by  the  direct  action  of  mechanically 
irritating  substances  floating  in  the  inspired  air,  as  fine  particles  of  steel 
and  other  metals,  particles  of  stone,  charcoal,  and  various  vegetable  pow- 
ders and  fungi.  Such  substances  when  inhaled  are  liable  to  impinge  on 
the  surface  of  the  bronchial  membrane  and  produce  direct  irritation  and 
inflammation,  both  acute  and  chronic.  Cases  originating  from  this  class 
of  causes  differ  from  the  ordinary  acute  bronchitis,  chiefly  in  the  mode  of 
beginning  and  in  the  greater  tendency  to  continue  in  the  chronic  form. 
Instead  of  slight  rigors,  coryza,  and  early  development  of  moderate  gen- 
eral fever,  the  patient  generally  complains,  first,  and  for  several  days,  of 
a  sense  of  tickling  or  fullness  in  the  air  tubes,  with  occasional  paroxysms 
of  violent  coughing  and  little  expectoration.  Sometimes  particles  of  the 
foreign  substance  that  is  producing  the  inflammation  may  be  seen  mixed 
with  the  mucus  or  matter  expectorated.  In  many  of  these  cases  there  is 
much  soreness  in  the  chest  and  considerable  dyspnoea,  especially  during 
the  night,  followed  by  severe  coughing  in  the  morning  and  a  more  free 
discharge  of  mucus,  occasionally  containing  little  streaks  of  blood,  but 
which  is  never  intimately  intermixed  with  the  sputa  as  in  pneumonia. 
If  the  patient,  by  change  of  occupation  or  otherwise,  ceases  to  be  exposed 
to  the  further  action  of  the  exciting  cause,  the  symptoms  soon  begin  to 
abate  and  a  complete  recovery  may  take  place  in  from  two  to  four  weeks. 
If  exposure  to  the  further  action  of  the  exciting  cause  is  not  avoided  the 
disease  will  necessarily  assume  a  chronic  form,  and  in  many  cases  produce 
such  changes  as  to  materiallv  shorten  the  life  of  the  patient. 

Capillary  BroncJiitis. — By  this  term  is  meant  inflammation  in  the 
smaller  bronchial  tubes,  but  not  necessarily  involving  the  true  bronchioles 
as  they  terminate  in  the  air-cells.  It  may  arise  from  all  the  causes  that 
are  capable  of  exciting  inflammation  in  the  larger  and  medium-sized 
tubes.  It  is  met  with  at  any  period  of  life,  but  is  most  frequent  in  in- 
fancy and  early  childhood,  and  next  in  persons  past  the  middle  period 
of  life.  The  chief  differences  in  the  clinical  history  of  this  and  the  ordi- 
nary acute  bronchitis  arise  from  the  greater  obstruction  to  the  ingress 
and  egrress  of  air  throug'h  the  inflamed  tubes.  Tiie  same  degree  of  tume- 
faction  of  the  membrane  lining  the  smaller  bronchi  that  occasions  but 
little  obstruction  in  the  larger  tubes,  is  capable  of  completely  obstruct- 
ing many  of  the  smaller  ones,  and  thereby  causing  much  dyspnoea  and 
sense  of  oppression,  with  frequency  of  respiration,  accompanied,  at  first, 
by  an  abundance  of  dry  rales  in  all  parts  of  the  chest,  followed  later  by 
the  complete  intermixture  of  dry  sounds  and  moist  sub-mucous  rales; 
the  latter  caused  by  more  or  less  exudation  or  secretion  of  mucus  from 
the  inflamed  mucous  membrane.  The  addition  of  the  tenacious  mucous 
exudation  to  the  previous  tumefaction  of  the  membrane  often  so  far  ob- 
structs the  ingress  of  air  to  the  air-cells  of  the  lungs,  that  the  respiration 
becomes  short,  very  frequent  and  noisy,  with  blueness  of  the  lips,  cold- 
ness of  the  extremities,  drowsiness  and  soon  death  from  suffocation.  This 
result,  however,  is  seldom  met  with  except  in  quite  young  children  and 
in  persons  enfeebled  by  age  or  by  previous  disease.  In  cases  which 
do  not  thus  tend  to  an  early  fatal  result  from  the  direct  obstruction  of  the 
bronchi,  the  respirations  continue  frequent,  in  young  children  sometimes 
numbering  fifty  or  sixty  respirations  per  minute,  with  much  dyspnoea  and 
restlessness.  The  pulse  is  also  very  frequent  but  not  in  proportion  to  the 
respirations;  the  expression  of  countenance  is  anxious  and  often  slightly 


SYMPTOMS.  39^ 

bloatotl,  with  a  leaden  hue  of  the  prolabia;  the  wings  of  tlie  nose  expand 
and  the  chest  heaves  with  each  inspiration,  giving  a  great  variety  of  dry 
whistling  sounds  ttiroughout  the  whole  chest,  which,  after  the  first  two  or 
three  days  become  mixed  with  sharply  defined  sub-mucous  rales,  and  in 
the  later  stages  gives  ])lace  to  the  latter  entirely.  The  cough  is  frequent 
and  inefficient  on  account  of  the  difficulty  of  getting  sufficient  air  to  make 
it  satisfactory.  The  temperature  varies  from  38^  to  39.5*^  C.  (101'^  to 
]03'^  F.),  seldom  rising  above  the  latter  figure  unless  complicated  with 
lobular  j^neumonia.  The  urine  is  generally  scanty  and  deficient  in  the 
chlorine  salts,  and  the  bowels  inactive.  The  labored  elforts  of  Ijreathing 
in  many  cases  make  the  upper  and  anterior  part  of  the  chest  appear  more 
prominent  than  natural,  and  even  more  resonant  on  percussion  on  account 
of  temporary  emphysema  from  over-distension  of  the  air-cells  in  those 
parts,  while  in  some  parts  of  the  lower  and  posterior  portions  there  is  less 
expansion  and  less  resonance  than  natural  from  the  occlusion  of  some  of 
the  bronchi  and  the  partial  obstruction  of  others,  leading  to  those  parts 
of  the  lungs. 

Between  the  third  and  fifth  days,  usually,  the  mucous  exudation, 
which  up  to  that  time  had  been  scanty  and  tenacious,  becomes  more 
abundant  and  more  opaque,  and  in  two  or  three  days  more,  assumes  a  dis- 
tinct muco-purulent  character,  and  is  much  more  easily  expectorated.  As 
that  which  comes  from  the  smaller  bronchial  tubes  is  less  mixed  with  air 
and  consequently  less  frothy  than  that  which  comes  from  the  larger  tubes, 
the  two  qualities  of  matter  may  often  be  recognized  in  the  same  mouthful 
of  sputa;  and  if  the  whole  be  placed  in  water,  that  from  the  smaller 
tubes  will  drop  lower  in  the  water,  or  sink  to  the  bottom  if  detached  from 
the  other,  which  floats  freely  upon  the  surface.  In  acute  cases,  at  the 
same  time  that  the  expectoration  becomes  more  opaque  and  more  easily 
dislodged  by  coughing,  all  the  more  important  symptoms  begin  slightly 
to  improve,  and  by  the  end  of  the  second  week  convalescence  is  fairly  es- 
tablished. Many  cases,  however,  are  less  acute,  slower  in  progress,  and 
do  not  reach  convalescence  in  less  than  three  or  four  weeks.  And  many 
of  this  class  manifest  a  strong  tendency  to  continue  indefinitely  in  a 
chronic  form,  more  especially  in  persons  past  the  middle  period  of  life. 
In  some  of  the  cases  that  do  not  continue  in  a  chronic  form,  the  bronchial 
membrane  is  left  in  a  condition  of  such  susceptibility  that  the  attack  is 
renewed  on  the  slightest  exposure  to  the  exciting  causes. 

Rheumatic  Bronchitis. — Although  many  systematic  writers  on  practical 
medicine  make  no  mention  of  this  form  of  bronchitis,  except  as  a  com- 
plication of  general  rheumatic  fever,  yet  cases,  both  of  acute  and  chronic 
inflammation  of  the  bronchi,  of  unmistakable  rheumatic  character,  have  so 
often  come  under  my  observation,  that  I  am  constrained  to  recognize  it  as 
a  distinct  form  of  disease.  In  regard  to  the  relative  frequency  of  the 
occurrence  of  this  class  of  cases,  I  find  in  a  brief  report  coverincr  nine 
hundred  and  sixty-five  cases  of  chronic  pulmonary  disease,  read  in  the 
Medical  Section  of  the  American  Medical  Association,  by  Dr.  F.  H. 
Davis,  in  ]877,  the  following  classification  of  the  cases: 

Chronic  catarrhal  bronchitis 403 

"        rheumatic  '^         283 

"        bronchitis  accompanied  by    gastric  derangement  and  spas- 
modic dyspnoea 119 

Chronic  bronchitis,  modified  by  syphilitic  disease 3? 

Hereditary  pulmonary  tuberculosis 56 


398  BRONCHITIS. 

Inflammatory  pulmonary  phthisis .   67 

Total 965=* 

You  thus  see  that  of  the  842  cases  of  chronic  bronchitis  included  in  the 
table,  the  writer  classes  28o,  or  a  trifle  more  than  thirty-three  per  cent., 
as  of  rheumatic  character.  That  the  relative  proportion  of  acute 
rheumatic  cases  is  less  than  those  of  a  chronic  grade  I  have  no  doubt; 
and  yet  their  number  is  not  so  small  as  to  be  insignificant  or  unworthy  oi 
careful  attention.  They  difl"er  in  clinical  history  from  ordinary  acute 
bronchitis,  chiefly  in  the  following  particulars:  Etiologijaliy,  a  large 
proportion  of  them  were  in  persons  of  a  rheumatic  diathesis,  either  hered- 
itary or  acquired,  and  at  tliose  seasons  of  the  year  characterized  by  a 
predominance  of  cold  and  damp  air,  with  frequent  changes  of  tempera- 
ture. Their  clinical  history  is  characterized  from  the  beginning  by  more 
continuous  dull  pain  in  the  chest,  often  extending  to  the  attachments  of 
the  diaphragm,  the  shoulders,  and  dorsal  portion  of  the  spine;  by  more 
persistent,  dry,  harsh  cough,  often  exhibiting  a  marked  spasmodic  char- 
acter and  accompanied  by  a  great  aggravation  of  the  pains  in  different 
parts  of  the  chest;  and  when  the  smaller  bronchi  are  involved,  the  stage 
of  dry  rales  is  much  more  protracted,  the  dyspno3a  and  suffocative 
paroxysms  of  coughing  more  uniformly  aggravated  at  night,  and  when 
mucous  exudation  does  take  place  it  remains  scanty  and  viscid,  rarely 
presenting  a  distinct  muco-purulent  character.  During  the  active  stage 
the  urine  is  less  in  quantity,  and  more  decidedly  acid  in  reaction  than 
natural,  and  the  bowels  generally  costive.  When  not  interfered  with  by 
appropriate  treatment,  these  cases  run  a  much  more  protracted  course, 
and  more  frequently  degenerate  into  a  chronic  form  than  those  of  an 
ordinary  catarrhal  character.  When  they  are  thus  allowed  to  run  a  pro- 
tracted course,  or  to  continue  in  a  chronic  form,  they  manifest  another 
tendency  of  great  importance,  namely,  to  have  the  disease  extend,  by  con- 
tinuity, from  the  fibrous  and  muscular  structures  of  the  small  bronchi  into 
the  connective  tissue  of  the  pulmonary  lobules,  inducing  sclerosis  of  the 
latter  tissue  and  consequent  compression  or  obliteration  of  the  alveoli,  or 
air-cells,  and  permanent  contraction  of  the  chest.  Much  and  careful 
clinical  observation  has  satisfied  me  that  many  of  the  cases  now  classed  by 
writers  SLS^fibrous  and  itz/lamniatori/  phthisis,  begin  as  simple  acute  or  sul)- 
acute  bronchitis,  which,  being  renewed  at  every  return  of  the  cold,  damp 
and  changeable  part  of  the  year,  not  only  ultimately  cause  permanent 
thickening  of  the  bronchial  structures,  but  gradually  invade  portions  of 
the  connective  tissue  of  the  lungs,  and  induce  similar  pathological  changes 
in  it,  thereby  causing  obliteration  of  the  alveoli  and  more  or  less  shrink- 
ing of  the  chest. 

Fsettdo- Membranous  Bronchitis. — This  affection  has  been  described 
by  different  writers  under  the  additional  names  of  plastic,  croupous  or 
croupal,  and  diphtheritic  bronchitis.  The  extension  of  the  inflammation 
and  membranous  exudation  to  the  bronchial  tubes  in  cases  of  diphtheritic, 
and  pseudo-membranous  tracheitis  and  laryngitis,  or  croup,  is  of  frequent 
occurrence.  But  as  a  distinct  disease,  limited  to  the  bronchial  membrane, 
you  will  meet  with  it  very  rarely.  In  1854,  Dr.  T.  B.  Peacock  noticed  in 
the  Transactions  of  the  London  Pathological  Society  thirty-four  cases 
collected  from  European  sources.  Biermer,  in  1867,  increased  the  num- 
ber to  fifty-eight.     Kretschy,  in  1874,  added  ten,  and  Chenstok  four  more 

*SeeTransacuoiis  of  American  Medical  Association,  Vol.  28,  p.  269, 1877. 


SYMPTOMS.  390 

cases,  making  in  all  seventy-two  cases  in  Europe.  In  1879,  D;-.  W.  (J. 
Glasgow,  of  St.  Louis,  road  to  the  Medical  Section  of  the  American  Med- 
ical Association  an  interesting  report  on  the  subject  of  Plastic  Bronchitis, 
in  which  he  notices  twenty-three  cases  which  had  occurred  in  this  country, 
accounts  of  which  were  obtained  from  an  extensive  correspondence  with 
leading  physicians  in  all  parts  of  the  United  States,  as  well  as  Iroin  care- 
ful search  through  our  periodical  medical  literature. 

These  statistics  are  certainly  sufficient  to  show  that  the  disease  is  of 
rare  occurrence,  both  in  this  country  and  Europe.  The  statistics  thus  far 
collected,  show  a  much  greater  prevalence  of  the  disease  in  males  than  in 
females;  and  that  the  larger  number  of  cases  occur  between  thenages  of 
fifteen  and  fifty  years,  although  one  case  is  reported  by  Dr.  T.  G.  Simons, 
of  Charleston,  S.  C,  as  quoted  by  Dr.  Glasgow,  at  four  years  of  age;  and 
Goumcens,  one  at  seventy-two.  In  a  large  proportion  of  the  cises  I'e- 
ported,  the  disease  existed  in  a  chronic  form.  When  acute,  and  affecting 
a  large  portion  of  the  bronchial  membr.ine,  it  is  liable  to  lead  to  an  early 
fatal  termination,  from  obstruction  to  the  ingress  of  air  to  the  air-cells  of 
the  lunjTS.  But  in  many  cases  the  disease  occupies  only  a  limited  num- 
ber of  the  bronchi,  and  recovery  has  generally  taken  place  in  from  two  to 
three  weeks.  The  symptoms  differ  from  those  of  ordinary  bronchitis  in 
only  two  important  particulars,  namely:  the  more  violent  and  suffocative 
character  of  the  cough,  and  the  actual  appearance  of  shreds,  patches,  or 
casts  of  pseudo-membrane  in  the  matters  ejected  by  coughing.  The  lat- 
ter is  the  only  reliable  diagnostic  symptom  by  which  it  can  be  certainly 
differentiated  from  all  other  forms  of  bronchial  inflammation.  When  the 
membranous  exudation  is  discharged  in  shreds  or  small  pieces,  it  may 
readily  escape  the  attention  of  the  physician;  and  even  considerable  casts 
when  expectorated  are,  in  some  cases,  so  surronnded  with  mucus  and  col- 
lapsed into  a  slightly  yellowish  mass  in  the  central  part  of  the  mouthful 
expe.-torated  that  they  might  be  regarded  as  only  a  mere  muco-purulent 
part  of  the  mucous  secretion.  If  you  throw  the  whole  into  water,  how- 
ever, and  agitate  it  a  little,  the  membranous  patches  and  casts  will  be 
quickly  unfolded  in  such  a  manner  as  to  be  easily  recognized.  It  is  dis- 
tinguished from  mucus,  by  leaving  it  in  a  solution  of  acetic  acid,  which 
causes  it  to  swell,  while  mucus  contracts  in  a  similar  solution.  It  has  the 
appeai^ance  of  having  been  formed  in  concentric  layers,  and  is  sometimes 
cast  off  so  complete  as  to  present  a  continuous  representation  of  one  or  both 
primary  and  several  of  the  secondary  bronchial  tubes.  Under  the  micro- 
scope it  has  the  same  fibrillated  appearance  as  other  pseudo-membranous 
formations. 

Chronic  JBronchitis. — Cases  of  acute  and  sulmcute  bronchitis,  belong- 
ing to  either  of  the  five  varieties  just  described,  may  be  protracted  until 
they  assume  a  chronic  form;  and  other  cases  of  each  variety  are  met  with 
which  have  been  chronic  from  the  beginning.  This  form  of  the  ilisease 
is  met  with  in  aged  persons,  more  frequently  than  at  an  earlier  period  of 
life.  In  children,  it  sometimes  follows  as  a  sequel  of  measles  and  whoop- 
ing cough,  and  in  adults  is  often  associated  with  tuberculosis,  emphv- 
sema,  and  cardiac  diseases. 

Etiology. — Chronic  bronchitis  is  capable  of  originating  from  any  and 
all  the  causes  that  have  been  enumerated  as  capable  of  producing  the 
more  acute  forms  of  the  disease,  and  consequently  prevails  most  under 
the  same  conditions  of  to;iography,  climate,  and  social  relations. 

Bymptoms. — The  symptoms  of  ordinary  chronic  bronchitis,  differ  from 
those  accompanying  the  acute  form  of  the  disease  chiefly,  in  the  absence 
of  general  fever,  and  the  existence  of  much  less  pain  or  feeling  of  sore- 


400  BRONCHITIS. 

ness  and  oppression  in  the  chest.  The  patient  generally  complains  of  a 
cough,  usually  more  severe  on  first  retiring  to  bed  at  night  and  on  rising 
in  the  morning,  but  occurring  at  intervals  through  the  day,  and  accom- 
panied by  a  raucous  or  muco-purulent  expectoration,  varying  much  in  its 
amount  and  tenacitj-.  In  the  great  majority  of  cases  occurring  in  younc^ 
persons  and  in  the  first  half  of  adult  life,  the  expectoration  is  simply  a 
whitish  or  slightly  opaque  mucus,  more  or  less  frothy  from  the  intermix- 
ture of  minute  bubbles  of  air,  and  easily  dislodged,  especially  in  the 
mornings.  In  old  persons,  and  in  cases  which  have  continued  a  long 
time,  the  expectoration  often  becomes  more  copious  and  more  decidedly 
purulent,  with  slight  feverishness  at  night,  and  some  loss  of  flesh.  In  all 
the  cases,  except  those  last  mentioned,  the  general  health  of  the  patients 
is  but  little  impaired,  the  appetite  and  secretions  usually  remaining  near- 
ly natural.  Those  pursuing  indoor  occupations,  or  are  sedentary  in  their 
habits,  will  be  prone  to  constipation  and  imperfect  digestion,  more,  how- 
ever, from  the  circumstances  just  mentioned,  than  from  the  effects  of  the 
bronchial  disease.  All  cases  of  chronic  bronchitis  are  subject  to  tempo- 
rary aggravation,  by  exposure  to  a  cold  and  damp  atmosphere,  whether 
indoors  or  out;  and  are  also  very  susceptible  to  increase  from  the  inhala- 
tion of  air,  containing  dust  or  floating  particles  of  solid  matter,  or  of  irri- 
tating gases.  Cases  of  ordinary  chronic  bronchitis,  rarely  prove  fatal 
without  the  intercurrence  of  some  other  disease,  and  yet  there  is  no  natu- 
ral limit  to  their  duration.  In  many  cases  the  symptoms  almost  disappear 
during  the  warm  months  of  summer,  but  return  with  the  first  period  of 
cold  and  wet  weather  of  autumn.  Such  patients  usually  find  permanent 
relief  by  changing  their   residence  to  a  mild  and  dry  climate. 

The  symptoms  of  the  rheumatic  grade  of  chronic  bronchitis  difl^er  from 
those  just  described,  mostly  in  the  more  severe  paroxysmal  character  of 
the  cough,  with  either  no  expectoration  or  only  a  scanty  quantity  of  a 
glairy,  tenacious  mucus;  more  soreness  or  dull  pain  in  the  intercostal 
muscles  and  attachments  of  the  diaphragm;  and  in  the  more  marked 
influence  of  sudden  and  severe  meteorological  changes.  Perhaps  the 
most  marked  and  distressing  cases  of  this  variety  of  bronchitis  are  those 
we  occasionally  meet  with  in  old  persons,  whose  joints,  especially  those 
of  the  extremities,  have  long  been  stifi"ened  and  sometimes  enlarged  from 
chronic  rheumatism,  and  who  are  harassed  and  worn  from  a  harsh, 
suffocative  cough,  the  worst  paroxysms  of  which  are  always  during  the 
latter  part  of  the  night  and  the  early  morning,  accompanied  by  the  ex- 
pectoration of  considerable  quantities  of  a  thick,  viscid,  and  very  tena- 
cious mucus,  which  is  dislodged  with  so  much  difficulty  that  in  the  midst 
of  the  more  violent  paroxysms  of  coughing  the  action  of  the  stomach  is 
reversed  and  its  contents  ejected  by  vomiting.  This  is  very  liable  to 
happen  just  after  breakfast  and  occasions  the  loss  of  the  morning  meal. 
The  condition  of  these  patients  is  very  generally  ameliorated  during  the 
warm  months  of  summer,  but  on  the  whole  they  emaciate  and  grow 
more  helpless  from  year  to  year,  until  they  die  from  either  exhaustion  or 
the  supervention  of  pulmonary  sclerosis  (fibroid  phthisis),  endocarditis, 
or  chronic  diarrhoea.  There  is  one  grade  of  rheumatic  irritation  which  is 
liable  to  attack  the  fibrous  texture  of  the  smaller  bronchi,  and  to  give  rise 
to  a  very  persistent  foim  of  asthma,  which  increases  with  every  returning 
cold  season  of  the  year,  but  as  asthma  in  all  of  its  forms  is  treated  in  other 
parts  of  this  work,  I  only  allude  to  it  in  this  connection. 

Pathology  and  Morhid  Anatomy. — The  special  patholog}''  of  inflamma- 
tion involving  the  mucous  membrane  and  other  structures  of  the  bronchi 
does  not  differ  from    that  of  similar  grades  of  inflammation  in  any  other 


ANATOMICAL    CHANGES.  401 

structures  of  the  boJy.  In  the  early  stag 3  of  acute  bronchitis  you  will  find 
more  or  less  intense  congestion  of  blood  in  the  vessels,  causing  redness 
and  tumefaction  of  the  membrane,  soon  followed  by  an  increased  flow  of 
mucus,  with  increase  or  proliferation  of  mucous  corpuscles  and  epithelium 
cells. 

In  pseudo-membranous  or  croupous  variety  of  bronchitis,  you  will  find 
the  bronchial  tubes  lined,  and  in  some  cases,  filled  with  a  plas'ic  exudation. 
Usually,  only  a  limited  number  of  the  bronchi  are  affected.  The  tube 
casts  that  may  be  expelled  are  generally  in  the  form  of  balls  that  may  be 
unrolled,  and  which  will  then  be  found  to  be  fragments  of  the  pseudo- 
membrane,  or  complete  cylindrical  casts  of  the  tubes.  They  are,  when 
expelled,  usually  yellowish  and  often  tinged  with  blood.  When  washed 
they  are  usually  white.  There  are  frequentlv  points  of  enlargement  along 
the  casts,  which  are  caused  either  by  the  presence  of  air-bubbles  w-ithin 
them,  or  by  a  more  rapid  exudation  from  that  point  on  the  bronchus.  The 
largest  casts  are  usually  solid  and  laminated  in  structure;  the  smaller 
ones  more  frequently  are  hollow,  containing  a  greater  or  less  number  of 
air-bubbles;  the  smallest  consist  of  a  single  solid  thread.  Under  the 
microscope  the  casts  seem  to  be  composed  of  a  structureless  or  fibrous 
substance,  holding  numerous  mucous  and  pus  cells,  more  or  less  numerous 
globules  of  fat,  and  occasional  epithelial  cells;  seldom  red  blood  corpuscles, 
although  these  may  be  numerous  on  the  surface. 

The  casts  are  usually  moderately  compact,  firm  and  elastic.  Toward 
the  end  of  the  disease,  however,  they  may  be  less  firm.  In  some  cases 
toward  the  close  of  life  epithelial  cells  are  abundant  in  them,  but  in  other 
cases  on  post  mortem  examination  the  epithelial  lining  of  the  bronchi  is 
found  nearly  or  quite  entire.  The  mucous  membrane  may  be  much  red- 
dened, or  on  the  other  hand,  paler  than  normal.  The  sub-mucous  tissues 
are  also  sometimes  involved  in  the  swelling,  and  occasionally  infiltrated 
with  serum,  while  leucocytes  or  white  corpuscles  are  seen  permeating  the 
capillary  walls  and  penetrating  the  sub-mucous  tissue,  or  mingling  with 
the  increased  epithelium  upon  the  surface.  The  several  inflammatory 
products  are  seen  adhering  to  the  surface  of  the  inflamed  membrane  and 
in  the  smaller  tubes,  often  so  filling  their  caliber  as  to  greatly  interfere 
with  the  ingress  and  egress  of  air  through  them,  and  of  course  adding  to 
the  dyspnoea  that  characterizes  the  capillary  form  of  bronchitis.  During 
the  later  stages  of  the  disease  you  will  see  pus  corpuscles  freely  inter- 
mingled with  the  mucus,  and  owing  to  the  exfoliation  of  much  of  the 
epithelium,  the  surface  of  the  mucous  membrane  often  appears  irregular, 
abraded,  or  ulcerated.  When  the  inflammation  has  been  protracted  into 
a  chronic  form,  the  vessels  appear  less  congested,  but  the  cell  proliferations 
continue  both  in  the  mucous  and  sub-mucous  structures,  causing  thickening 
and  increased  density,  with  a  still  more  purulent  quality  of  secretion. 
The  bronchial  glands  are  also  sometimes  seen  enlarged,  and  either  soft- 
ened, colored  with  pigment,  or,  more  rarely,  calcified.  In  addition  to 
the  foregoing  changes,  Iti  many  cases  of  the  capillary  form  of  bronchitis 
you  may  find  some  lobules  of  the  lungs  collapsed  from  the  complete  oc- 
clusion of  the  bronchi  leading  to  them,  by  the  accumulation  of  tenacious 
macus  with  other  inflammatory  products.  And  in  the  same  cases  the  air- 
cells  in  other  parts  of  the  lungs,  more  frequently  the  upper  and  anterior 
parts,  are  enlarged  from  over-distension  constituting  a  degree  of  emphy- 
sema. In  very  chronic  cases,  especially  of  the  rheumatic  variety,  you  may 
find  considerable  hypertrophy  of  the  connective  tissue  of  the  bronchi,  and 
in  other  cases  atrophy  of  the  same  tissue,  the  latter  generally  accompanied 
by  more  or  less  dilatation  of  the  tubes. 

26 


402  BEOXCHITIS. 

For  a  representation  of  one  of  the  most  complete  specimens  of  pseudo- 
membranous casts  from  the  bronchi,  the  reader  is  referred  to  the  paper  of 
Dr.  Glasgow  in  the  transactions  of  the  American  Medical  Association, 
already  referred  to. 

Diagnosis. — The  principal  diseases  from  which  acute  inflamm-:ition  of 
any  part  of  the  bronchial  mucous  membrane  needs  to  be  differentiated, 
are  pneumonia,  pleurisy,  laryngitis,  tracheitis,  and  asthma,  while  it  is  still 
more  important  to  keep  a  clear  line  of  diag-nosis  between  the  chronic 
grades  of  bronchial  inflammation  and  the  earlier  stages  of  pulmonary 
phthisis  and  of  emphysema.  From  nearly  all  the  diseases  named  it  is 
separated  by  negative  evidence  or  the  absence  of  symptoms  and  physical 
signs  which  necessarily  exist  in  those  affections.  You  find  in  bronchitis 
neither  the  rusty  expectoration,  nor  high  temperature,  nor  fine  crepitant 
rales  of  pneumonia;  nor  the  acute  pains  or  short,  stifled  cough  or  friction 
sounds  of  pleurisy  in  the  early  stage ;  and  still  less  will  you  find  in  the 
middle  and  later  stages,  any  of  the  dullness  on  percussion  that  character- 
izes the  corresponding  stages  of  the  other  two  diseases.  In  true  asthma 
the  active  symptoms  are  distinctly  paroxysmal,  without  fever  or  increase 
of  temperature,  and  the  respirations  during  the  paroxysms  are  slow,  with 
marked  prolongation  of  the  expiratory  act;  while  in  bronchitis,  both  in 
the  larger  and  smaller  tubes,  the  symptoms  are  continuous,  the  tempera- 
ture increased,  and  the  respirations  more  frequent  than  natural.  All 
grades  of  bronchitis  are  easily  distinguished  from  laryngitis  and  tracheitis 
by  auscultation,  which  will  enable  you  to  trace  all  the  morbid  sounds  to 
the  chest  in  the  former,  and  to  the  front  part  of  the  neck  in  the  two  'atter. 
The  great  advantage  to  the  patient  of  having  pulmonary  tuberculosis,  and 
other  forms  of  phthisis,  recognized  in  the  early  stage  of  the  disease,  makes 
the  diagnosis  between  it  and  chronic  bronchitis  a  matter  of  piimary  im- 
portance. This  you  can  readily  do  if  you  take  the  trouble  to  acquire  a 
reasonable  degree  of  skill  in  the  practice  of  auscultation  and  percussion. 
In  all  forms  and  stages  of  pulmonary  phthisis,  whether  from  primary  tu- 
bercular deposits,  pneumonic  exudation  followed  by  caseous  degeneration, 
■or  from  interstitial  fibroid  sclerosis,  you  will  find  increased  vocal  fremitus 
and  diminished  resonance  on  percussion;  neither  of  which  are  present  in 
-any  ffrade  of  uncomplicated  bronchitis. 

it  is  true  that  in  the  advanced  stage  of  some  very  severe  cases  of  capil- 
lary bronchitis  there  occurs  sufficient  oedema  to  increase  the  vocal  fremitus 
and  diminish  the  resonance  over  some  parts  of  the  chest.  But  the  ac- 
companying symptoms  and  immediately  preceding  history  of  such  cases 
■is  sufficient  to  separate  them  from  any  stage  of  phthisis. 

The  same  remark  is  applicable  to  those  rare  cases  in  which  an  attack  of 
pseudo-membranous  bronchitis  results  in  the  complete  occlusion  of  one  or 
more  of  the  bronchi  and  the  permanent  collapse  of  the  pulmonary  lobules 
to  which  the  occluded  tubes  lead.  If  in  addition  to  the  plain  difference 
in  the  physical  signs  already  mentioned,  you  remember  that  in  all  the 
forms  of  phthisis  there  is  progressive  loss  of  flesh,  some  increase  of  tem- 
perature, and  acceleration  of  pulse,  with  a  contraction  of  the  antero-pos- 
terior  diameter  of  the  upper  part  of  the  chest,  while  none  of  these  changes 
usually  result  from  bronchitis  alone,  you  will  find  no  difficulty  in  keeping 
the  line  of  diagnosis  clear  between  these  two  diseases.  And  yet  there  is 
probably  no  more  frequent  or  important  error  committed  in  diagnosis  than 
that  of  mistaking  the  early  stage  of  pulmonary  phthisis  for  bronchitis. 
This  niay  arise  in  part  from  the  i'act  that  bronchitis  often  supervenes  and 
3ontinues  coincidently  with  phthisis.  But  you  must  remember  that 
whenever  there  is  increased  vocal  fremitus  and  diminished   resonance  in 


DIAGNOSIS.  403 

any  given  case,  tliere  is  some  altered  condition  of  tlie  lung  structure,  and 
consequently  some  I'orm  of  disease  besides  bronchitis,  however  plain  the 
ordinary  symptoms  of  the  latter  may  be  at  the  same  time.  You  can  dis- 
tinguisli  pulmonary  emphysema  from  chronic  bronchitis  by  the  abnormally 
increased  resonance  from  percussion  in  the  former,  especially  over  the 
upper  and  anterior  parts  of  the  chest,  and  in  the  peculiar  depression  of 
the  spaces  above  the  clavicles  and  between  the  ribs  at  the  beginning  oi 
the  inspiratory  act,  and  their  return  to  over  fullness  near  its  close,  while 
none  of  these  changes  accompany  any  grade  of  simple  bronchial  inflam- 
mation. 


LECTUKE  XLII. 


Bronchitis— Its  Varieties  continued  ;  Their  Prognosis  and  Treatment.     Asthmatic  Bronchitis— 
Catarrhal  Asthma — Hay-Fever ;  Their  Cliuicai  History  and  Treatment. 

GENTLEMEN:  In  the  preceding  lecture  I  directed  your  attention 
chiefly  to  the  clinical  history  of  the  different  varieties  and  grades  of 
bronchitis,  the  pathological  changes  which  take  place  in  the  inflamed 
structures  during  their  progress,  and  their  diagnosis  or  differentiation  from 
other  affections  of  the  respiratory  organs.  I  now  direct  your  attention  to 
their  prognosis  and  treatment. 

Pr'ognosis. — The  prognosis  in  bronchitis  depends  much  upon  the 
particular  part  of  the  membrane  afi"ected,  the  grade  of  the  inflammatory 
process,  the  age,  and  the  previous  condition  of  the  patient.  When  the 
inflammation  is  limited  to  the  lining  of  the  larger  and  medium  sized  air 
tubes,  and  is  not  of  the  plastic  or  pseudo-membrannus  variety,  there  is 
but  little  tendency  to  produce  fatal  results  at  any  period  of  life,  especially 
if  the  patients  have  not  been  debilitated  by  previous  disease  or  affected  by 
some  constitutional  predisposition.  When  the  membrane  lining  the  smaller 
tubes  is  the  seat  of  disease,  constituting  capillary  bronchitis,  there  is  more 
danger  to  life,  especially  in  young  children  and  in  old  persons.  In  the 
more  severe  attacks  involving  both  sides  of  the  chest,  the  obstruction  to 
the  passage  of  air  through  the  smaller  bronchi,  caused  by  the  congestion  and 
rapid  accumulation  of  inflammatory  products  occurring  in  infancv  or  in 
those  much  enfeebled  by  age,  death  from  apnoea  or  insufficient  supply  of 
air  to  sustain  the  function  of  respiration,  is  liable  to  occur  in  from  three 
to  seven  days.  Another  source  of  great  danger  in  this  class  of  cases  is 
from  the  supervention  of  lobular  pneumonia.  For  these  reasons  the 
capillary  form  of  acute  bronchitis  has  resulted  in  a  moderately  high  ratio 
of  mortality. 

The  pseudo-membranous  variety  of  the  disease  is  still  more  dangerous, 
especially  when  the  inflammation  invades  a  large  number  of  the  bronchi; 
and  for  the  obvious  reason  that  the  adhering  plastic  material  constituting 
the  false  membrane,  being  difficult  to  dislodge,  is  much  more  liable  to 
accumulate  until  it  present-i  a  fatal  obstruction  to  the  ingress  of  air. 
When  the  disease  is  limited  in  its  extent  or  is  of  a  chronic  grade  of 
activity  there  is  a   good   prospect   of  recovery.     The  duration  of  acute 


404  BKONCHITIS. 

bronchitis  of  all  varieties,  when  it  ends  in  the  recovery  of  the  patient,  is 
from  one  to  three  weeks.  The  chronic  forms  of  bronchitis,  when  uncom- 
plicated by  other  diseases  or  constitutional  cachexias,  seldom  terminate 
fatally;  and  yet  they  manifest  no  tendency  to  a  self-limited  duration. 
Many  of  this  class  of  cases  improve  much  during  the  warmest  months  of 
summer,  and  are  regularly  aggravated  by  the  return  of  cold  and  wet  changes 
in  the  autumn.  In  other  cases  you  will  find  the  changes  of  the  seasons 
to  produce  but  little  effect  on  the  symptoms  or  progress  of  the  disease, 
and  yet  the  patients  live  out  their  three  score  and  ten  years. 

Treatment. — The  indications  to  be  fulfilled  or  objects  to  be  accom- 
plished in  the  treatment  of  the  different  grades  of  bronchitis,  are  the  same 
as  I  have  stated  to  you  in  speaking  of  the  treatment  of  inflammation  in 
other  parts  of  the  respiratory  mucous  membrane,  namely:  to  diminish 
the  morbid  excitability  of  the  inflamed  structure;  to  lessen  the  local 
hyperaemia  and  thereby  limit  the  amount  of  exudation  and  accumulation 
of  inflammatory  products;  to  counteract  secondary  functional  disturbances 
by  lessening  febrile  heat  and  promoting  the  eliminations  from  the  skin  and 
kidneys,  and  to  hasten  the  disintegration  and  removal  of  such  plastic 
exudations  as  may  have  taken  place  either  upon  the  surface  or  into  the 
texture  of  the  inflamed  membrane.  Of  course,  you  must  at  all  times  give 
due  attention  also  to  the  regulation  of  the  diet,  drinks,  exercise,  clothing, 
temperature  and  all  other  hygienic  matters  influencing  your  patients. 

The  three  first  objects  I  have  named  as  desirable  to  accomplish  belong 
more  particularly  to  the  early  stage  of  acute  and  subacute  attacks,  but 
are  present  in  some  degree  throughout  the  whole  course  of  the  disease; 
while  the  last  belongs  to  the  later  stages  of  the  acute,  and  to  all  stages 
of  the  chronic  grades  of  the  inflammation.  While  the  foregoing  indica- 
tions to  be  fulfilled  or  objects  to  be  accomplished,  are  present  in  all  the 
various  grades  and  stages  of  inflammation  of  the  bronchi,  the  particular 
means  for  accomplishing  them  will  be  modified  by  the  age  and  previous 
physical  condition  of  the  patient;  the  nature  of  the  predisposing  and  ex- 
citing causes;  the  extent  of  the  disease,  and  the  stage  of  its  advancement; 
or,  in  other  words,  the  nature  and  extent  of  the  pathological  changes  al- 
ready accomplished.  For  instance,  the  same  remedial  agents  that  would 
be  most  efficient  in  relieving  the  morbid  excitability  and  the  vascular  full- 
ness of  the  first  stage  of  acute  inflammation  in  a  young  or  middle-aged, 
and  previously  health v,  vigorous  subject,  might  be  positively  injurious  or 
even  fatal  if  used  in  the  same  stage  of  inflammation  in  a  subject  pre- 
viously anemic  and  feeble,  or  debilitated  from  age,  or  from  causes  ca- 
pable of  impairing  the  quality  of  the  blood  and  favoring  a  typhoid  condi- 
tion of  the  system.  Consequently  the  practitioner,  who  not  oidy  sees 
clearly  the  objects  most  desirable  to  accomplish,  but  who  most  judiciously 
selects  and  adjusts  the  means  or  agents  he  uses  to  the  special  conditions 
of  each  patient,  will  meet  with  the  highest  degree  of  clinical  success. 
In  the  first  stage  of  acute  attacks,  involving  the  bronchi  of  both  kmgs,  in 
vigorous  adult  persons,  and  especially  if  the  inflammation  extends  into 
the  smaller  tul)e.s  causing  much  dyspnoea  and  dry  rales,  there  is  no  single 
remedy  that  will  so  certainly  and  speedily  check  the  intense  engorgement 
of  vessels  in  the  bronchial  membrane,  and  thereby  gain  time  for  the  ac- 
tion of  other  remedies,  as  one  prompt  and  liberal  abstraction  of  blood  by 
venesection.  In  cases  of  a  little  less  severity,  and  in  children,  ihe  appli- 
cation of  from  two  to  twelve  leeches  to  the  upper  and  anterior  part  of  the 
chest,  the  number  being  regulated  by  the  age  of  the  patient,  will  be  a 
good  substitute  for  the  venesection.  And  in  case  leeches  are  not  at  hand, 
extensive  dry  cupping  over  both    the   anterior   and   posterior  parts  of  the 


TREATMENT.  405 

chest,  may  be  applied  with  much  benefit.  Immediately  after  the  venesec- 
tion, leeching,  or  cupping,  and  without  these,  in  cases  of  only  ordinary 
severity,  the  whole  chest  may  be  enveloped  in  an  emollient  poultice 
or  in  folded  napkins,  wet  in  warm  water  and  covered  with  oiled  silk; 
and  at  the  same  time  the  following  combination  may  be  given  inter 
nally: 

1^      Liquor  Ammonii    Acetatis,  60.0  c.  c.  fii 

Tincturag  Opii  CamphoratiTe.  75.0       "  3iiss 

Vini  Antimonii,  15.0       "  |ss 

Tinctur.'B  Veratri  Viridis,  6.0       "  3'ss 

Mix.  Give  to  an  adult  four  cubic  centimeters,  or  one  teaspoonful,  in  a 
tablespoonful  of  water,  every  two,  three,  or  four  hours  according  to  the 
severity  of  the  case.  The  same  may  be  given  to  children,  the  dose  being 
properly  adjusted  to  the  age  of  the  child.  If  you  find  the  tongue  coated, 
the  bowels  inactive,  and  urine  high  colored,  from  six  to  thirty  centigrams 
(gr.  i  to  v)  of  calomel,  according  to  the  age  of  the  patient,  may  he  given 
and  followed  in  four  or  five  hours  by  a  saline  laxative  sufficient  to  procure 
two  or  three  evacuations  from  the  bowels.  Under  the  influence  of  these 
remedies,  the  high  fever  and  great  sense  of  soreness  and  oppression  in  the 
chest,  which  exist  in  the  first  stage  of  the  more  acute  cases,  in  previously 
healthy  subjects,  rapidly  diminish,  giving  place  to  more  moist  rales, 
easier  breathitig,  and  some  expectoration.  As  soon  as  such  amelioration 
(jf  symptoms  has  been  obtained,  you  may  discontinue  the  mixture  con- 
taining veratrum  viride,  and  substitute  the  following  formula,  in  its  place: 

ij,      Syrupus  Scillfe  Compositi,  45.0  c.  c.         fiss 

Tincturae   Sanguinariae,  15.0  "  ?ss 

TincturjB  Opii  Camphoratae,  00.0  "  3ii 

Mix.  Give  to  an  adult  four  cubic  centimeters,  (fl.  3I)  in  a  little 
additional  water,  every  three  or  four  hours.  If  the  patient  suffers  much 
from  severe,  sore  pain  in  the  head,  aggravated  by  coughing,  or  from  nerv- 
ous restlessness,  you  may  add  of  bromide  of  potassium  sixteen  grams 
(3iv)  to  the  above  formula,  which  will  render  it  raon^  efficient  in  relieving 
those  symptoms  and  in  promoting  rest.  Under  such  quieting  and  ex- 
pectorant influence,  aided  by  a  mild  laxative  when  needed,  the  cough,  sore- 
ness and  oppression  in  the  chest,  and  all  other  active  symptoms,  usually 
diminish  from  day  to  day,  and  convalescence  ensues  in  from  seven  to  nine 
days.  If,  after  the  first  three  or  four  days,  you  find  the  temperature  to 
rise  in  the  evening  and  the  cough  to  become  more  troublesome,  interfer- 
ing with  rest  during  the  first  part  of  the  night,  followed  by  some  sweat- 
ing in  the  early  morning,  a  single  dose  composed  of  sulphate  of  quinia 
from  three  to  six  decigrams  (gr.  v  to  x)  pulverized  sanguinaria  root  three 
centigrams  (gr.  -j),  and  codeine  sixteen  milligrams  (gr.  ^),  given  between 
six  and  eight  o'clock  each  evening,  for  three  or  four  evenings,  will  often 
contribute  much  to  the  rest  of  the  patient  and  hasten  the  establishment  of 
convalescence.  You  will  sometimes  meet  with  cases,  especially  in  pa- 
tients debilitated  by  previous  ill-health  or  aj-e,  in  which  the  fever  subsides 
after  the  first  three  or  four  days,  leaving  tJie  patient  with  a  feeling  of  un- 
usual weakness,  a  deep,  harassing  cough  and  copious  muco-purulent  ex- 
pectoration, and  little  or  no  appetite.  In  such  cases  tonics  and  the  more 
stimulating  class  of  expectorants  are  indicated.  You  can  give  a  mixture  of 
equal  parts  of  the  syrup  of  piunus  virginiana,  syrup  of  senega,  and  cam- 
phorated tincture  of  opium,  in  doses  oi  four  cubic  centimeters  or  one  tea- 


406  BRONCHITIS. 


spoonful  every  four  or  six  hours,  and  thirteen  centigrams  (gr.  ii)  of  qui- 
nhie  three  times  a  day,  and  it  will  generally  produce  a  rapid  improvement 
in  all  the  symptoms.  In  some  of  the  cases  last  decsribed  there  is  added 
to  the  other  symptoms  a  troublesome  nausea  and  disposition  to  vomit  with 
the  paroxysms  of  coughing,  in  which  I  have  found  the  following  formula 
a  good  substitute  for"the  mixture  containing  the  prunus  virginiana  and 
senega: 

]^      Acidi  Carliolici,  0."0  grams  gr.  viii 

Glyceriiiaj,  30.(10    c.  c.  fi 

Tinctiira;  Opii   Camphnratre,  GO. 00       ''  311 

Aqufe,  60.00       "  3ii 

Mix.  Give  four  cubic  centimeters  (fl.  3i),  or  one  teaspoonful  before 
each  meal  time  and  at  bed  time,  giving  the  quinine  a  little  after  the 
meals.  If  more  anodyne  influence  is  required  to  procure  rest  at  night, 
vou  can  add  sixteen  milligrams  (gr.  ^),  of  codeine  to  the  teaspoonful  of 
carbolic  acid  mixture,  given  at  bed  time. 

If,  as  sometimes  happens  in  cases  of  acute  bronchitis,  both  of  the 
catarrhal  and  capillary  varieties,  the  inflammation  invades  some  of  the 
lobules  of  the  lungs,  as  indicated  by  undue  rise  of  temperature,  greater 
expansion  of  the  wing  of  the  nose  during  insj)n-ation,  with  short  expira- 
tion, and  diminished  resonance  with  fine  crepitation  over  limited  portions 
of  the  chest,  you  will  find  the  most  certain  and  speed}?^  relief  to  follow 
the  application  of  a  blister  over  the  seat  of  the  pneumonia  and  the  in- 
ternal use  of  the  following  formula: 

5,     Ammonii  Muriatis 

Antimonii  et  Potassii  Tartratis 
Morphise  Sulphatis 
Extract!  Glycyrrhizge  Fluidi 
Syrupus  Simplicis 

Mix.  Give  to  adults  four  cubic  centimeters  (fl.  31)5  mixed  with  a  table- 
spoonful  of  water  every  three  or  four  hours,  until  some  relief  is  obtained, 
and  then  at  longer  intervals.  For  children  you  should  diminish  the 
doses  in  proportion  to  the  diminution  of  agp.  Quinine  and  laxatives  may 
be  used  in  these  cases,  under  the  same  indications  as  in  uncomplicated 
bronchitis.  In  the  severe  attacks  of  capillary  bronchitis  in  young 
children  many  writers  recommend  emetics  and  subsequently  nauseating 
doses  of  antimony  or  ipecacuanha.  But  I  have  not  seen  sufficient  benefit 
to  result  from  emetic  doses  of  these  agents  to  compensate  for  the  early 
prostration,  and  sometimes  continued  gastric  irritability,  which  they  are 
liable  to  induce.  I  prefer  the  proper  application  of  leeches  at  the  very 
beginning,  followed  by  emollient  applications  to  the  chest,  and  the  same 
remedies  internally  as  already  mentioned,  aided,  perhaps,  by  an  earlier 
use  of  quinine  and  digitalis,  if  the  cardiac  action  becomes  weak  and 
frequent.  In  all  this  class  of  cases,  however,  much  caution  should  be 
exercised  in  regard  to  the  use  of  opiates,  either  alone  or  in  combination 
with  other  remedial  agents,  lest  their  narcotizing  influence  should  diminish 
the  force  and  frequency  of  the  respiratory  movements  too  much,  and  en- 
courage the  accumulation  of  the  inflammatory  products  in  the  smaller 
bronchi  to  such  a  degree  as  to  produce  apnoea  or  death  from  the  exclusion 
of  air  from  the  alveoli,  or  air-cells  of  the  lungs.     And  yet,  just  enough  of 


12.00  grams 

3iii 

0.13      " 

gr.  ii_ 

0.20      " 

gr.  iii 

30.00  c.  c. 

|i 

90.00    " 

!iii 

TEEATMENT.  407 

these  quieting  agents  to  diminish  excitability  and  allay  excessive  restless- 
ness is  as  desirable  id  children  as  in  adults.  In  the  plastic,  or  pseudo- 
niembrcuious  form  of  bronchitis  it  is  an  object  of  much  importance,  in  the 
first  stage,  to  limit  the  amount  of  plastic  exudation,  and  later,  to  hasten 
the  loosening  and  disintegration,  or  discharge  of  such  layers  of  false 
membrane  as  may  have  formed  on  the  bronchial  mucous  surface.  For 
these  purposes  you  may  give  alterative  doses  of  calomel  alternately  with 
tlie  doses  of  the  formula  containing  the  liquor  ammonii  acetatis  already 
given,  during  the  first  twenty-four  hours;  and  subsequentl}^,  ])retty  full 
doses  of  the  iodides  of  sodium  or  potassium,  or  of  the  bi-carbonates.  In 
acute  cases  in  children,  when  the  symptoms  indicate  that  the  false  mem- 
brane is  loosening  and  the  dyspnoea  is  great,  an  emetic  that  will  induce 
prompt  and  free  vomiting  may  hasten  its  expulsion  and  afford  much  relief. 
In  the  cases  which  I  have  described  as  rheumatic  bronchitis  of  the  more 
acute  or  active  grade,  the  most  prompt  and  satisfactory  degree  of  relief 
has  been  obtained  by  the  administration  of  the  following  combination  of 
remedies  in  the  early  stage: 

]J     Sodii  Salicylatis  25.00  grams  3vi 

Glycerinae  15.00  c.  c.  3iv 

Vini  Colchici  Radicis  25.00     "  3vi 

Syrupus  Scillas  Compositi  45.00     "  3jss 

Tinctur£e  Opii  Camphoratas  60.00     ''  Ijj 

Mix.  Give  four  cubic  centimeters  (fl  3i)  every  three  or  four  hours,  in  a 
little  additional  water.  In  several  cases  in  which  this  grade  of  inflamma- 
tion was  located  chiefly  in  the  smaller  bronchi,  causing  very  distressing 
and  persistent  dyspnoea,  I  have  given  an  equal  mixture  of  the  wine  of 
colchicura  root  and  the  acetated  tincture  of  opium,  in  doses  of  twenty- 
five  to  thirty  minims  every  three  hours  at  first,  with  more  benefit  than  any 
other  remedies  I  had  used.  And  after  some  degree  of  relief  had  been 
obtained  by  lengthening  the  interval  between  the  doses  to  four  or  six 
hours,  and  continuing  it  a  few  days,  all  the  symptoms  were  removed. 

When  the  disease  occurs  in  old  persons,  accompanied  by  severe 
paroxysms  of  coughing,  and  only  a  scanty  and  very  viscid  mucous  expec- 
toration, much  benefit  may  sometimes  be  derived  from  the  use  of  the  car- 
bonated alkalies,  such  as  the  carbonate  of  ammonium,  or  bi-carbonate  of 
sodium,  dissolved  in  an  equal  mixture  of  the  fluid  extract  of  the  phytolacca 
decandria,  liquor  ammonii  acetatis,  and  camphorated  tincture  of  opium, 
in  such  proportion  that  the  patient  will  get  three  decigrams  (gr.  v),  of 
carbonate  of  ammonium  in  each  dose  of  the  mixture.  It  is  proper  to  re- 
mind you,  however,  that  there  are  many  mild  attacks  of  bronchitis,  caused 
by  exposure  to  sudden  and  severe  meteorological  changes,  which,  if  seen 
during  the  first  twenty-four  hours,  can  be  speedily  arrested  by  a  hot  or 
stimulating  foot  bath  and  a  full  dose  of  the  compound  powder  of  opium 
and  ipecacuanha  (pulv.  Doveri),  taken  in  the  evening,  and  followed  the 
next  morning  i)y  a  saline  laxative,  and  two  or  three  moderate  doses  of 
quinine  during  the  day.  Similar  results  can  also  be  obtained,  in  some 
cases,  by  the  use  of  any  agents  that  will  allay  irritability  and  at  the  same 
time  produce  a  free  or  copious  elimination  from  the  skin  and  kidneys.  An 
efficient  diaphoretic  dose  of  pilocarpin,  or  a  full  warm  bath,  followed  by 
two  or  three  moderate  doses  of  quinine  will  succeed  well  if  employed  in 
the  initial  stage  of  the  disease.  Unfortunately,  but  few  patients  will  applv 
to  you  for  aid  until  after  this  stage  has  passed. 

Treatment  of  ChronU:  Bronchitis. — Most  of  the  cases  of  chronic  bron- 


408  BRONCHITIS. 

chitis  are  treated  satisfactorily  by  a  more  moderate  use  of  the  same 
remedial  agents  that  have  been  recommended  in  the  acute  and  subacute 
grades  of  the  disease;  aided  by  a  judicious  regulation  of  diet,  dress  and 
exercise.  In  a  great  majority  of  the  cases  of  ordinary  chronic  bronchitis 
tlie  formula  already  given,  containing  the  muriate  of  ammonium,  or  the  one 
containing  the  compound  syrup  of  squills,  if  given  to  adults  in  doses  of 
four  cubic  centimeters  (fl  3i)  before  each  meal  and  at  bed-time,  mixed 
vi'ith  a  table-spoonful  of  water,  vpill  afford  the  necessary  relief  without 
confining  the  patients  to  the  house.  If  the  bowels  become  constipated 
while  using  either  of  these  prescriptions,  the  evil  may  be  obviated  by 
taking  one  of  the  following  pills  every  evening: 

IJ      Extracti  Hyoscyami  2.00  grams  gr.  xxx 

Ferri  Sulphatis,  2.00       "  "    xxx 

Pulveris  Aloes,  2.00       "  "    xxx 

Pilulae  Hydrargyri,  2.00       "  "    xxx 

M.  ft.  pillulre,  xxx — If  one  pill  taken  every  evening  does  not  prove 
sufficient  to  prompt  one  natural  intestinal  evacuation  each  morning,  you 
can  order  another  to  be  taken  after  breakfast.  The  patients  should 
adhere  to  a  plain,  nutritious  and  easily  digestible  diet,  avoiding  the  use  of 
all  varieties  of  alcoholic  drinks;  wear  good  flannel  underclothes  all  the  time; 
and  take  moderate  daily  out-door  exercise,  so  long  as  their  strength  will 
permit.  In  addition  to  the  several  remedies  that  have  been  mentioned  as 
applicable  to  the  treatment  of  the  different  varieties  of  acute  and  subacute 
bronchitis,  there  are  many  others  which  I  have  found  more  or  less 
beneficial  in  the  treatment  of  chronic  cases.  Among  the  more  important 
of  these  are  the  iodides  of  potassium  and  sodium,  the  grindelia  robusta, 
eucalyptus  globulus,  Oenothera  biennis,  cimicifuga  racemosa,  asclepias 
tuberosa,  balsams  copaiba  and  tolu,  gum  benzoin,  turpentine,  cod-liver  oil, 
and  the  hypophosphites  of  soda,  lime  and  iron.  Others  have  used  a  still 
larger  number  of  remedies  by  inhalation.  As  a  general  rule,  where  you 
find  the  cough  harsh  and  the  expectoration  scanty,  with  the  predominance 
of  dry  rales,  you  will  obtain  the  best  results  from  the  use  of  such  remedies 
as  the  muriate  and  iodide  of  ammonium  and  the  iodides  of  potassium  and 
sodium,  given  in  conjunction  with  small  doses  of  antimony  and  some  mild 
anodyne.  On  the  other  hand,  if  you  find  the  expectoration  abundant  and 
of  a  muco-purulent  character,  the  balsamic  and  terebinthinate  remedies 
given  in  connection  with  such  tonics  as  the  lacto-phosphate  of  calcium, 
phosphate  of  iron,  sulphates  of  quinine  and  strychnine,  with  codia, 
hyoscyamin,  or  lupulin  at  night,  to  procure  rest,  will  afford  the  greatest 
relief.  In  some  of  these  cases  I  have  obtained  very  good  effects  from  a 
combination  of  two  parts  of  the  syrup  of  iodide  of  calcium  with  one  of  the 
flui  i  extract  of  hops,  given  in  doses  of  four  cubic  centimeters  (fl  3i) 
each  morning,  noon,  tea-time,  and  bed-time.  When  chronic  bronchitis  is 
complicated  with  pharyngitis  and  laryngo-tracheitis  much  palliative 
influence  may  be  obtained  by  judiciously  directed  inhalations,  either  in 
the  form  of  vapor  or  atomization.  But  when  the  disease  is  limited  to  the 
bronchi  alone,  inhalations  produce  much  less  influence  over  its  progress, 
or  in  relieving  the  more  distressing  symptoms.  And  unless  the  nature  of 
the  material  used  is  judiciously  selected  with  reference  to  the  particular 
stage  and  grade  of  the  disease,  the  inhalations  will  be  more  likely  to  do 
harm  than  good.  There  are  two  conditions  of  the  bronchi  met  with  in 
different  cases  of  chronic  bronchial  inflammation,  to  which  local  appli- 
cations can  be  made  in  the  form  of  vapor,  by  inhalation,  with  much  benefit. 


TEEATMEXT.  409 

The  first  is  indicated  by  an  abundant  purulent  or  muco-purulent  ex- 
pectoration, sometimes  fetid  and  at  other  times  not.  For  such  the  full 
deep  inhalations  of  aqueous  vapor  impregnated  with  some  antiseptic  and 
anodyne,  will  be  of  great  service.  One  of  the  best  combinations  that  can 
be  used  for  this  purpose  is  that  of  carbolic  acid  with  camphorated  tincture 
of  opium  in  the  proportion  of  two  grams  of  the  fo.raer  (gr.  xxx)  to  ninety 
cul)ic  centimeters  (fiii)  of  the  latter. 

Four  cubic  centimeters  (fl.  3i),  of  this  mixture  may  be  put  into  250 
cubic  centimeters  (fl.  f  viii),  of  hot  water  in  an  inhaling  bottle,  and  the 
vnpor  inhaled  freely  live  minutes  at  a  time  two  or  three  times  each  day. 
The  second  condition  alluded  to  is  characterized  by  a  persistent,  harsh, 
irritative  cough,  with  little  or  no  expectoration,  indicating  a  sensitive  and 
congested  condition  of  the  mucous  membrane,  with  no  natural  secretory 
action.  Such  cases  may  generally  be  much  relieved  by  adding  to  the 
antiseptic  and  anodyne  mixture  just  given,  some  one  of  the  oleo-resin  or 
balsamic  preparations,  of  which,  perhaps,  none  are  more  efficient  than  that 
which  is  known  in  the  shops  as  oil  of  Scotch  pine.  Four  cubic  centi- 
meters (3i),  of  this  may  be  added  directly  to  the  quantity  of  the  other  in- 
gredients already  given,  and  then  used  in  the  same  manner.  The  com- 
l)ination  thus  used  appears  to  allay  the  morbid  sensitiveness  and  speedily 
establish  a  better  secretory  action.  There  is  another  important  class  of 
cases,  met  with  most  frequently  in  persons  of  both  sexes  between  twelve 
and  twenty  years  of  age.  They  present  a  narrow,  imperfectly  develc>ped 
chest,  with  so  sensitive  a  condition  of  the  bronchial  membrane  that  every 
trifling  exposure  to  cold  and  damp  air  renews  the  vascular  hyperaemia  and 
cough  until  both  become  permanent,  and  the  morbid  process  extends  into 
the  connective  tissue  of  the  pulmonary  lobules,  establishing  what  some 
pall  interstitial  pneumonia,  and  others,  fibroid  phthisis.  In  the  earlier  stage 
of  all  of  this  class  of  cases  the  systematic  daily  practice  of  full,  deep  inhala- 
tions of  pure  atmospheric  air,  coupled  with  a  judicious  exercise  of  the 
muscles  of  the  chest  and  arms  will  do  more  to  remove  all  symptoms  of 
bronchial  disease  and  preserve  the  general  health  of  the  patient,  than  all 
the  medicines  that  have  been  hitherto  devised.  There  is  much  evidence 
it)  favor  of  u^ing  compressed  air  for  inhalation  in  these  and  some  other 
cases  of  chronic  bronchial  inflammation.  The  late  Dr.  F.  H.  DaxHs,  of 
ihis  city,  who,  during  his  brief  professional  career,  gave  much  attention 
to  the  treatment  of  diseases  of  the  respiratory  organs,  and  who  had  good 
opportunities  for  clinical  observation,  sa3^s,  when  speaking  of  the  same 
class  of  young  subjects,  that,  "  The  inhalation  of  compressed  air  for  from 
five  to  ten  minutes  once  or  twice  a  day  produced  marked  and  rapid  im- 
provement in  all  the  cases.  The  s  ze  of  the  chest,  on  full  inspiration, 
was  increased  from  one-half  inch  to  one  inch  in  the  first  month,  and  a  habit 
of  fuller,  deeper  breathing  and  a  more  erect  carriage  w^as  established."* 

But  he  adds,  with  proper  emphasis,  that  the  inhalations  to  be  perma- 
nently curative  must  be  continued  faithfully  for  many  months,  and  be 
accompanied  by  a  judicious  regulation  of  all  the  habits  of  life.  Every 
physician  of  much  practical  experience  knows,  however,  that  in  defiance  of 
ali  the  remedies  and  methods  of  treatmen:;  hitherto  devised,  there  are  many 
oases  of  clironic  bronchial  inflammation  which  will  continue  and  be  aggra- 
vated at  every  returning  cold  season  ot  the  year  so  long  as  the  patient  lives 
in  a  climate  characterized  by  a  predominance  of  cold  and  damp  air,  with  fre- 
quent and  extreme  thermometric  changes.  And  yet  a  large  proportion 
of  these,    by  changing    their  residence  to  a  mild  and  comparatively  dry 

*Pee  paper  read  be  ""ore  the  <^hieagoiSociety  of  Physicians  and  Surgeons,  April,  1877,  on  the  r.e.- 
piratioii  of  Compressed  and  Raritied  Air  in  Pulmonary  l)iseases. 


410  ASTHMATIC    BEONCHITIS. 

climate,  either  greatly  improve  or  entirely  recover.  Consequently,  in  all 
the  more  severe  and  persistent  cases  sucli  a  change  is  of  paramount  im- 
portance, and  should  be  made  whenever  the  pecuniary  circumstances  of 
the  patient  will  permit.  Probably  the  best  districts  in  our  own  country 
to  which  the  class  of  patients  under  consideration  can  resort  are  the 
southern  half  of  California,  the  more  moderately  elevated  places  in  New 
Mexico  and  the  western  part  of  Texas,  Mobile  in  Alabama,  Aiken  m 
South  Carolina,  and  most  of  the  interior  parts  of  Georgia  and  Florida. 
My  own  observations  lead  me  to  the  conclusion  that  the  unfortunate 
invalid  suffering  from  any  grade  of  bronchial  inflammation  can  find  in 
some  one  of  the  regions  I  have  named,  all  the  relief  that  he  could  gain 
in  the  most  celebrated  health  resorts  on  the  other  side  of  the  Atlantic. 

In  cases  accompanied  by  known  scrofulous  or  other  cachectic  conditions 
involving  general  impairment  of  nutrition  in  which  sea  air,  in  connection 
with  mildness  of  climate  would  be  desirable,  the  Bermuda  Islands  may 
be  resorted  to  with  a  prospect  of  much  benefit.  In  selecting  places  of  re- 
sort for  the  classes  of  invalids  under  consideration,  care  should  be  exer- 
cised to  prevent  their  choosing  a  residence  on  a  wet  soil  on  the  one  hand, 
or  in  a  region  subject  to  much  dust,  sand,  or  other  particles  of  matter 
floating  in  the  air,  on  the  other.  The  latter  constitutes  a  serious  objec- 
tion to  many  parts  of  the  elevated  plains  lying  on  either  side  of  the  great 
mountain  chain  running  parallel  with  our  Pacific  coast  You  should  also 
remind  all  these  patients  that  faithful  adherence  to  strictly  temperate  and 
judicious  habits  of  life,  with  regular  daily  outdoor  exercise,  is  essential  to 
their  welfare  in  whatever  climate  they  may  choose  to  live. 

Asthmatic  Bronchitis — Catarrhal  Asthma. — Hay  Femr. — Perhaps 
there  will  be  no  better  time  during  the  college  term  than  the  present, 
to  call  your  attention  to  a  brief  consideration  of  certain  morbid  conditions 
of  the  bronchi,  which  involve  both  an  undue  sensitiveness  and  congestion 
of  the  lining  membrane  to  such  a  degree  as  to  approximate  closely  a  true 
inflammatory  condition.  The  cases  which  will  come  to  you  under  the 
popular  name  of  asthma,  may  be  divided  into  two  classes.  The  cases  be- 
longing to  one  class,  are  characterized  by  paroxysms  of  dyspnoea  of  tempo- 
rary duration,  with  intervals  of  entire  absence  of  all  respiratory  symptoms  or 
febrile  phenomena.  These  are  dependent  on  some  form  of  nervous  derange- 
ment, either  direct  or  reflex,  and  consequently  will  receive  due  attention 
in  the  third  division  of  local  diseases.  Those  belonging  to  the  other  class 
are  characterized  by  some  degree  of  persistent  morbid  sensitiveness  of 
the  mucous  membrane,  both  of  the  nasal  and  bronchial  passages,  with  more 
or  less  frequent  attacks  of  d3'spnoea,  generally  aggravated  during  the 
night,  partially  subsiding  during  the  day,  and  lasting  from  three  or 
four  days  to  as  many  months.  This  class  of  cases  are  divisible  clinically 
into  three  groups.  The  first  group  embraces  such  cases  as  are  associated 
with  a  chronic,  rheumatic  or  gouty  diathesis  or  are  symptomatic  of  renal 
or  cardiac  diseases.  In  such,  the  paroxysms  of  bronchial  constriction 
or  asthma  occur  at  entirely  irregular  intervals,  or  whenever  accidental 
causes  supervene,  without  regard  to  special  periodicity  or  season  of  the 
year.  The  second  group  embraces  such  cases  as  recur  at  the  commence- 
ment of  every  cold  season  and  continue  with  varying  degrees  of  severity 
until  the  commencement  of  the  following  summer.  The  third  group  em- 
braces those  peculiar  cases  which  are  strictly  periodical,  recurring  at  a 
given  time  during  the  warm  season  of  each  year,  ;  ome  commencing  in 
June,  some  in  July,  and  a  much  larger  number  in  August,  and  conse- 
quently are  popularly  called  hay  asthma,  or  hay  fever.  In  the  first  group 
of  cases  the  symptoms  during  the  intervals  between  the  paroxysms  belong 


SYMPTOMS.  411 

rather  to  the  associated  constitution  il  or  local  aff-ctions,  than  to  the 
bronchial  trouble;  yet  in  nearly  all  ol'  theni  there  is  sli<^ht  habitual  coui:,-h 
and  slujrtness  of  breath  with  some  wheezing  whenever  attempting  very 
active  exercise.  In  most  instances  the  active  paroxysms  commence  in 
the  night,  without  any  premonitory  nasal  or  catarrhal  symptoms,  and  are 
characterized  by  great  sense  of  tightness  or  constriction  in  the  chest,  ex- 
treme dyspnoea,  the  act  of  inspiration  and  expiration  being  both  difficult 
and  prolonged  as  if  the  air  was  forced  through  very  narrow  tubes  and  ac- 
companied both  in  the  ingress  and  egress  by  all  grades  of  dry  sounds, 
from  the  rough  and  sonorous  to  the  finest,  sibilant  and  piping.  The  pa- 
tient is  obliged  to  sit  upright,  an  1  presents  a  rather  full  and  anxious  ex- 
pression of  countenance;  slight  elevation  of  temperature;  moderate  accel- 
eration of  the  pulse;  cool  and  congested  appearance  of  the  surface  of  the 
extremities;  suspended  digestion ;  inactive  state  of  the  bowels,  and  the 
urine  sometimes  copious  and  limpid  as  water,  at  others  scanty  and  high 
colored. 

As  the  morning  approaches  the  dry  rales  become  mixed  with  sharply 
defined  sub-mucous  rales  and  more  frequent  attempts  to  cough,  with  a 
scanty  amount  of  white,  frothy  expectoration.  The  patient  complains  of 
great  weariness  and  desire  to  sleep,  without  the  ability  to  do  so.  In  most 
cases  by  daylight,  the  dyspnoea  has  so  far  abated  that  the  patient  can  re- 
cline at  an  angle  of  forty-live  degrees,  and  sleep. from  ten  to  fifteen  min- 
utes at  a  time,  from  which  he  rises  suddenly  to  the  upright  position  and 
coughs  hiirshly,  with  more  expectoration  of  thick,  tenacious  mucus,  and 
more  decided  moist  rales  in  the  chest.  The  partial  rel.ef  thus  gained  usu- 
ally continues  through  the  fore  part  of  the  day,  and  in  some  instances 
until  eight  or  nine  o'clock  in  the  evening.  But  all  the  more  severe  symp- 
toms return  at  night  and  pursue  the  same  course  as  during  the  preceding 
night  and  morning.  If  not  interfered  with  by  appropriate  treatment,  the 
same  series  of  phenomena  usually  continue  from  two  to  seven  days,  when 
all  the  more  distressing  symptoms  rapidly  disappear,  coincident  with  a 
critical  evacuation  either  through  the  skin,  kidneys,  or  bowels,  which 
leaves  the  patient  enfeebled  but  comfortable.  In  the  second  group  of 
cases  there  are  no  recognizable  symptoms  during  the  warm  months  of 
summer  except  an  unusual  tendency  to  catarrhal  congestion  in  the  nostrils 
on  slight  exposures  to  currents  of  air,  or  sudden  atmospheric  changes. 
But  during  the  cold,  wet  and  changeable  weather  of  the  latter  part  of 
autumn  the  regular  paroxysms  are  usually  ushered  in  by  the  same  symp- 
toms as  an  ordinary  attack  of  influenza.  There  are  rigors,  followed  by 
moderate  general  fever,  dull  pains  in  the  head  and  back,  stuffing  of  the 
nostrils,  and  sliglit  soreness  of  the  throat.  In  two  or  three  days  the  febrile 
symptoms  have  disappeared  and  the  catarrhal  iiritation  in  the  nostrils  is 
subsiding,  but  as  night  comes  on  the  patient  feels  a  sense  of  tightness 
with  slight  dry  wheezing  in  his  chest,  andalittle  disposition  to  cough.  He 
retires  at  the  usual  time  but  has  hardly  become  iincoiiscious  in  sleep,  be- 
fore he  is  aroused  by  dyspnoea  and  all  the  symptoms  described  as  charac- 
terizing the  paroxysms  in  the  first  group  of  cases.  The  asthmatic  part  of 
the  difficulty  having  thus  begun,  usually  continues  in  some  degree 
throughout  the  whole  of  the  cold  season  of  the  year.  The  dyspnoea  and 
dry  rales  are  pretty  unifoimly  increased  during  the  first  half  of  the  night, 
but  lessened  with  more  moisture  toward  morning,  ending  in  considerable 
coughing  and  mucous  expectoration  in  the  morning;  and  usually  after  the 
first  week  or  two  the  patient  is  able  to  be  up  and  attending  to  some  work 
or  business  during  the  day  and  suffering  onlv  moderately  during  the  night. 
In  some  cases  during  the  steady,  dry  cold  of  xnid- winter  all  symptoms  will 


412  ASTHMATIC    BEONCHITIS. 

so  far  disappear  as  to  allow  the  patient  to  appear  quite  well;  but  they  are 
pretty  uniformly  renewed  with  more  or  less  severity  by  every  marked 
chanare  involving  cold  and  damp  air.  In  some  cases,  however,  the  disease 
is  so  severe  and  continuous  that  tiie  patient  is  obliged  to  keep  in-doors 
and  be  bolstered  up  in  bed  or  sit  in  a  chair  every  night  during  the  co!d 
season,  unless  he  flees  to  a  mild  and  dry  climate.  Casps  belonging  to  this 
group  may  occur  at  any  period  of  life,  but  you  will  meet  with  them  far 
more  frequently  in  ]  atients  over  forty  years  of  age  than  at  an  earlier 
period.  PatlioloTically  this  group  of  cases  would  appear  to  consist  of  a 
mild  grade  of  chronic  bronchitis  involving  such  a  morbid  seubitiveness  of 
the  bronchial  nerves  as  to  add  the  constricting  infl  ences  which  cause 
the  distressing  dyspnoea  that  so  tcjrments  the  patient  and  robs  him  of  rest 
at  night.  In  the  third  group  of  cases  the  patients  usually  present  no 
symptoms  of  irritation  or  trouble  of  any  kind  in  the  air  p-rissages,  in  the 
interval  between  the  attacks.  But  suddenly,  at  some  particular  time  each 
summer,  they  are  attacked  with  coryza  or  symptoms  of  simple  irritation  of 
the  Sfhneiderian  m?mbrane.  In  from  one  to  three  days  this  subsides,  but 
coincident  with  such  subsidence  the  patients  begin  to  feel  the  sense  of 
tightness  in  the  chest  which  soon  culminates  in  a  full  paroxysm  of  dyspnoea 
with  all  the  s^^mptoms  mentioned  in  describing  the  paroxysms  in  the  first 
group  of  cases.  The  regular  increase  of  all  the  symptoms  at  night  pre- 
vents the  patients  from  taking  the  recumbent  position,  robs  them  of  all 
restful  sleep,  aiid  causes  a  great  sense  of  weariness  and  inability  to  inake 
much  effort  to  be  up  or  out  >  iiring  the  day.  When  once  begun,  the 
natural  tendency"  of  all  of  this  class  of  cases  is  to  continue  from  one  to 
three  months,  or  until  the  frosts  of  autumn  appear.  You  will  not  fail  to 
notice  that  the  distinguishing  features  of  all  cases  belonging  to  this  group, 
are  their  strict  periodicity,  their  commencement  in  the  summer,  and  their 
definite  self-limited  duration. 

JJiagnosis. — The  cases  belonging  to  all  the  groups  I  have  described  are 
distinguished  from  the  other  varieties  of  bronchitis  by  the  distinct 
paroxysmal  character  of  the  phenomena,  the  apparently  spasmodic  quality 
of  the  dyspnce.i,  and  the  little  tendency  to  muco-purulent  expectoration 
or  the  accumulation  of  inflimmatory  products  in  the  bronchial  membrane. 
From  pneumonia,  pulmonary  cedema,  tuberculosis,  and  pleuritic  effusions, 
they  are  distinguisiied  by  the  predominance  of  dr}^  wheezing  rales,  pro- 
longed expiratory  acts,  and  the  absence  of  both  increased  vocal  fremitus 
and  dullness  on  percussion.  From  pulmonary  emphysema  they  are  dis- 
tinguished by  the  paroxysmal  character  of  the  dyspno3a  and  its  temporary 
duration,  whde  that  of  emphysema  is  more  continuous  and  generally 
permanent. 

Prognosis. — None  of  the  cases  belonging  to  the  class  of  affections  now 
under  consideration  are  liable  to  terminate  fatally  unless  they  become 
complicated  with  other  more  dangerous  forms  of  disease.  Indeed,  many 
of  the  cases  affected  with  annually  recurring  attacks  of  asthmatic  bron- 
chitis iiave  lived  beyond  three  score  and  ten  years. 

Treatment. — As  the  cases  ])elonging  to  the  first  and  second  groups  are 
pathologically  similar  to  the  milder  grades  of  catarrhal  and  rheumatic  bron- 
chitis, with  the  a<ldition  of  irritation  of  the  muscular  fibers  of  the  smaller  bron- 
chi causing  their  contraction,  so  you  will  find  the  treatment  I  have  already 
explained  as  applicable  to  those  varieties  equally  applicable  in  the  cases 
l>elonging  to  the  groups  named;  provided,  you  can  add  some  element  or 
influence  that  will  more  directly  lessen  the  morbid  sensitiveness  of  the 
nerves  controlling  the  action  of  the  muscular  fibers  and  thereby  relieve 
their  spasmodic  contraction.       In   the   limited   number  of  cases  that  are 


TREATMENT.  413 

distinctly  connected  with  the  rheumatic  or  gouty  diatheses  the  nervous 
irritation  is  dependent  on  the  retention  in  the  blood  of  the  same  morbid 
material  that  causes  local  irritation  in  other  parts  of  the  fibrous  structures 
of  the  body.  Consequently  the  most  speedy  and  effectual  relief  is  to  be 
obtained  by  combining  with  the  anti-rheumatic  or  anti-gout  remedies  som.e 
agents  that  will  lessen  the  sensibility  of  the  bronchial  nerves,  and  there- 
by lessen  the  constriction.  In  many  of  the  rheumatic  cases  I  have  seen  very 
great  relief  obtained  by  simply  adding  to  the  treatment  I  have  already 
advised  for  rheumatic  bronchitis  a  simple  dose  composed  of  from  three 
to  five  decigrams  (gr.  v  to  viii)  of  sulphate  of  quinia  and  fifteen  milligrams 
(gr.  ^)  of  codeia,  between  eight  and  nine  o'clock  each  evening.  In  cases 
complicated  with  the  gouty  diathesis  I  have  found  no  combination  more 
promptly  beneficial  than  the  bromide  of  lithium  and  wine  of  colchicum, 
as  in  the  following  formula:  ^ 

'^      Lithii  Bromidi,  20.0  grams     3v 

Vini  Colchici  Radicis,  20.0    c.  c.       3v 

Elixer  Sinplicis,  120.0    c.  c.       ?iv 

Mix.  Of  this  four  cubic  centimeters  (fl  3i)  may  be  given  every  three,  four, 
or  six  hours  until  relief  is  obtained  or  the  colchicum  begins  to  disturb  the 
bowels. 

In  a  large  proportion  of  the  cases  belonging  to  the  second  group,  as 
previously  desci-ibed,  the  combination  of  bromide  and  iodide  of  potassium 
with  the  fluid  extract  of  the  grindelia  robusta  and  stramonium  will  afford 
much  relief.     The  following  is  a  convenient  formula: 

5 


Potassii  Bromidi, 

25.0  grams 

3vi 

Potassii  lodidi. 

15.0  grams 

3iv 

Extracti  Grindeliee  Fluidi, 

60.0     c.  c. 

!ii 

Tincturfe  Stranaonii, 

15.0     c.  c. 

3iv 

Elixir  Simplicis, 

45.0     c.  c. 

jiss 

Mix.  Of  this  four  cubic  centimeters  (fl.  3i)  may  be  given  in  a  little 
additional  water  every  four  or  six  hours,  until  some  relief  is  obtained, 
after  which  it  may  be  continued  three  times  a  day  until  the  relief  is  more 
complete.  In  maoy  of  thes'e  cases  the  addition,  to  this  treatment,  of  a 
single  powder  of  sulphate  of  quinia  and  codeia  at  night,  will  give  much 
better  rest,  without  inducing  unpleasant  secondary  effects.  In  some  of 
these  cases,  the  formula  I  have  already  given  you  during  the  present 
hour,  containing  muriate  of  ammonia  with  small  quantities  of  antimony 
and  morphia,  may  be  substituted  for  that  containing  the  bromides  and 
iodides,  continuing  to  use  the  quinia  three  times  a  day.  without  the 
codeia.  Some  writers  strongly  recommend  the  use  of  morphia  by  hypo- 
dermic injection,  either  alone  or  in  conjunction  with  chloral  hydrate  by 
the  stomach.* 

There  is  no  doubt  about  theefficac}^  of  the  hypodermic  injection  of  the 
sulphate  of  morphia,  in  temporarily  relieving  the  paroxysms  of  dysp- 
noea; but  very  great  caution  is  required  in  its  use  in  all  such  cases. 
When  the  patient  has  already  been  laboring  under  the  dyspnoea  several 
hours  and  the  blood  is  consequently  impregnated  with  an  excess  of  the 
retained  carbonic  acid  gas,  the  quick  development  of  the  narcotic  influ- 
ence of.an  ordinary  hypodermic  injection  of  the  sulphate  of  morphia,  not 

*  See  Practice  of  Medicine,  by  Bartholow,  p  420. 


414  *  HAY-ASTHMA. 

only  affords  prompt  relief  to  the  dyspnoea,  and  induces  sleep,  but  co- 
operating with  the  depressing  qualities  of  the  retained  carbonic  acid  gas, 
there  is  great  danger  of  so  far  paralyzing  the  respiratory  function  that 
death  will  follow  in  a  few  hours.  Two  such  cases  have  come  to  my 
knowledge  in  this  city,  during  the  past  year.  Both  were  supposed  to  be 
laboring  under  simple  severe  paroxysms  of  catarrhal  asthma,  to  which 
they  had  been  subject,  when  the  attending  physician  gave  not  more  than 
fifteen  milligrams  (gr.  ^)  of  morphia  hypodermically.  In  each  case  the 
breathing  soon  became  easier  and  sleep  followed.  In  a  little  while  the 
patients  began  to  breathe  more  heavily,  and  to  make  no  response  to  efforts 
to  arouse  them,  and  died  in  from  six  to  eight  hours. 

I  have  known  similar  results  to  follow  in  some  cases  of  delirium  tre- 
mens, in  which  liberal  doses  of  chloral  hydrate  had  been  given,  until  the 
system  was  well  supplied  with  it,  and  yet  not  controlling  the  nervous 
agitation  and  morbid  vigilance,  a  hypodermic  injection  of  morphia  was 
resorted  to  by  the  attending  physician,  with  the  effect  of  speedily  induc- 
ing a  sleep  from  which  there  was  no  awaking.  It  is  my  duty  to  caution 
you,  therefore,  against  resorting  to  hypodermic  injections  of  morphia  or 
other  active  opiate  preparations  when  the  blood  is  already  imperfectly 
decarbonized  from  existing  dyspnoea,  or  impregnated  with  -previous  lib- 
eral doses  of  other  narcotics  or  ansesthetics,  lest  the  sudden  development 
of  the  additional  effect  of  your  hypodermic  should  carry  the  suspension 
of  nerve  sensibility  one  step  too  far,  and  fatally  paralyze  the  respiratory 
movements. 

•  In  the  treatment  of  the  third  group  of  cases,  or  those  popularly  called 
hay-asthma  or  hay-fever,  a  great  variety  of  remedies  have  been  tried  with 
but  little  apparent  benefit.  In  some  cases  that  have  come  under  my 
observation  during  the  last  few  years  the  usual  annual  attack  has  been 
prevented,  and  in  others  rendered  very  mild,  by  commencing  the  use  of 
quinine  two  weeks  before  the  time  for  the  expected  attack,  giving  from  two 
to  three  decigrams  (gr.  iiitov)  morning  and  evening  during  the  first  week, 
and  the  same  doses  three  times  a  day  during  the  second  and  third  weeks, 
or  until  one  full  week  after  the  time  the  attack  had  usually  commenced. 
At  the  same  time  with  the  use  of  the  quinine  internally,  the  patients  have 
been  required  to  inhale  through  the  nostrils  three  or  four  times  a  day,  the 
vapor  of  the  oil  of  eucalyptus  globulus  from  a  small  vial  which  they  could 
carry  in  their  pockets.  The  number  of  cases  thus  treated  for  the  purpose 
of  preventing  an  attack  is  not  large  enough  to  test  the  real  value  of  the 
plan;  but  so  far  as  it  has  been  faithfully  tried  it  has  proved  positively 
beneficial.  Of  course,  in  all  these  cases,  due  attention  was  given  to  the 
legularity  of  the  digestive  organs  and  the  excretory  functions  of  the  skin 
and  kidneys.  After  the  patient  has  passed  one  week  beyond  the  regular 
time  for  the  attack  to  commence,  without  its  recurrence  the  use  of  the 
quinine  may  be  diminished  to  thirteen  centigrams  (gr.  ii),  mortiing  and 
evening,  and  one  week  later  to  only  one  dose  every  morning.  But  the 
inhalation  of  the  vapor  of  the  eucalyptus  should  be  continued  two  or 
three  times  a  day  until  the  season  for  the  active  prevalence  of  the  disease 
is  passed.  Instead  of  inhaling  the  vapor  of  the  eucalyptus  oil,  others 
have  used  with  supposed  benefit  free  washing  of  the  nostril  with  a  solu- 
tion of  sulphate  of  quinia,  every  morning  and  evening,  for  the  purpose 
of  destroying  the  germs  which  are  supposed  to  impinge  on  the  Schnei- 
derian  membrane  and  to  be  the  active  agents  in  producing  the  disease. 

On  the  same  theory  of  causation,  one  man  is  reported  to  have  prevented 
the  return  of  his  usual  attacks  by  constantly  wearing  a  gauze  veil  over 
his  mouth  and  nostrils.     When  preventive  treatment    has   been  neglected 


TREATMENT.  415 

or  hcas  proved  unsuccessful,  and  an  attack  has  already  commenced,  I  have 
seen  much  relief  obtained  by  the  use  of  a  mixture  of  the  fluid  extracts  of 
the  grindelia  robusta,  the  eucalyptus  globulus,  and  tincture  of  stramo- 
nium, with  bromide  of  potassium  as  in  the  following  formula: 

i^     Potassii  Bromidi,  25.0  grams  3vi 

Extracti  Grindelife  Robustte  Fluidi,  60.0     c.  c.  ^.ii 

Extracti  Eucalypti  Globuli  Fluidi,  60.0     c.  c.  rii 

Tinctur^e  Stramonii,  15.0     c.  c.  3iv 

Mix.  Four  cubic  centimeters  (fl.  3')  of  this  mixture  may  be  given 
every  four  or  six  hours,  in  a  little  sweetened  water;  and  in  addition  from 
two  to  three  decigrams  (gr.  iii  to  v)  of  sulphate  of  quinia  each  morning 
and  evening.  When  much  dyspnoea  has  supervened,  hfteen  milligrams 
(gr.  ^)  of  codeia  or  morphia  may  be  added  to  the  evening  dose  of  the  qui- 
nine. In  the  early  stage,  while  the  membrane  lining  the  nostrils  is  con- 
gested, presenting  the  ordinary  symptoms  of  coryza,  the  nostrils  should  be 
r'nsed  every  morning  with  a  solution,  either  of  quinine,  carbolic  acid,  or  ben- 
zoate  of  sodium,  and  the  vapor  of  the  oil  of  eucalyptus  inhaled  frequently 
during  the  day.  In  many  cases,  the  patients  obtain  much  temporary  relief 
from  smoking  pastiles  or  cigarettes  made  of  stramonium  leaves  previously 
soaked  in  a  solution  of  nitrate  of  potassium.  When,  as  sometimes  hap- 
pens in  the  night,  the  paroxj^sms  of  dyspnoea  become  very  distres-^ing, 
and  the  means  already  mentioned  fail  to  afford  relief,  the  temporary  and 
cautious  inhalation  of  either  ether,  chloroform,  or  nitrite  of  am}^  may  be 
resorted  to.  In  some  of  this  class  of  cases  you  will  find  a  degree  of  sore- 
ness in  the  chest  and  feverishness  indicating  a  more  decided  inflimmatory 
action  in  the  bronchial  membrane.  In  such,  the  formula  I  have  given  you 
containing  muriate  of  ammonia  (see  page  406)  should  be  given  in  place  of 
that  containing  the  grindelia  robusta,  or  from  six  to  ten  decigrams  (gr.  x 
to  xv)  of  iodide  of  potassium  may  be  given  dissolved  in  the  syrup  of  gly- 
cyrrhiza  three  times  a  day.  Many  other  remedies  have  been  tried  and  rec- 
ommended by  different  parties  in  the  treatment  of  this  disease,  but  they 
all  generally  fail  to  do  more  than  palliate  the  more  distressing  symptoms 
until  the  season  for  the  continuance  of  the  disease  has  passed  when  it 
ceases  spontaneously,  leaving  the  patient  much  impaired  in  strength,  both 
of  body  and  mind;  but  from  which  he  recovers  in  a  few  weeks,  with  the 
assistance  of  plain  food,  pure  air  and  moderate  exercise. 

Pro2')hylaxis. — From  the  fact,  developed  by  common  observation  and 
confirmed  by  the  investigations  of  Dr.  Morrell  Wyman  and  others,  that 
this  variety  of  disease  prevails  only  in  certain  (iistricts  of  country  and  at 
seasons  of  the  year  when  vegetation  is  well  developed,  and  does  not  pre- 
vail in  other  locations,  it  has  generally  been  supposed  to  originate  from 
the  inhalation  of  fungi,  or  the  pollen  of  flowering  grasses  floating  in  the  air. 
But  whether  the  disease  is  caused  by  these,  or  by  the  organic  germs  dis- 
covered by  Helmholtz,  or  by  neither,  the  impo.tmt  fact  remains,  that 
large  districts  of  country  are  entirely  exempt  from  the  prevalence  of  the 
disease.  And  consequently  the  most  certain  of  all  the  prophylactic 
measures  is  for  the  susceptible  parties  to  resort  to  some  one  of  these  local- 
ities during  the  season  of  the  liability  to  an  attack,  or  still  better  to  make 
such  locality  their  permanent  place  of  n^sidence.  In  our  country  the 
places  of  non-prevalence  of  this  disease  embrace  the  mountain  districts  of 
New  Hampshire,  Vermi  nt  and  New  York,  continuing  with  the  Allegheny 
range  southward  to  its  termination  in  the  Southern  States;  also  the  island 
of  Mackinaw,  Marquette,  and  all  the  territory  around  Lake  Superior;   to- 


416  PNEUMONIA. 

gether  with  the  great  mountain  ranges  stretching  from  Dakota  to  the  ta- 
ble lands  of  Western  Texas,  and  the  western  or  Pacific  slope  of  the  Sierra 
Nevadas.  In  almost  any  part  of  these  elevated  regions  and  in  some  more 
limited  districts  not  elevated,  the  sufFere*  from  bronchial  asthma  or  hay- 
fever  may  obtain  entire  exemption,  either  by  a  temporary  resort  during 
the  season  of  his  liability  to  an  attack  or  by  a  permanent  residence. 


LECTURE  XLIII. 


Pneumonia— Its  Historjr,  Causes,  Symptoms,  Pathological  Anatomy,  Diagnosis  and  Prognosis. 

GENTLEMEN:  The  disease  to  which  I  invite  your  attention  during  the 
present  hour,  is  one  of  the  most  important  inflammatory  affections 
that  you  will  meet  in  your  ordinary  fields  of  general  practice.  By  pneumonia 
is  meant  an  inflammation  of  the  parenchyma  of  the  lung.  Descriptions  of 
the  disease,  more  or  less  accurate,  are  to  be  found  in  the  earliest  records 
of  medical  literature,  although  it  was  not  clearly  differentiated  from 
bronchitis  and  pleurisy  until  the  beginning  of  the  present  century.  By 
many  of  the  early  writers  it  was  called  peri-pneuraonia,  by  others 
malignant  pleurisy,  bilious  pleurisy,  and  when  complicated  with 
capillary  bronchitis,  peri-pneumonia-  notha.  By  Dr.  Gallup,  in  his  history 
of  the  epidemics  of  Vermont  from  1800  to  1815,  and  by  other  early  New- 
England  writers,  the  disease  is  often  called  malignant  pleurisy,  peri- 
pneuraonia,  and  pneumonia  typhoides.  From  these  writers  it  would  appear 
that  the  disease  was  not  only  of  frequent  occurrence  in  the  latter  part  of 
winter  and  early  spring,  but  in  some  localities  assumed  a  very 
malignant  and  fatal  character.  At  the  present  time  it  is  generally  called 
pneumonia,  pneumonitis,  or  pjneumonic  fever.  By  most  writers  two 
varieties  are  recognized,  namely,  tiie  croupous  and  the  catarrhal.  The 
first  name  is  used  to  designate  such  cases  as  attack  the  parenchyma  of 
the  lung  primarily,  and  the  second,  such  as  are  complicated  with  or  are 
secondary  to  the  symptoms  of  bronchitis.  When  the  inflammation  attacks 
a  section  of  the  lung  it  is  called  lobar  pneumonia;  when  it  invades 
separate  lobules,  either  primarily  or  by  extension  from  the  smaller  bronchi, 
it  is  called  lobular  or  disseminated  pneumonia;  and  if  the  latter  continues 
in  a  chronic  form  it  is  generally  called  interstitial  pneumonia  and  some- 
times fibroid  phthisis  or  pulmonary  sclerosis.  When  it  has  prevailed  in 
malarious  districts,  and  the  accompanying  fever  has  shown  distinct  ex- 
acerbations and  remissions  it  has  been  styled  bilious  pneumonia  or  luiig 
fever. 

JEtiolorjy. — The  prevalence  of  pneumonia  is  influenced  by  climate, 
season  of  the  year,  occupation  and  habits,  age,  sex,  and  previous  condition 
of  health.  The  statistics  presented  by  Dr.  Samuel  Forrey  in  his  work  on  the 
climate  of  the  United  States,  to  which  I  have  referred  in  previous  lectures, 
appeared  to  show  that  pneumonia  was  most  prevalent,  and  caused  the 
highest  ratio  of  mortality,  in  what  he  called  the  middle  climatic  belt,  which 
embraces  that  part  of  our  country  lying  between  the  thirty-third  and  the 


CAUSES.  417 

tliirty-ninth  parallels  of  latitude,  and  extending  from  the  Atlanac  coast  to 
the  eastern  slope  of  the  Rocky  Mountains.  It  is  in  that  belt  of  country 
that  you  find  long  continued  and  high  summer  heat,  and  though  the 
winters  are  short  they  usually  embrace  one  or  more  periods  of  intense 
cold,  which  gives  the  thermoraetric  combination  of  long  and  warm  sum- 
mers, short  and  cold  winters,  and  a  wide  range  between  the  warmest  days 
of  summer  and  the  coldest  days  of  winter.  Other  circumstances  being 
equal  it  was  where  these  characteristics  were  most  marked  that  he  found 
attacks  of  pneumonia  to  occur  numerically  most  frequent  and  to  prove 
most  fatal.  It  must  be  remembered,  however,  that  the  statistics  compiled 
by  Dr.  Forrey,  and  to  some  extent  re-produced  by  Dr.  Drake  in  his  work 
on  the  topograph}^  and  diseases  of  the  Interior  Valley  of  the  Continent, 
relate  exclusively  to  adult  males,  as  represented  by  soldiers  and  officers 
in  the  United  States  army.  And  while  this  makes  the  conditions  for 
comparison  in  some  respects  more  uniform,  yet  the  liability  of  soldiers  to  be 
frequently  changed  from  one  place  to  another,  and  the  absence  of  both  chil- 
dren and  old  persons,  may  cause  the  result  to  be  somewhat  different  from 
what  it  would  be  if  the  comparison  could  be  based  on  equally  correct  statis- 
tics of  the  sickness  and  mortality  in  a  resident  population  of  all  ages  and 
both  sexes.  The  statements  made  by  standard  writers  in  regard  to  the 
effects  of  climate  on  the  prevalence  and  mortality  of  pneumonia  are  very 
general  and  in  some  respects  contradictory.  Thus  one  of  the  latest  writers 
on  practical  medicine  says:  "Its  prevalence  is  extensive  over  the  globe, 
and  it  is  found  nearly  alike  in  all  latitudes."  *  xVnother  simply  remarks 
that  "  it  occurs  in  ail  degrees  of  latitude,  under  every  variety  of  climate, 
and  at  all  ages."  f 

These  expressions  would  lead  you  to  suppose  that  climate  exerted  little 
or  no  influence  over  the  prevalence  of  the  disease.  On  the  other  hand,  Drs. 
Drake  and  Flint  represent  the  disease  as  much  more  prevalent  and  fatal 
in  the  Middle  and  Southern  States  than  in  the  Northern.  The  latter 
says:  "In  this  country  the  disease  occurs  in  the  Middle  and  Southern 
much  oftener  than  in  the  Northern  States. "J  You  will  be  able  to  judge 
better  of  the  value  of  these  general  statements,  and  also  concernins:  the 
differences  between  statistics  exclusively  from  military  posts  compared 
with  those  from  large  cities  with  their  mixed  and  dense  populations,  by 
the  following  figures  relative  to  the  ratio  of  mortality  from  pneumonia  in 
the  cities  of  Chicago,  New  Orleans  and  San  Francisco  for  the  year  1882, 
derived  from  the  official  reports  of  the  health  officers  of  the  cities  named  : 
The  whole  number  of  deaths  from  pneumonia  in  Chicago  in  1882,  as  re- 
ported from  the  health  office,  was  782;  that  is,  1  for  every  G45  of  the 
entire  population,  as  giveri  in  the  census  of  1880.  The  whole  number 
reported  in  New  Orleans  for  the  same  year  was  only  203,  or  one  for  every 
1088,  of  the  population  as  given  by  the  same  census.  The  whole  num- 
ber of  deaths  from  pneumonia  reported  in  San  Francisco,  during  1882, 
was  452,  which  makes  one  death  to  every  518  of  the  population.  Lest 
there  should  have  been  some  extraordinary  or  unusual  prevalence  of  the 
disease  in  Chicago  in  1882,  I  extended  ray  examination  of  the  records  to 
three  consecutive  years,  and  found  the  average  ratio  of  deaths  from  pneu- 
monia for  the  years  1 880-1-2,  to  have  been  one  in  765  of  the  whole  pop- 
ulation. You  thus  see  that  the  actual  mortuary  statistics  show  a  very 
decidedly  greater  prevalence  of  pneumonia  in  this  city,  representing  the 

*  See  Science  and  T  raclice  of  Medicine,  Vol.  II..  p.  2W,  1582,  by  A.  B.  Palmer,  il.  D.,  etc. 
tSee  Practice  of  Medicine,  p.  32-5, 1881.    Bv  Roberts  Bartholow,  M.  D. 
t  See  I'ractice  of  Medicine,  p.  i68,  ItSl.    By  Austin  Fliut,  M.  D. 

27 


418  PNEUMONIA. 

nortliorn  part  of  the  great  interior  valley  of  our  country  tlian  in  Now  Or- 
leans, which  represents  the  southern  part  of  the  yarae  valley.  Without 
taking  time  to  work  out  the  details,  I  have  extended  the  examination  far 
enough  to  show  that  the  same  results  would  appear  if  the  comparison 
should  be  extended  to  the  cities  of  Buff  do,  New  York  and  Boston,  in 
contrast  with  Mobile,  Jacksonville  and  Charleston,  as  representino-  the 
north-eastern  and  south-eastern  parts  of  our  country. 

A  similar  examination  of  such  official  returns  as  are  within  mv  reach 
concerning  the  mortality  from  pneumonia  in  the  cities  of  Washington, 
Cincinnati  and  St.  Louis,  representing  the  middle  belt  or  zone,  as  de- 
scribed by  Dr.  Forrey,  appears  to  show  a  slightly  larger  ra'io  of  deaths 
in  proportion  to  the  population  than  the  cities  of  the  northern  belt.  The 
difference,  however,  is  not  great.  From  such  fragmentary  facts  as  I  have 
been  able  to  gather  from  reports  on  epidemics  and  on  the  prevalence  of 
acute  diseases,  made  to  the  American  Medical  Association  and  to  several 
of  the  State  medical  societies,  I  think  the  same  relative  ratio  of  mortality 
from  pneumonia  exists  in  the  country  districts  of  the  Northern,  Middle 
and  Southern  belts  as  in  the  cities  I  have  named.  While  it  is  true,  there- 
fore, that  pneumonia  prevails  to  some  extent  over  a  large  part  of  the  in- 
habited portions  of  the  globe,  it  is  nevertheless  influenced  very  much  by 
climate;  being  more  prevalent  and  causing  a  higher  ratio  of  mortality 
in  the  middle  and  northern  parts  of  the  United  States  than  in  the  south- 
ern. The  same  rule  applies  to  the  Pacific  slope,  embracing  the  States  of 
California  and  Oregon,  which  are  represented  by  some  writers  as  enjoying 
a  singular  immunity  from  the  disease;*  while  the  statistics  of  mortality 
in  Sail  Francisco  for  1882,  as  I  have  already  stated  to  you,  show  a  higher 
ratio  of  mortality  from  it,  than  either  Chicago  or  New  Orleans.  The  Jfact 
that  pneumonia  is  more  prevalent  in  cold  than  warm  climates  is  corrobo- 
rated by  the  influence  of  season  of  the  year. 

Sexisons. — Of  the  782  deaths  from  pneumonia  in  Chicago  in  1882,  295 
occurred  during  the  first  quarter,  245  during  the  second,  8->  during  the 
third  and  158  during  the  fourth.  Of  the  203  deaths  reported  in  New  Or- 
leans for  the  same  year,  86  occurred  during  the  first  quarter,  58  during 
the  second,  35  the  third  and  24  the  fourth.  In  San  Francisco  for  the 
same  year,  of  452  deaths  from  this  disease,  225  occurred  duHng  the  first 
quarter,  108  the  second,  44  the  third  and  75  the  fourth. 

From  these  figures  it  appears  that  about  two- thirds  of  all  the  deaths 
occur  during  the  first  six  months  of  the  year,  and  that  the  causes  of  the 
disease  reach  their  highest  degree  of  activity  about  the  middle  or  climax  of 
the  winter  season,  and  continue  active  until  the  beginning  of  summer. 
-From  a  table  giving  the  number  and  causes  of  deaths,  in  the  city  of 
Memphis  in  1852,  I  learn  that  the  number  of  deaths  from  pneumonia  was 
26.  The  population  was  then  estimated  to  be  12,000,  which  would  be  1 
in  4^1  of  the  population.  Of  the  26  cases  12  occurred  during  the  first 
quarter,  4  the  second,  7ione  the  thirds  and  10  the  fourth. f 

The  statistics  derived  from  the  various  military  posts  give  the  highest 
ratio  of  attacks  during  the  first  quarter,  while  in  some  places  the  next 
highest  was  in  the  second  and  others  in  the  fourth;  but  all  agree  in  giving 
the  lowest  ratio  of  both  cases  and  deaths  in  the  third  quarter,  composed- 
of  July,  August  and  September.  Throughout  the  countries  of  Europe 
the  same  influence  of  the  seasons  is  observable  as  in  this  country. J 

Occupation  ayid  Habits. — Pneumonia  is   undoubtedly  mure   frequently 

*See  Reynolds'  System  of  Melicine,  American  edition,  Vol.  II,  p.  154. 
tSee  Transac-tioiis  oi  tlie  AmericHn  Medical  Association.  Vol.  VI,  p.  'i'ld,  1853. 


tSee  Transactions  oi  the  American  Medical  Association.  Vol.  VI^  p. 
J  .-ee  Reynold's  System  ot  Medicine,  American  edition,  Vol.  II,  p  155 


CAUSES.  419 

met  with  amon^  those  classes  whose  occupations  cause  them  to  be  most 
exposed  to  the  vicissitudes  of  the  seasons,  and  are  scantily  supplied  wiih' 
the  means  of  protection.  In  the  Southern  States  the  colored  population 
suffer  in  a  greater  ratio  than  the  white,  especially  in  the  plantation 
districts.  The  same  is  true  concerninp^  the  Monp^olians  in  San  Francisco, 
and  the  poorer  laboring  classes  of  the  foreign  population  in  all  the 
Northern  cities.  Perponal  habits  also  exert  an  important  influence. 
Living  and  sleeping  in  overcrowded  apartments;  wearing  insufficient 
clothing  to  protect  the  surface  from  sudden  and  severe  atmospheric 
chatifjes;  and  more  than  all,  the  free  use  of  alcoholic  drinks.  The  latter 
act  directly  by  impairing  the  vasomotor  nerve  influence  and  lessening  the 
efficiency  of  the  processes  of  disintegration  and  elimination,  and  indirectly, 
by  leading  those  under  their  excessive  influence  into  severe  exposures, 
w-hile  the  power  of  vital  resistance  is  impaired. 

Age. — You  will  find  cases  of  pneumonia  occurring  at  all  periods  of  life. 
But  as  might  be  inferred  from  what  I  have  just  said  about  the  influence 
of  occupations  and  habits,  it  occurs  more  frequently  in  the  middle  period 
of  adult  life,  that  is,  from  twenty  to  forty  years  of  age  than  either  earlier 
or  later  in  life.  The  next  periods  most  liable  to  attacks  are  those  of  in- 
fancy, or  under  five  years  and  over  sixty. 

Sex. — The  same  circumstances  that  determine  the  attacks  to  occur  more 
frequently  among  the  most  exposed  part  of  the  adult  population,  also 
operate  to  render  the  attacks  more  frequent  in  men  than  in  women,  in 
the  ratio  of  two  or  three  to  one.  This  applies,  however,  chiefly  to  the 
cases  occurring  during  the  active  period  of  adult  life;  the  excess  among 
males  be'ng  much  less  in  early  childhood  than  at  the  subsequent  periods. 

Previous  Condition  of  Health. — You  will  see  it  stated  by  some  writers 
that  pneumonia  attacks  the  vigorous  and  healthy  more  frequently  than 
the  infirm.  This  opinion  has  doubless  arisen  from  the  fact  that  it  is  chiefly 
the  vigorous  and  healthy  who  engage  in  such  occupations  as  subject  them 
to  the  exposures  and  hardships  most  likely  to  induce  attacks,  while  the 
weaker  and  more  delicate  seek  less  severe  work  and  better  protection.  If 
both  classes  were  subjected  to  the  same  degree  of  labor  and  exposures, 
there  is  no  doubt  but  the  weaker  would  give  a  much  higher  ratio  of  at- 
tacks than  the  more  robust.  And  yet,  with  the  exception  of  pulmonary 
tuberculosis,  I  have  not  been  able  to  see  any  special  predisposition  to 
attacks  of  pneumonia  during  the  progress  of  other  diseases  or  constitutional 
cachexies.  That  the  presence  of  jDrimary  tubercular  deposits  greatly 
favors  the  development  of  pneumonic  inflammation  in  the  tissues  sur- 
rounding such  deposits,  I  have  no  doubt. 

Exciting  Causes. — Many  cases  of  pneumonia  occur  without  any  appar- 
ent exciting  causes.  Many  other  cases  are  traceable  to  exposure  to  cold 
currents  of  air  upon  limited  parts  of  the  surface,  or  to  such  protracted 
severe  cold  as  to  chill  the  whole  body  and  depress  the  vason)otor 
influence  over  the  systemic  circulation.  Severe  exercise  in  the  face  of 
strong  cold  winds  is  very  liable  to  provoke  an  attack.  In  advanced  life, 
after  the  cartilages  of  the  ribs  nave  become  bony  and  the  frame  work  of 
the  chest  less  movable,  all  severe  physical  exercise  is  more  liable  to  be 
•  followed  by  pneumonic  inflammation.  Some  fatal  cases  have  occurred  in 
such  persons  under  my  own  observation,  directly  induced  by  unusual  run- 
ning to  reach  a  railroad  depot  before  an  expected  train  should  pass. 
There  is  no  tangible  evidence  that  pneumonia  is  caused  by  any  specific 
materies  morbi,  whether  organic  or  inorganic.  On  the  contrary,  its 
occurrence,  to  some  extent,  in  all  civilized  countries  and  at  all  seasons  of 
the  year,  yet  being  markedly  influenced   in   the  degree  of  its  prevalence 


420  Pls^EUMOXIA. 

by  both' climate  and  seRSon,  its  frequent  association  with  pleurisy  on  the 
one  side  and  bronchitis  on  the  other,  its  constant  variations  in  the 
amount  of  lung  tissue  involved,  being  in  a  large  majority  of  cases  uni- 
lateral, and  in  most  of  them  coii fined  to  one  or  two  lobes,  and  its  entire 
exemption  from  the  law  that  one  attack  destroys  the  susceptibility  to 
subsequent  attacks,  render  the  question  of  its  dependence  on  any  one 
specific  exciting  cause  highly  improbable,  and  give  it  much  more  fully 
the  characteristic  of  an  acute  local  infiaramation,  than  of  a  general  febiile 
disease. 

Symptoms. — The  symptoms  and  progress  of  pneumonia  vary  in  some 
degree  from  the  varying  circumstances  under  which  it  occurs.  In  most 
cases  of  acute  lobar  pneumonia  the  attack  commences  with  a  chill  or 
chilliness  simultaneously  with  a  dull  or  deep  seated  pain  in  one  side  of 
the  chest,  and  sense  of  oppression  or  difficulty  in  breathing.  The  cold- 
ness soon  gives  place  to  increased  heat;  redness  of  the  face;  shorter  and 
quicker  breathing;  increased  pain  or  sense  of  oppression  in  the  chest, 
with  some  cough.  The  pulse  becomes  more  full  and  frequent;  the  urine 
less  in  quantity  but  containing  an  excess  of  urea  and  a  deficiency  of  the 
chlorides;  and  bowels  quiet.  In  many  cases  there  is  pain  in  the  fore- 
head increased  by  the  jar  of  coughing,  and  aching  pains  in  the 
back  and  limbs.  At  first  the  cough  is  moderate  with  little  or  no 
expectoration;  but  it  increases  in  depth  and  frequency  and  during  the 
second  day  there  is  more  or  less  expectoration  of  a  thick  mucus,  which 
increases  during  the  third  and  fourth  days  and  usually  becomes  intimately 
intermixed  with  blood,  constituting  the  "rusty  spu  a  "  mentioned  in  ail 
your  works  on  practice,  as  characteristic  of  pneumonic  inflammation.  All 
the  general  febrile  symptoms,  together  with  the  local  pain  and  oppression 
in  the  chest,  continue  to  increase  until  the  climax  is  reached,  usually  be- 
tween the  beginning  of  the  fourth  and  the  end  of  the  sixth  da^^s.  At  that 
time  you  will  gentwally  find  the  face  still  somewhat  flushed,  expression 
dull,  mind  often  wandering,  especially  during  the  night,  respirations  short 
with  diminished  expansion  of  one  or  both  sides  of  the  chest,  pulse  frequent, 
soft,  and  in  some  cases  decidedly  weak,  cough  frequent  with  pretty  free 
bloody  expectoration,  and  a  temperature  between  39.5^  and  41.6°  C.  (103° 
and  106°  F.).  If  the  inflammation  has  involved  the  whole  of  one  lung  or 
a  large  part  of  both,  the  diminished  oxygenation  and  decarbonization  of 
the  blood  may  cause  the  flush  on  the  face  to  appear  purplish  or  leaden  in 
color,  the  mind  to  be  more  dull  and  drowsy,  some  coarse  raucous  rales  in 
the  chest,  with  very  imperfect  expansion,  and  a  weak,  variable  pulse.  In 
cases  progressing  unfavorably  the  drowsiness  and  mental  wandering  in- 
crease, the  expectoration  shows  less  blood  and  more  intermixture  of  pus, 
the  breathing  becomes  more  oppressed,  with  increasing  difficulty  in  clear- 
ing the  bronchial  tubes  of  the  constantly  accumulating  rauco-purulent 
exudation,  the  cardiac  impulse  and  the  whole  circulation  diminish  rapidly 
in  force,  and  finally  the  surface  becomes  covered  with  a  clammy  sweat,  the 
discharges  become  involuntary,  the  larynx  and  trachea  move  up  and  down 
at  every  inspiration  and  expiration,  the  chin  soon  drops,  the  breathing 
becomes  very  frequent  and  noisy,  and  life  ceases,  more  frequently  between 
the  sixth  and  ninrh  days  from  the  beginning  of  the  attack.  In  cases  pro- 
gressing more  favorably,  after  reaching  the  climax  of  both  general  and 
local  symptoms  between  the  third  and  fifth  days  all  the  more  prominent 
symptoms  remain  nearly  stationary  one  or  two  days,  after  which  the  tem- 
perature rapidly  declines,  the  expectoration  contains  less  blood,  changing 
first  to  a  tawny  or  reddish  yellow,  and  subsequently  to  an  opaque  or  muco- 
purulent appearance  and  easily  dislodged  by  coughing,  the   soreness  and 


SYMPTOMS.  421 

oppression  rapidly  diminish,  the  pulse  becomes  slower  and  more  natural, 
and  the  secretions  more  free.  These  changes  take  place  so  rapidly  that, 
in  the  milder  cases,  convalescence  is  established  in  from  seven  t<:j  nine 
days  from  the  initial  chill,  while  in  the  more  severe  the  same  result  is  not 
reached  in  less  than  from  eleven  to  fourteen  days.  Thus  far  in  the  clin- 
ical history  of  the  disease  I  have  directed  your  attention  to  such  symptoms 
as  you  may  observe  without  special  physical  exploration,  butthe  additional 
knowledge  to  be  obtained  concerning  the  existence,  extent,  and  stage  of 
progress  of  pneumonia,  by  proper  auscultation  and  percussion,  is  of  such 
importance  that  these  methoils  of  investigation  should  never  be  neglected. 
Immediately  after  the  initial  chill  and  during  the  first  stage  of  the  inflam- 
matory process,  auscultation  over  the  affected  part  of  the  chest  readily 
detects  a  fine,  dry,  crepitant  rale,  rather  sudder)ly  and  sharply  developed 
in  the  last  part  of  the  act  of  inspiration  and  ceasing  with  the  beginnino- 
of  the  expiratory  act.  At  the  same  time  and  place  there  is  slightly  in- 
creased fremitus  of  voice  and  a  shade  less  than  the  natural  resonance  on 
percussion.  In  from  twenty-four  to  forty-eight  hours  in  most  cases  the 
fine  crepitatit  rale  begins  to  diminish,  giving  place  to  a  sub-mucous  or 
moist  rale  with  still  more  vocal  fremitus  and  more  decided  dullness  on 
percussion.  These  physical  signs  continue  rather  to  increase  until  the 
climax  of  the  disease,  between  the  fourth  and  seventh  days,  accompanied 
by  an  increasing  amount  of  coarse,  raucous  ronchus.  If  the  case  progresses 
unfavorably  the  same  dullness  on  percussion,  increased  vocal  fremitus, 
and  coarse  mucous  ronchus  continue  until  the  fatal  result.  But  if  the 
tendency  is  to  recovery,  in  one  or  two  days  after  reaching  the  climax  the 
dullness  and  vocal  fremitus  begin  to  diminish,  and  finally  disappear  with 
the  establishment  of  convalescence.  You  perceive  that  the  fine  crepitant 
rsile  is  coincident  with  the  stage  of  simple  engorgement  of  the  pulmonary 
capillaries  and  consequ  mt  pressure  upon  the  alveoli  or  air  cells,  and  that 
it  disappears  as  the  exudation  progresses,  filling  up  the  alveoli  and  inter- 
stitial spaces  instead  of  simply  compressing  them,  while  the  vocal  fremitus 
and  dullness  from  percussion,  only  slight  during  t  e  stage  of  engorgement, 
become  decided  and  well  marked  as  characteristic  of  the  stage  of  exuda- 
tion and  solidification,  and  gradually  disappear  durinar  the  stage  of  resolu- 
tion. In  some  cases  the  crepitant  rale  reappears  for  a  brief  time  at  a  cer- 
tain stage  of  the  process  of  resolution,  and  is  then  called  "crepitus  re- 
dux."  By  carefully  noting  these  physical  signs  from  day  to  day,  in  con- 
nection with  the  ordinary  symptoms,  you  will  be  able  to  attain  a  very 
accurate  knowledge  both  of  the  extent  and  stage  of  progress  of  the  in- 
flammation in  any  given  case. 

Malarial  Influences. — Having  detailed  to  you  the  more  important 
symptoms  and  physical  signs  of  the  ordinary  typical  cases  of  acute  lobar 
pneumonia,  I  must  remind  you  of  certain  important  deviations  from  this 
standard,  that  you  are  liable  to  meet  with  more  or  less  frequently.  For 
instance,  n  strongly  malarious  districts  there  are  many  members  of  the 
community  who  hive,  habitually,  less  than  the  normal  quantity  of  red 
corpuscles  and  plastic  elements  in  their  blood,  and  the  vital  affinity  or 
tonicity  of  whose  tissues  is  belov/  the  standard  of  good  health.  It  is  well 
known  that  in  all  such  communities  pneumonia  is  apt  to  prevail  more  or 
less  during  the  last  half  of  winter  and  the  early  part  of  sj)ring.  Cases 
occurring  under  such  circumstances  are  more  uniformly  ushered  in  by  a 
decided  chill,  followed  by  a  more  rapid  development  of  a  high  grade  of 
fever,  with  more  acute  pain  and  sense  of  opp  ession  in  the  chest,  more 
frontal  headache,  and  early  crepitant  rale  over  a  larger  part  of  one  lung. 
But  the  state  of  the  blood  and  the  properties  of  the  tissues  are  both  favor- 


422"  PNEUMONIA. 

able  to  early  and  copious  exudation.  Consequently  the  decided  dnllness 
on  percussion  comes  earlier  with  more  copiously  bloody  expectoration 
and  more  oppressed  breathing.  In  most  of  these  cases  the  fever  distinctly 
remits  in  the  morning  and  exacerbates  in  the  afternoon  and  first  half  of 
the  night;  and  as  it  approaches  its  climax  there  is  more  delirium  and  a 
greater  degree  of  exhaustion,  A  large  proportion  of  these  cases  tending 
to  recovery,  terminate  the  general  symptoms  rather  abruptly  by  critical 
evacuations  from  the.  skin,  kidneys  or  bowels;  after  which  the  affected 
part  of  the  lung  clears  up  by  resolution  with  remarkable  rapidity.  On 
the  contrary,  in  cases  progressing  toward  a  fatal  result,  after  reaching  the 
climax  of  the  exudative  stage,  the  skin  and  eyes,  in  many,  present  a  yel- 
low or  jaundiced  hue;  the  urine  scanty  and  of  a  leddish  yellow  color; 
pulse  frequent,  but  soft  and  weak;  mind  dull  or  wandering;  respirations 
short,  with  sudden  fall  of  the  abdominal  muscles  in  expiration;  cough 
frequent,  and  accompanied  by  copious  reddish  yellow  expectoration  con- 
sisting of  muco-purulent  material  mixed  \vith  the  red  corpuscles,  and 
indicating  the  existence  of  a  diffuse  suppurative  process  in  the  inflamed 
part  of  the  lungs.  Most  of  the  cases  presenting  such  symptoms,  reach  a 
fatal  degree  of  exhaustion  and  the  patients  die  during  the  second  Aveek 
of  their  progress.  During  the  first  ten  years  of  my  residence  in  this  city 
(Chicago),  while  there  was  neither  proper  sewerage  nor  an  adequate  sup- 
ply of  water  from  the  lake,  and  malarious  or  periodical  fevers  were  preva- 
lent in  some  degree  during  every  summer  and  autumn,  I  saw  many  cases 
of  pneumonia  during  the  winter  and  spring  seasoiis  presenting  all  the 
modifications  in  symptoms  and  progress  I  have  indicated. 

Typhoidal  Influences. — In  the  more  densely  populated  cities,  manu- 
facturing towns,  and  long-settled  country  districts,  where  the  sanitary 
conditions  exist  which  predispose  to  the  development  of  typhoid  fever, 
diphtheria,  etc.,  the  attacks  of  pneumonia  are  characterized,  generallv,  by 
a  less  marked  chill  at  the  commencement,  less  acute  pain  in  the  chest,  a 
slow  rise  of  temperature,  a  softer,  weaker  pulse,  and  a  more  dull,  heavy 
expression  of  countenance.  The  first  or  congestive  stage  is  usually  short, 
exudation  commencing  early  but  progressing  more  slowly  than  in  cases 
influenced  by  malaria,  and  generally  giving  rise  to  less  l)lood  in  the  ex- 
pectoration, but  of  a  darker  color;  and  when  the  crisis  is  passed,  the  proc- 
ess of  re-absorption  and  removal  of  the  exudative  material  goes  on  slower 
and  sometimes  less  perfectly.  In  cases  which  are  progressing  unfavor- 
ably, about  the  end  of  the  first  week  the  pulse  becomes  more  frequent 
and  weak;  respirations  short  and  abdominal;  the  tongue  and  mouth  dry; 
the  mind  dull  and  sometimes  delirious;  cough,  and  expectoration  moder- 
ate in  amount,  but  the  latter  dark  or  reddish  brown  color  and  consisting 
of  muco-purulent  matter  mixed  wnth  dark  blood;  the  intestinal  evac.ua- 
tions  thin  and  brown  but  not  frequent,  and  usually  by  the  middle  or  lat- 
ter part  of  the  second  week,  the  efforts  at  coughing  do  not  clear  the  bron- 
chial tubes  of  the  accumulating  sputa;  the  coarse,  moist  rales  increase 
over  the  whole  chest,  the  lips  and  countenance  show  a  leaden  paleness, 
the  pulse  sinks  to  a  mere  thread,  skin  becomes  wet  with  a  cool  sweat,  and 
the  patient  dies.  A  large  proportion  of  the  cases  of  pneumonia  which 
have  occurred  in  this  city  during  the  last  twenty  years,  have  been  of  this 
grade. 

Rheumatic  Pneumonia. — When  speaking  of  bronchitis  in  a  former 
lecture,  I  stated  that  rheumatic  inflammation  was  liable  to  occur  in  the 
fibrous  structure  of  the  smaller  bronchi,  and  sometimes  to  extend  into  the 
connective  tissue  of  the  lungs  in  a  chronic  form,  and  cause  pulmonary 
sclerosis.     I  have  also  met  with  occasional  cases  of  more  acute  rheumatic 


RHEUMATIC  PNEUMONIA.  423 

inflammation  primarily  attacking  the  pulmonary  structures,  and  constitut- 
ing a  dangerous  and  persistent  form  ot"  pneumonia.  I  have  seen  one 
such  case  in  consultation  during  the  present  winter.  A  man  aged  fifty 
years  had  been  attacked  two  weeks  previous  to  my  visit  with  severe  pain 
in  the  lower  part  of  the  right  side  of  the  chest,  accompanied  by  some 
cough,  shortness  of  breath,  and  general  fever,  with  a  fair  degree  of  the 
fine  crepitant  rrde  and  slight  dullness  on  percussion.  On  the  second  day 
the  crepitant  rale  had  ceased  over  the  lower  part  of  the  right  lung,  giving 
place  to  a  slight  amount  of  sub-mucous  rale  and  decided  dullness  on  per- 
cussion, but  the  expectoration  was  scanty,  tenacious  and  only  tinged  with 
blood.  At  the  same  time  there  was  a  line  higher  up  over  which  the  fine 
crepitant  lale  was  very  distinct,  indicating  an  extension  of  the  inflamma- 
tion upward.  The  same  progress  upward  continued  until  the  whole  of 
that  lung  had  been  invaded  and  rendered  dense  from  the  exudation, 
giving  hU  the  physical  signs  of  hepatization,  and  a  temperature  varying 
from  39°  to  40.5°  C.  (i03°  to  105°  F.).  The  inflammation  then  attacked 
the  lower  lobe  of  the  left  lung,  and  at  the  time  of  ray  visit  was  occupying 
more  than  half  of  that  lung;  the  night  previous  the  patient  had  been 
attacked  with  severe  pain  in  the  cardiac  region,  with  great  sense  of  op- 
pression in  the  whole  chest,  while  the  pulse  was  rapid,  irregular,  and  weak. 
I  found  in  addition  to  the  physical  signs  of  hepatization  over  the  whole  of 
the  right  and  more  than  half  of  the  left  side  of  the  chest,  plain  en- 
docardial murmurs  indicating;  active  inflammation  in  the  lining:  of  the  left 
cavities  of  the  heart.  The  extremities  were  cool  and  purplish;  the  pulse 
frequent,  irregular  and  soft;  respirations  short  with  moist  rales  andbut 
little  expansion  of  the  chest;  and  mind  wandering.  He  died  about 
twenty-four  hours  later.  No  post  mortem  examination  was  allowed. 
Throughout  the  whole  course  of  the  disease,  the  expectoration  had  been 
tenacious  mucus  without  pus,  and  only  scantily  mixed  with  blood;  and  the 
pain  in  the  chest  had  been  unusually  severe  and  persistent.  These  facts, 
with  the  final  development  of  endocarditis,  and  the-  further  fact  that  the 
patient  had  been  subject  to  occasional  attacks  of  articular  rheumatism 
for  several  years,  left  no  doubt  on  my  mind  but  that  the  present  attack 
was  one  of  subacute  rheumatic  inflammation  of  the  parenchyma  of  the 
lungs.     In  other  words  a  genuine  rheumatic  pneumonia. 

Catarrhal  Pneumonia — Lobular,  or  Disseminated  Prieutnonia. — Lob- 
ular catarrhal  pneumonia,  as  described  by  most  writers,  is  a  secondary 
afi"ection,  occurring  in  connection  with  capillary  bronchitis,  and  is  met 
with  far  more  frequently  in  early  childhood  and  in  old  age  than  at  any  of 
the  intermediate  periods  of  life.  As  the  pneumonic  inflammation  in 
these  cases  results  from  either  a  direct  extension  of  the  inflammatory 
action  from  the  bronchioles  to  the  alveoli  of  the  lung,  or  from  a  prior 
occlusion  of  the  bronchi  atid  collapse  of  the  alveoli  or  clusters  of  cells, 
(atelectasis)  involving  capillary  congestion  and  inflammation,  it  neces- 
sarily develops  in  the  individual  lobules,  and  not  in  a  section  of  the  lung 
as  in  lobar  pneumonia.  And  as  individual  lobules  may  be  involved 
leaving  other  lobules  between  them  unaffected,  such  cases  have  given  rise 
to  the  phiase  "disseminated  pneumonia."  So  far  as  the  inflamed  lobules  are 
concerned  they  pass  through  the  same  stages  of  congestion,  exudation, 
hepatization,  and  resolution  or  suppuration,  as  occur  in  lobar  inflamma- 
tion. The  co-existence  of  capillary  bronchitis  in  almost  all  of  the  cases 
of  the  lobular  form  of  pneumonia,  is  well  calculated  to  obscure  some  of  the 
more  important  diagnostic  symptoms  of  the  latter.  For  instance,  the  mix- 
ture of  dry  and  moist  rales  generally  heard  so  readily  over  the  greater 
part  of  the  chest  in  capillary  bronchitis,  is  so  much  more  prominent  than 


424  CATAEBHAL    PNEUMOlflA. 

the  fine  crepitant  rSle  of  the  pneumonia  that  ths  latter  is  seldom  dis- 
ti:!^uished;  while  the  separation  of  the  affected  lobules  by  the  interven- 
tion of  others  not  affected,  causes  the  dullness  on  percussion  and  fremitus 
of  voice  to  be  less  marked  than  in  the  second  stage  of  ordinary  lobar 
pneumonia.  And  if  the  number  of  lobules  involved  is  small,  the 
pneumonic  part  of  the  disease  may  escape  detection.  Usually,  however, 
the  increased  fremitus  and  diminished  resonance,  coupled  with  the  dimin- 
ished expansion  of  the  chest,  shortness  of  the  expiratory  act,  and  the 
higher  temperature,  are  sufficient  to  indicate  the  existence  of  the 
pneumonic  complication,  even  if  no  rusty  sputa  are  seen. 

Pathological  Anatomy. — The  very  vascular  and  distensile  character  of 
the  lung  structure  allows  the  ordinary  anatomical  changes  which  take 
place  in, the  different  stages  of  all  inflamed  tissues,  to  reach  a  high  degree 
of  development.  The  intense  vascular  engorgement  of  the  first  stage 
gives  to  the  inflamed  portion  of  lung  a  bright  red  color,  with  less  crepi- 
tation between  the  fingers  and  less  complete  collapse.  In  the  second  stage, 
that  of  exudation  and  solidification,  the  redness  is  a  shade  darker,  the  crep- 
itation between  the  fingers  and  the  tendency  to  collapse  entirely  lost,  and 
the  cut  surface  presents  a  red,  granular  appearance  from  which  oozes  a 
scanty  amount  of  red  frothy  serum,  mixed  with  blood  from  the  larger 
severed  vessels.  Examined  under  the  microscope  the  capillary  vessels 
surrounding  the  alveoli  are  seen  greatly  distended  and  in  many  places 
obstructed  by  the  corpuscular  elements  of  the  blood;  while  the  alveoli 
and  interstitial  spaces  of  the  connective  tissue  are  filled  with  leucocytes 
or  migrating  corpuscles,  liquor  sanguinis,  and  more  or  less  solidified  fibrin 
and  plastic  elements  of  the  blood.  If  death  takes  place  during  the  third 
stage  the  inflamed  portion  of  lung  is  less  intensely  red,  a  little  less  firm  or 
hard  to  the  feel,  but  still  without  crepitation  or  collapse  under  pressure. 
When  incised  the  cut  surface  presents  a  lighter  grayish  color,  less 
granular,  and  from  it  oozes  a  somewhat  frothy  sero-purulent  fluid,  with' 
blood  from  the  orifices  of  the  severed  blood-vessels.  Examined  more 
closely  the  cut  surface  in  most  cases  is  found  to  contain  many  small  con- 
cavities or  minute  abscesses  which  have  been  laid  open  by  the  incision; 
while  the  miscroscope  shows  the  alveoli  and  interstitial  spaces  still  filled 
with  inflammatory  products  but  everywhere  undergoing  the  process  of 
purulent  degeneration  by  which  the  leucocytes  and  proliferating  cell 
elements  have  assumed  the  form  of  pus  corpuscles.  In  some  of  the  more 
highly  plastic  or  phlegmonous  grades  of  pneumonia  the  suppurative 
degeneration  will  be  found  confined  to  the  more  central  part  of  the  in- 
flamed structure,  and  the  pus  will  have  collected  into  one  or  more  larger 
and  more  circumscribed  abscesses.  And  in  cases  of  still  less  frequent 
occurrence  the  vessels  in  a  portion  of  the  lung  tissue  have  been  so  com- 
pletely  obstructed  by  the  accumulated  inflammatory  products,  as  to 
suspend  all  circulation  in  that  part,  and  the  post  mortem  examination 
reveals  the  existence  of  gangrene  or  death  of  the  part,  witli  diffuse  sup- 
puration surrounding  the  slough. 

Diagnosis. — In  giving  >  ou  the  clinical  history  of  the  different  grades 
and  stages  of  pneumonic  inflammation,  I  have  pointed  out  so  fully  the 
ordinary  symptoms  and  physical  signs  that  characterize  or  serve  to  dis- 
tinguish, not  only  the  disease  itself,  but  also  each  stage  of  its  progress, 
that  it  would  be  an  unnecessary  repetition  to  enumerate  them  again  at 
this  time. 

Prognosis. — The  majority  of  recent  writers  represent  lobar  pneumonia, 
or  pneumonitis,  as  a  self-limited  disease,  of  comparatively  brief  dura- 
lion,  and  in  much  the  largernumber  of  cases  ending  in  resolution  or  spon- 


PROGNOSIS.  425 

taneous  recovery.  And  these  circumstances  are  claimed  as  evidence  that 
the  disease  is  a  general  zymotic  fever  instead  of  a  mere  local  inflamina- 
tioi.  Such  writers  do  not  appear  to  have  comprehended  the  fact  that  all 
acute  local  infl.immations  are  necessarily  sell'-liinited  in  their  duration; 
and  that  they  pass  throutrh  certain  stages  either  to  resolution  and  recov- 
ery or  to  destruction  of  the  inflamed  structures  with  more  uniformity 
than  any  one  of  the  general  fevers.  The  special  prognosis  in  all  cases  of 
pneumonia  will  be  influenced  by  the  age  of  the  patient,  his  previous  con- 
stitutional condition  and  tendencies,  the  extent  of  lung  tissue  involved, 
the  special  character  of  the  inflammatory  process,  and  the  diseases  with 
which  it  may  be  complicated.  All  other  circumstances  being  the  same,  a 
much  higher  ratio  of  deaths  will  occur  in  children  under  five  years,  and 
in  adults  over  fifty,  than  at  any  intermediate  periods  of  life.  This  is 
probably  owing  to  the  fact  that  at  the  two  extremes  of  life  there  is  less 
vital  resistance  to  the  prog-ress  of  any  acute  disease,  and  that  a  very  large 
proportion  of  the  cases  occurring  at  these  periods  are  complicated  with 
general  capillary  bronchitis.  When  the  disease  attacks  persons  of  a 
distinctly  scrofulous  or  tuberculous  diathesis  there  is  a  mucli  greater 
tendency  to  early  and  difi"use  purulent  degeneration  of  the  exudative 
material  and  consequently  to  a  higher  ratio  of  deaths.  The  same  remark 
applies  also  to  such  cases  as  occur  in  subjects  afleeted  with  constitutional 
syphilis.  No  one  circumstance,  however,  exerts  more  influence  over  the 
rate  of  mortality  than  the  extent  of  lung  tissue  involved  in  tlie  inflamma- 
tion. Inasmuch  as  the  oxygenation  and  decarboniz  ttion  of  the  blood 
(changes  essential  to  the  continuance  of  life)  are  directly  dependent  on 
the  continuance  of  the  supply  of  fresh  air  in  the  pulmonary  alveoli  and 
the  proper  movement  of  the  blood  around  such  alveoli,  it  is  evident  that 
whenever  the  products  of  pneumonic  exudation  occupy  the  alveoli,  infun- 
dibuli  and  intei-stitial  spaces  of  so  large  a  part  of  the  lung  structure  as  to 
interrupt  or  greatly  diminish  the  amount  of  these  changes,  the  life  of  the 
patient  will  be  lost  or  placed  in  great  danger.  But  so  long  as  the  inflam- 
mation does  not  occupy  deci  ledly  more  than  one  half  of  one  lung,  or  only 
one  lobe  of  each  lung,  there  will  be  but  little  danger  from  the  direct 
interference  with  the  oxygenation  and  decarbonization  of  the  blood;  and 
if  there  are  no  complications  with  other  diseases  or  unfavorable  constitu- 
tional conditions,  such  cases  will  pretty  uniformly  recover  under  favor- 
able hygienic  management  alone.  In  cases  of  double  pneumonia  in 
which  more  thr^n  half  of  each  lung  is  involved  and  filled  up  with  the  in- 
flimmatory  products,  death  usually  results  from  apnoea  before  the  third 
stage  of  the  inflammatory  process  is  reached.  When  the  disease  is  uni- 
lateral, though  involving  the  whole  lung,  or  double,  and  involving  only 
a.  little  less  than  one  half  of  each,  the  patients  will  not  usually  die  directly 
from  apnoea  or  the  exclusion  of  air;  and  yet  the  interchange  of  the  car- 
bonic acid  gas  for  oxygen  as  the  blood  passes  through  the  pulmonary 
vessels  will  lie  so  much  diminished  that  the  blood  passes  into  the  left  cav- 
ities of  the  heart  and  is  sent  through  the  whole  arterial  system  in  a  con- 
dition which  renders  it  incapable  of  maintaining  the  full  activity  of  the 
nervous  and  secretory  structures  generally.  Consequently  the  patient's 
mind  becomes  dull  or  wandering;  his  countenance  dingy;  his  pulse  fre- 
quent and  soft  or  weak;  cardiac  impulse  diminished;  moist  rales  in- 
crease in  the  chest;  the  surface  relaxes  and  the  skin  becomes  covered 
with  perspiration;  and  a  little  later  the  sphincters  relax,  allowing  invol- 
untary discharges  and  death.  The  latter  takes  place,  in  most  of  these 
cases,  durnig  the  second  week  after  the  commencement  of  the  attack,  and 
is  very  generally  attributed  to  asthenia  or  cardiac  weakness.     But  what 


426  PNEUMONIA. 

causes  the  asthenia?  Plainly,  just  two  factors.  First,  the  imperfect  oxy- 
genation and  decarbonization  of  the  blood,  as  just  described;  and  second, 
the  diversion  of  three  or  four  pounds  of  blood  from  the  general  circulation 
and  its  lodgment  as  exudative  material  in  the  alveoli,  infundibuli,  bron- 
chioles, and  interstitial  spaces  of  the  connective  tissue  of  the  inflamed 
part  of  the  lungs,  constituting  a  form  of  depletion  very  much  more 
dangerous  to  the  patient  than  the  loss  of  one  or  two  pounds  by  venesec- 
tion to  relieve  the  vascular  engorgement  of  the  first  stage  of  the  morbid 
process. 

Another  circumstance  which  exerts  an  influence  on  the  prognosis  is  the 
special  character  of  the  inflammation  as  determined  by  the  nature  of  the 
predisposing  causes  and  sanitary  surroundings  of  the  patient.  You  maj'- 
regard  it  as  a  general  rule,  that  tha  presence  of  all  such  causes  as  favor 
the  development  of  a  typhoid  or  asthenic  condition;  or  of  the  active  prev- 
alence of  the  malaria  that  causes  periodical  fevers;  or  of  any  special 
epidemic  influence,  will  increase  the  ratio  of  mortality'-  from  pneumonic 
inflammation.  The  same  is  true  in  regard  to  such  cases  of  pneumonia  as 
occur  in  individuals  already  laboring  under  any  one  of  the  general  febrile 
affections,  or  any  serious  disease  of  the  heart  or  kidneys.  Pneumonia  is 
not  a  very  infrequent  complication  of  such  cases  of  typhoid,  malarious  and 
eruptive  fevers  as  occur  during  the  cold  and  changeable  seasons  of  the 
year.  Measles  and  whooping-cough  are  particularly  liable  to  become 
complicated  with  the  pulmonary  inflammation.  And  in  all  such  cases,  as 
well  as  in  those  that  occur  in  connection  with  organic  diseases  of  the 
heart,  there  is  greater  danger  of  a  fatal  termination  than  from  an  equal 
extent  of  pneumonic  inflammation  without  the  co-existence  of  other  dis- 
eases. 

From  the  foregoing  observations  you  will  readily  infer  that  the  statis- 
tics given  by  different  writers  concerning  the  ratio  of  mortality  from  pneu- 
monia are  of  very  little  value  unless  accompanied  by  the  facts  concerning 
the  various  modifying  influences  to  which  I  have  referred. 


LECTURE  XLIV. 


Pneumonia    Continued— Its    Treatment.    Chronic     Pneumonia— Its   SymBtoms,  Pathological 
Anatomy,  D.agnosis  and  Trjatment. 

GENTLEMEN:  You  will  find  in  the  text  books  and  literature  of  the 
profession  many  and  widely  difi'ering  methods  of  treatment  for 
j)neumonia  at  different  times,  and  by  different  writers  at  the  same  time. 
You  will  find  among  these,  the  method  by  blood-letting,  by  antimonials, 
by  mercurials,  by  expectation,  by  alcoholics,  by  sulphate  of  quinia,  by  cold 
affusion  or  the  pack,  and  by  nothing  except  rest  and  nourishment.  You 
will  see  each  of  these  metiiods  discussed,  not  in  regard  to  their  appli- 
cability to  particular  cases  and  stages  of  the  disease,  but  in  comparison 
with  ail  the  other  methods,  as  special  modes  of  treatment  applicable  to  all 
cases  alike.  And  as  nearly  all  the  cases  of  uncomplicated  unilateral 
pneumonia  tend  to  recovery  the  advocates  of  each  method  make  a  fair  show 


TREATMENT.  427 

of  success.  And  when  one  like  M.  Barthez,  in  his  paper  presented  to  the 
French  Academy  of  Medicine  in  1862,  on  the  expectant  treatment  of 
pneumonia  in  children,  skillfully  eliminates  from  his  statistics  all  lobular, 
pseudo-lobar,  catarrhal,  and  broncho-  pneumonic  cases,  together  with 
such  as  occur  in  the  progress  of  other  diseases,  it  is  not  surprising  that 
he  should  report  the  extraordinary  ratio  of  only  one  death  in  106  cases.* 
By  such  a  course  nearly  all  the  cases  involving  any  danger  to  life  are  set 
aside,  and  of  course  those  remaining  to  be  reported  on,  ought  to  recover 
under  an}'-  treatment  not  positively  detrimental.  If  the  statements  I 
made  to  you  iu  the  thirty-third  lecture  of  the  present  course,  concerning 
the  fixed  and  variable  elements  of  the  inflammatory  process,  and  the 
modifications  the  latter  are  capal)le  of  inducing  are  correct,  as  well  as  the 
views  presented  in  the  lecture  of  yesterday  concerning  the  modifying  in- 
fluence of  different  causes  on  the  character  and  results  of  pneumonia,  you 
can  not  fail  to  recognize  the  inutility  of  attempting  to  treat  all  cases  of 
the  disease  by  any  one  method  or  by  the  same  remedial  agents  in  the 
different  stages  of  its  progress.  On  the  contrary,  the  special  objects  to  be 
accomplished  or  indications  to  be  fulfilled  in  the  treatment  of  pneumonia, 
vary  with  each  successive  stage  in  the  progress  of  the  infiamraation.  In 
the  first  stage,  characte  ized  by  increased  excitability  of  texture  and  in- 
tense engorgement  and  distension  of  vessels,  the  plain  indications  are  to 
allay  the  excitability  and  lessen  the  vascular  fullness;  and  in  the  same 
ratio  that  you  succeed  in  fulfilling  these  will  you  lessen  the  amount  of 
exudation  and  hepatization  which  are  to  constitute  the  second  stage  of 
the  disease. 

When  the  latter  has  already  supervened,  however,  then  your  leading 
objects  must  be  to  hasten  the  disintegration  and  promote  the  removal  of 
the  exudative  material,  thereby  inducing  resolution  before  suppuration  or 
caseous  degeneration  should  take  place.  But  if  the  latter  processes  do 
make  a  fair  beginning,  constituting  the  third  stage,  or  that  usually  called 
gray  hepatization,  your  main  objects  must  be  to  limit  the  degenerative  proc- . 
esses  and  sustain  the  nutrition  and  strength  of  the  patient.  Such  are  the 
rational  indications  for  treatment  founded  on  the  important  pathological 
conditions  present  in  each  successive  stage  of  the  disease;  but  the  particu- 
lar means  most  efficient  for  accomplishing  the  several  objects  named,  as 
well  as  the  time  and  manner  of  their  use,  will  be  materially  influenced  by 
certain  coincident  conditions  relating  chiefly  to  the  quality  of  the  blood  and 
the  general  tonicity  of  the  tissues.  For  instance,  if  a  patient  when  at- 
tacked with  pneumonia  has  good  blood,  of  natural  degree  of  plasticity, 
and  an  active  vital  affinity  giving  to  his  tissues  a  good  degree  of  tonicity, 
his  case  will  present  all  the  characteristic  symptoms  of  an  active  or 
sthenic  grade  of  inflammation.  O  i  the  other  hand,  if  the  patient  when 
attacked  had  already  been  exposed  to  malarial  influences  until  his  blood 
was  more  or  less  impoverished  of  its  red-corpuscles  and  nutritive  con- 
stituents, with  laxity  of  tissues,  or  if  he  had  been  living  in  the  impure 
air  of  over-crowded  dwellings,  or  in  the  midst  of  other  conditions  favoring 
typhoid  developments,  until  the  plasticity  of  his  blood  and  the  tonicity  of 
his  tissues  were  both  impaired,  his  case  would  present  all  the  character- 
istic features  and  tendencies  of  an  asthenic  inflammation. 

While  it  is  true,  therefore,  ttiat  it  is  desirable  to  allay  the  irritation 
and  lessen  the  vascular  fullness  in  the  first  stage  of  all  acute  inflam- 
mations, whether  sthenic,  asthenic,  or  specific,  yet  the  means  for  accom- 
plishing these  results  most  safely  and  efficiently,  must  vary  much  in  the- 

*  See  Meigs  and  Pepper  on  Diseases  of  Children,  4lh  Ed.,  pp.  180-1, 1870. 


428  PKEUMONIA. 

several  varieties.  IMorbid  susceptibility  may  be  allayed  by  anodynes, 
anaesthetics,  and  sedatives;  and  the  vascular  fullness  or  congestion  m  ly 
be  diminished  by  lessening  the  quantity  of  blood  in  the  vessels  of  tie 
part  either  by  venesection,  by  increasing  the  contraction  of  the  vessels 
themselves  through  the  influence  of  the  vasomotor  nerves,  and  by  lessen- 
ing the  action  of  the  heart  in  forcing  the  blood  into  the  vascular  system. 
A  careful  examination  of  the  actual  clinical  results  obtained  in  the 
management  of  acute  inflammatory  afi"ections  during  the  last  half  century 
shows  that  m  the  fiist  stage  of  the  active  sthenic  grade  of  pneumonia  one 
prompt  and  decisive  venesection,  followed  by  such  cardiac  sedatives  as 
will  lessen  the  force  and  frequency  of  the  heart's  action,  is  not  only  the 
most  efficient  mode  of  relieving  the  vascular  fullness,  and  therel^y  limit- 
ing the  amount  of  subsequent  exudation,  but  it  has  been  followed  l)y  the 
highest  ratio  of  recoveries.  In  the  same  stage  of  those  cases  occurring 
in  patients  whose  blood  is  already  dim  nisheu  in  plasticity,  and  vessels 
more  or  less  relaxed  from  malarious  influences,  from  two  or  three  deci- 
grams (gr.  iii  to  v)  of  sulphate  of  c^uinia,  given  every  two  to  three 
hours,  alternately,  with  some  mild  cardiac  sedative  and  alterant,  will  often 
as  effectually  check  the  vascular  fullness  as  will  the  bleeding  in  the  purely 
sthenic  cases.  In  those  cases,  however,  occurring  in  patients  who  are  liv- 
ing in  the  midst  of  sanitary  conditions  strongly  predisposing  to  attacks  of 
typhoid  or  typhus  fevers,  the  adjustment  of  remedies  to  meet  the  indica- 
tions in  the  first  is  more  difficult.  In  such  patients  direct  depletion  by 
bleedins:  is  seldom  borne  without  positive  injury,  and  quinia  frequently 
fails  to  produce  the  effect  desired.  When  called  to  this  class  within  the 
first  twenty-four  hours  after  the  initial  chill,  I  have  usually  ordered  six 
powders,  each  containing  sulphate  of  quinia  0.200  grams  (ur.  iii);  calo- 
mel O.O06  grams  (a'r.  i);  sanguiiiaria  pulverized  0.033  grams  (gr.  ss); 
and  glycyrrhiza  pulverized  0.060  grams  (gr.  i);  one  to  be  given  every 
four  hours,  and  four  cubic  centimeters  (fl.  3")  of  the  following  mixture 
between: 

I^  L'quoris  Ammonii  x\cetatis,  60  c.  c.  §ii 
'i'mclurge  Opii  Camphoratae,  60  c.  c.  §ii 
Tincturee  Aconiti  Radicis,  4    c.  c.  |i 

At  the  same  time  cover  the  whole  affected  side  of  the  chest  with  a  lin- 
seed-meal poultice;  and  if  the  skin  is  hot  and  dry,  have  all  th;^  surface 
not  covered  by  the  poultice  frequently  sponged  with  milk-warm  water. 
As  soon  as  the  six  powders  have  been  taken,  if  the  bowels  have  not 
moved  spontaneously,  they  should  be  induced  to  move  by  an  enema  or  a 
mild  laxative.  That  the  distinctions  I  have  made  in  regard  to  the  modi- 
fications or  grades  of  pneumonia,  and  the  variations  which  they  require 
111  the  choice  of  remedies  for  fulfilling  the  indications  presented  in  the 
first  stage  of  the  disease,  are  neither  theoretical  nor  fanciful,  but  such  as 
actually  confront  us  at  the  bedside  of  our  patients,  I  have  had  abundance 
of  evidence  in  mv  own  clinical  experience. 

From  1837  to  1847, 1  was  practicing  in  a  hilly,  rugged  region,  free  from 
malaria,  and  supplied  with  pure  air  and  good  water,  in  the  interior  of 
New  York,  near  the  northern  line  of  Pennsylvania,  where  the  winters 
were  cold,  and  during  which  attacks  of  pneumonia,  pleurisy,  bronchitis, 
and  rheumatism  w-ere  frequent,  and  uniformly  of  the  sthenic  type.  In 
every  case,  when  called  during  the  first  stage  of  the  disease,  I  b  ed  freely 
once  and  sometimes  twice,  and    gave    internally  sedative    doses  of  tartar 


TREATMENT.  4L'y 

emetic^  alternately,  with  alterative  aiul   anodyne   doses  of  calomol  and 
Dover's  powder. 

The  relief  to  the  patient  was  always  well  marked,  and  sometimes  so  do- 
cisive  as  to  render  the  amount  of  exudation  in  the  second  stage  unimpor- 
tant, and  to  enable  the  patients  to  be  up  and  dressed,  with  all  the  indica- 
tions of  complete  convalescence  on  the  fourth  and  fifth  days.  In  the 
spring  of  1847,  I  moved  to  the  city  of  New  York,  where,  during  a  resi- 
dence of  little  more  than  two  years,  I  saw  but  few  cases  of  pneumonia, 
and  those  among  the  poor  surrounded  by  bad  sanitary  conditions. 

In  the  autumn  of  1849,  I  came  to  this  city,  then  without  sewers,  and 
only  a  small  part  of  it  supplied  with  lake  water.  Yet  the  tide  of  immi- 
gration was  such  that  every  boarding-house  was  overcrowded,  and  we  had 
an  abundance  of  the  idio-miasms  added  to  the  malaria  naturally  prevalent 
in  the  locality.  Here,  during  the  succeeding  ten  years,  I  had  a  rare 
opportunity  for  studying  the  modifying  effects  of  malaria  and  the  causes 
favoring  typhoid  fever  on  all  the  acute  inflammations,  both  in  their  sepa- 
rate actio!)  and  in  all  degrees  of  their  commingling.  I  saw,  during  the 
latter  part  of  winter  and  early  spring  of  each  year,  many  cases  of  pneu- 
monia very  promptly  relieved  by  the  free  use  of  quinine  in  the  first  stage; 
while  in  other  cases  more  strong. y  influenced  by  the  causes  of  typhoid 
diseases,  the  quinine  either  produced  but  little  apparent  <  fiFect,  or  else 
added  much  to  the  dullness  of  hearing  and  stupidity  of  the  mental  facul- 
ties generally:  and  occasionally  a  case  confronted  me  with  all  the  charac- 
teristics of  the  sthenic  type  as  strongly  as  I  had  seen  at  an  earlier  period 
in  the  interior  of  New  York,  and  in  which  a  prompt  and  full  venesection 
had  the  same  beneficial  effects.  In  a  few  of  the  more  severe  attacks  of 
pneumonia  under  strongly  malarious  influences,  I  have  seen  much  benefit 
from  one  very  early  and  free  bleeding,  followed  by  quinine  in  efficient 
doses.  But  I  have  never  seen  benefit  from  blood-letting  in  cases  occur- 
ring in  the  midst  of  such  sanitary  conditions  as  decidedly  favor  the  devel- 
opment of  typhoid  or  typhus  fevers.  In  the  winter  of  ISSO-'Sl,  in  a 
well-marked  case  of  this  variety,  I  opened  a  vein  in  the  arm  for  the 
express  purpose  of  ascertaining  experimentally  what  the  effect  would  be. 
]Decided  indications  of  syncope  came  before  I  had  taken  an  ordinary  tea- 
cupful  of  blood,  and  I  was  obliged  to  tie  up  the  arm  and  administer  car- 
bonate of  ammonia  and  camphor  as  restoratives.  I  have  called  your 
attention  to  the  treatment  of  the  first  or  congestive  stage  of  pneumonia 
thus  luUy,  because  it  is  only  in  this  stage  that  measures  designed  for 
directly  lessening  the  vascular  fullness  and  consequently  rendering  the 
subsequent  stages  milder  and  shorter,  cati  be  used  with  benefit  to  the 
patient.  When  exudation  has  already  taken  place,  and  the  second  singe 
of  the  disease  is  fairly  developed,  further  depletive  and  sedative  measures 
are  useless  and  generally  injurious.  In  this  stage,  the  continiiance  of 
poultices  over  the  chest,  and  in  some  cases  the  addition  of  a  blister,  and 
the  administration  of  alterant,  anodyne,  and  expectorant  mixtuies,  and 
mild  nourishment,  will  constitute  the  treatment  best  calculated  to  pro 
mote  resolution  and  prevent  either  purulent  or  caseous  degeneration. 
The  following  is  one  of  the  best  alterant,  anodyne,  and  expectorant  com- 
binations that  I  have  used: 

'^,     Ammonii  Muriatis,  12.0  ^  grams  3iiJ 

Antimonii  et  Potassi  Tartratis,  0.13      "  gr.  ii 

Morphiae  Sulphatis,  0.20      "  gr.  iii 

SyrupusGlycyrrhizse,  130.00    c.  c.  fiv. 

*  At  that  time  the  more  prompt  and  valuable  sedative  properties  of  the  veratrum  viride,  aconite, 
and  gelseminum  were  not  known. 


430  PNEUMONIA. 

Four  cubic  centimeters  (fl.  3i)  may  be  given  to  an  adult  every  three  or 
four  hours,  mixed  with  a  tablespoonful  of  water.  If  the  urine  is  scanty, 
a  mixture  of  two  parts  of  liquor  aramonii  acetatis,  two  of  spirits  of  ni- 
trous ether,  and  one  part  of  tincture  of  digitalis,  may  be  given  in  doses 
suited  to  the  age  of  the  patient,  half  way  between  the  doses  of  the  other 
mixture.  In  most  cases  from  two  to  three  decigrams  (gr.  iii  to  v)  of 
sulphate  of  quinia  may  be  given  with  benefit,  three  times  a  day,  until 
convalescence  is  established. 

In  addition  to  the  foregoing  outline  of  the  treatment  required  in  the 
different  grades  and  stages  of  pneumonic  inflammation,  I  must  direct  your 
attention  to  some  special  conditions  of  importance  liable  to  occur  during 
the  progress  of  cases  of  this  disease.  One  of  these  conditions  is  presented 
in  some  rare  cases  at  the  very  commencement  of  the  attack,  and  consists 
of  an  almost  universal  congestion  or  engorgement  of  the  pulmonary  vessels 
immediately  following  the  initial  chill,  indicated  by  a  purplish  or  leaden 
hue  of  the  surface;  short  and  hurried  breathing  with  very  limited  expan- 
sion of  the  chest;  small,  frequent,  and  weak  pulse;  cool  extremities,  but 
high  temperature  of  the  trunk  of  tiie  body;  fine  crepitant  rales  over  the 
whole  chest,  and  great  sense  of  oppression  or  weakness.  If  such  cases 
are  seen  very  soon  after  the  commencement  of  the  attack,  it  is  well  to 
open  a  vein  in  the  arm,  and  if  the  blood  can  be  made  to  flow  freely  it 
speedily  lessens  the  oppressed  breathing,  improves  the  color  of  the  surface, 
and  causes  the  pulse  to  become  fuller  and  slower.  At  the  same  time  six 
decigrams  (gr.  x.)  of  sulphate  of  quinia  should  be  given  and  repeated 
every  two  hours  until  three  doses  have  been  taken,  after  which  the  time 
may  be  lengthened  to  four  hours.  You  may  gain  some  further  aid  in 
restoring  the  tone  of  the  pulmonarj'  vessels  b}^  giving  half  way  between 
the  doses  of  sulphate  of  quinia  two  decigrams  (gr.  iii)  of  ergotine,  and 
after  the  immediate  danger  from  overwhelming  congestion  of  the  pulmo- 
nary vessels  has  been  relieved  the  subsequent  treatment  may  be  the  same 
as  in  other  cases  of  severe  pneumonia.  But  if  the  venesection  results  in  a 
failure  to  obtain  more  than  a  few  cubic  centimeters  (fl.  ju)  of  dark  blood, 
making  no  impression  on  the  circulation  or  the  respiratory  movements, 
the  whole  chest  and  trunk  of  the  body  should  be  wrapped  in  a  sheet  wet 
in  cold  water,  and  the  quinine  and  ergot  given  internally  as  just  directed. 
Such  cases  are  met  with  chiefly  in  highly  malarious  districts  and  are  always 
dangerous;  but  if  the  congestion  of  the  first  stage  can  be  relieved  in  a 
measure,  the  first  crisis  will  pass  by,  and  the  subsequent  progress  of  the 
case  be  easily  controlled. 

Another  condition  of  very  much  more  frequent  occurrence  may  present 
itself  to  you  in  the  latter  part  of  the  second  or  during  any  part  of  the 
third  stage  of  the  disease.  It  is  indicated  by  a  quick,  weak  pulse;  short 
and  quick  systolic  action  of  the  heart;  a  dingy  hue  of  the  surface  from 
slowness  of  the  circulation  in  the  cutaneous  capillaries  and  impaired  vaso- 
motor influence;  dullness  on  percussion  and  abundant  mucous  rales  over 
the  afi^ected  parts  of  the  lungs;  the  sputa  thin  and  mixed  with  blood, 
or  decidedly  muco-purulent;  the  expiratory  act  short  with  sudden  fall  of 
the  abdominal  muscles;  and  the  mind  either  dull  and  drowsy  or  wander- 
ing. This  is  the  condition  described  in  your  books  as  indicating  danger 
from  cardiac  weakness^  and  therefore  demanding  the  liberal  use  of 
alcoholic  remedies,  under  the  impression  that  alcohol  is  capable  of 
strengthening  the  systolic  action  of  the  heart.  Having  already  given  you 
the  results  of  my  own  clinical  and  experimental  observations  concerning 
the  incorrectness  of  this  impression,  when  speaking  of  the  treatment  of 
typhoid   fever,  I  will   not  repeat   what   was   tlien   said.     But    as  the  eon- 


TEEATMENT.  431 

diMon  under  consideration  is  the  one  of  chief  danger  in  most  cases  of 
severe  pneumonia,  it  is  of  great  practical  importance  to  have  clear  and 
correct  ideas  concerning  its  nature.  Why  is  the  cardiac  force  diminished 
and  the  whole  systemic  circulation  still  more  enfeebled  in  these  cases? 
Plainly  from  two  causes.  First,  the  volume  of  blood  in  the  vascular 
system  has  been  largely  depleted  hy  the  exudation  and  lodgment  of  from 
one  to  two  liters  (fl.  |xxx  to  3IX)  of  it,  in  the  inflamed  and  hepatized 
portion  of  the  lungs.  Second,  the  filling  up  of  so  large  a  part  of  lung- 
structure  has  so  far  diminished  the  oxygenation  and  decarbonization  of 
the  blood  that  it  fails  to  sustain  the  sensibility  and  action  of  the  whole 
vasotnotor  and  cardiac  nervous  systems.  The  negative  eflFect  of  a  de- 
ficient amount  of  oxygen  and  the  positive  sedative  and  anaesthetic  effect 
of  an  excess  of  carbonic  acid  gas  in  the  blood,  are  obviously  the  chief 
agents  in  diminishing  the  force  of  circulation  through  their  anaesthetic 
and  sedative  effect  on  the  nervous  structures  just  mentioned.  Your 
remedial  measures,  then,  should  be  such  as  will  directly  increase  the 
activity  of  the  vasomotor  nerves,  and  improve  the  oxygenation  and 
decarbonization  of  the  blood,  and  thereby  increase  the  action  of  the 
muscular  coat  of  the  small  vessels  and  sustain  the  molecular  movements 
in  the  secreting  organs  and  tissues  generally.  To  merely  increase  the 
muscular  force  of  the  heart,  if  this  were  possible,  without  simultaneously 
increasing  the  action  of  the  smaller  vessels  and  quickening  molecular 
movements  in  the  tissues,  would  only  result  in  a  temporary  show  of  im- 
provement to  be  speedily  followed  by  more  accumulation  in  the  already 
obstructed  and  enfeebled  pulmonary  capillaries.  The  measures  which  I 
have  found  best  calculated  to  relieve  the  condition  under  consideration, 
are  a  fair  sized  blister  over  the  affected  side  of  the  chest,  and  the  use  of 
the  following  remedies  internally.  I  dissolve  ten  grams  (3ii  ss)  of  chlorate 
of  potassium  and  fifteen  grams  (3  iv)  pulverized  gum  arabic  in  260  cubic 
centimeters  (?  viii)  of  water,  and  give  fifteen  cubic  centimeters  or  an  ordi- 
nary tablespoonful  every  three  hours,  in  conjunction  with  from  thirteen  to 
twenty  centigrams  (gr.  ii  to  iii)  of  sulphate  of  quinia;  and  half  way  be- 
tween these  doses  four  cubic  centimeters  (fl.  3i)  of  the  following  formula: 

I^     Liquoris  Ammonii  Acetatis,  60.0  c.  c.  |ii 

Tincturas  Opii  Camphoratae  80.0  "    "  |i 

Tincturae  Digitalis,  30.0  "    "  |i 

Ammonii  Carbonatis,  8.0  grams  3ii 

Mix.  Dilute  each  dose  with  two  tablespoonfuls  of  sweetened  water 
when  given.  At  the  same  time  I  require  from  thirty  to  sixty  cubic  cen- 
timeters (fl.  ^i  to  |ii)  of  milk  and  fifteen  cubic  centimeters  (fl.  fss)  of  a 
strong  infusion  of  coffee,  to  be  given  every  two  hours.  To  this  sugar  may 
be  added  or  not  as  the  patient  prefers.  If  when  night  comes  the  cough 
is  frequent  and  the  patient  restless,  I  give  a  single  dose  of  the  formula 
containing  muriate  of  ammt  niura,  which  I  gave  you  in  the  earlier  part  of 
the  present  lecture.  During  the  last  thirty-five  years  1  have  been  called 
to  many  cases  of  acute  pneumonia  in  which  the  patients  had  continued  to 
fail  notwithstanding  the  liberal  use  of  alcoholic  remedies  and  nourish- 
ment, and  have  entirely  omitted  the  former,  substituting  therefor  the 
treatment  I  have  just  detailed  with  the  most  satisfactory  results.  The 
chlorate  of  potassium  indirectly,  and  the  digitalis,  coffee  and  quinine  di- 
rectly, constitute  our  most  reliable  cardiac  and  vasomotor  tonics  in  these 
cases. 

When  giving  you  the  clinical  history  of  pneumonia,  I  stated  that  cases 


432  CHRONIC    PXEUMONIA. 

had  been  occasionally  met  with  in  which  the  inflammation  terminate'd  in 
the  formation  of  one  or  mure  circumscribed  abscesses  in  the  parenchyma 
of  the  lung.  Such  cases  are  very  liable  to  terminate  fatally  from  exhaust- 
ion. But  in  some  instances  the  abscess  has  formed  an  opening  into  one 
or  more  of  the  bronchi,  and  the  pus  has  been  discharged  by  co  gh  ig  in 
large  quantities,  often  streaked  with  blood  and  emitting  a  mo.  e  or  less 
offensive  odor.  If  the  abscess  is  not  large  and  the  bronchial  opening  is 
sufficient  to  afford  free  exit  to  the  matter,  the  patient  may  steadily  im- 
prove until  full  recovery  takes  place,  leaving  only  a  cicatrix  in  the  place 
of  the  abscess.  But  if  the  bronchial  opening  communicating  with  the 
abscess  is  small,  the  purulent  discharge  will  take  place  at  irregular  inter- 
vals, only  partially  draining  the  suppurative  cavitj'-,  and  exciting  more  or 
less  irritation  in  the  lining  of  the  bronchi  through  which  the  matter  passes 
on  its  way  out,  until  the  hectic  fever  and  copious  night  sweats  result  in 
entire  suspension  of  nutrition  and  death  of  the  patient.  A  fev/  months 
since,  a  case  of  this  kind  came  into  the  Mercy  Hospital,  giving  the  clin- 
ical history  of  an  acute  attack  of  inflammation  of  the  lower  and  middle 
parts  of  the  left  lung,  and  afi"ording  all  the  rational  and  physical  signs  of 
an  abscess  in  the  parenchyma  of  the  left  lung,  having  its  center  a  little 
below  and  to  the  left  of  the  nipple.  The  patient  had  begun  to  discharge 
by  coughing  at  irregular  intervals  about  twice  in  twenty-four  hours  large 
quantilies  of  pus  emitting  a  very  offensive  odor.  The  patient  continuing 
rapidly  to  fail  in  flesh  and  strength,  what  was  supposed  to  be  the  center 
of  the  abscess  was  punctured  with  an  aspirator  needle  by  my  colleague. 
Prof.  E.  Andrews,  in  one  of  his  surgical  clinics.  Finding  pus,  a  free 
incision  was  made  giving  exit  to  a  considerable  quantity  of  very  thick 
and  offensive  pus.  An  improved  drainage  tube  was  inserted  and  the 
cavity  daily  washed  out  with  mild  antiseptic  solutions.  From  this  time 
his  cough  and  expectoration  diminished  rapidly  until  both  ceased,  and  in 
a  few  weeks  he  had  ^o  far  regained  his  flesh  and  strength  as  to  enable 
him  to  attend  to  his  ordinary  business,  though  still  under  the  supervision 
of  the  professor  of  clinical  surgery. 

Gangrene  of  some  portion  of  the  lung  as  the  result  of  acute  pneumo- 
nitis, is  still  more  rare  than  circumscribed  abscesses,  and  more  certainly 
fatal  in  its  results.  The  treatment  must  consist  of  anodynes  to  promote 
rest,  antiseptic  inhalations  to  lessen  the  offensiveness  of  the  breath,  and 
such  tonics  as  tend  to  sustain  the  nutritive  processes,  with  as  much  plain, 
easily  digestible  food  as  the  stomach  will  bear. 

CHRONIC  PNEUMONIA. 

A  chronic  form  of  disease  of  evident  inflammatory  character  is  occasion- 
ally met  with  in  the  connective  tissue  and  parenchyma  of  the  lungs.  In 
one  class  of  cases  it  has  followed  as  the  sequel  of  a  more  acute  attack  of 
(hither  pneumonia  or  of  broncho-pneumonia,  while  in  another  class  it  has 
supervened  without  any  preceding  acute  or  subacute  symptoms.  The 
cases  belonging  to  the  latter  class  have  been  described  by  some  writers  as 
true  pulmonary  cirrhosis  resulting  from  the  same  form  of  morbid  action 
in  the  connective  tissue  as  that  which  attends  cirrhosis  of  the  liver. 

Clinical  History. — The  cases  you  will  meet  following  acute  pneumonic 
attacks  differ  much  in  their  symptoms,  progress  and  results.  They  are 
capable,  however,  of  being  arranged  in  two  groups.  Those  constituting 
the  first  group  are  met  with  as  the  sequelae  of  acute  pneumonia  in  patients 
already  affected  by  some  constitutionrd  predisposition  or  diathesis,  such  as 
the  scrofulous,  tuberculous  or  syphilitic.     In  many  such  cases  the  primary 


SYMPTOMS.  466 

pneumonic  attack  runs  its  course,  and  the  patient  presents  the  appear- 
ance of  convalescence.  That  is,  his  fever  subsides,  secretions  become 
natural,  appetite  returns,  and  he  begins  to  move  about  and  thinks  he  will 
soon  be  as  well  as  usual.  Still,  when  carefully  noticed,  he  looks  unusually 
pale  in  the  morning  and  becomes  weary  from  very  little  exertion;  his 
pulse  is  found  from  ten  to  fifteen  beats  faster  than  natural,  especially  in 
the  afternoon  and  evening;  his  resoirations  acce^lerated  in  about  the  same 
proportion,  with  unnatural  shortness  of  breath  when  walking  or  ascending 
stairs;  and  a  failure  to  regain  the  usual  amount  of  flesh.  After  remaining 
in  this  condition  for  a  period  varying  from  two  or  three  weeks  to  as  many 
months,  he  begins  again  to  cough  some,  especially  in  the  mornings;  to 
feel  occasional  pains  in  his  chest;  to  look  more  flushed  and  feverish  in  the 
evening,  and  frequently  to  sweat  in  the  last  half  of  the  night.  He  thinks 
he  has  taken  "some  cold,"  and  recalls  his  physician,  wh{^  now  finds  him 
with  all  the  symptoms  of  incipient  hectic  fever.  His  pulse  is  quick  and 
irritable,  varying  from  100  to  130  per  minute;  respirations  short  and  fre- 
quent, especially  when  attempting  a  little  exercise;  cough  frequent  but 
most  severe  in  the  latter  part  of  the  night  and  early  morning,  accom- 
panied by  an  expectoration  of  more  or  less  yellowish  muco- purulent  mat- 
ter; temperature  varies  from  38'  C.  (101^  F.)  in  the  morning,  to  40°  C. 
(104"  F.)  in  the  evening,  with  some  sweating  on  the  approach  of  morning; 
his  urine  is  redder  than  natural  and  less  in  quantity,  and  his  appetite 
poor.  A  physical  examination  shows  decided  increased  fremitus  of  voice 
and  dullness  on  percussion  over  the  side  in  which  the  pneumonia  was 
primarily  located,  with  tubular  respiration  and  some  degree  of  sharp  sub- 
mucous rales  in  one  or  more  places  which  are  not  temporarily  removed 
altogether  by  an  act  of  coughing.  Such  patients  now  emaciate  rapidly; 
the  expectoration  becomes  more  copious  and  purulent,  often  containing 
little  masses  of  caseous  matter  and  sometimes  shreds  of  coimective  tissue; 
the  night  sweats  become  more  profuse;  the  appetite  fails;  apthse  appear 
in  the  fauces;  the  intestinal  discharges  become  thin  and  are  repeated 
from  two  to  four  or  six  limes  in  the  twenty-four  hours,  and  the  patient 
generally  reaches  a  fatal  degree  of  exhaustion  in  from  three  to  six  months 
after  the  primary  attack.  These  are  the  kind  of  cases  which  were  desig- 
nated by  the  older  writers  as  quick  or  '•'•galloplncf''  consumption.  An  ex- 
planation of  the  symptoms  and  progress  I  have  detailed  is  to  be  found  in 
the  fact  that  the  exudative  material  which  accumulated  in  the  inflamed  pul- 
monary structure  during  the  primary  attack,  was  of  such  quality  that 
instead  of  undergoing  resolution  as  convalescence  approached,  it  under- 
went caseous  degeneration,  and  subsequently  purulent  change;  the  com- 
mencement of  the  latter  giving  rise  to  renewal  of  active  symptoms  and 
the  subsequent  extensive  suppurative  changes  in  the  lung  structure. 

A  similar  exudation  sometimes  accompanies  a  low  grade  of  pneumonic 
inflammation  following  a  primary  pulmonary  hemorrhage  in  persons  pre- 
disposed to  phthisis,  and  subsequently  undergoes  the  same  successive 
changes,  constituting  an  acute  caseous  form  of  consumption  as  described 
by  Niemeyer  and  others. 

The  cases  of  chronic  pneumonia  following  acute  attacks  constituting 
the  second  group  to  which  I  have  alluded,  occur  in  a  very  different  class 
of  patients  from  those  I  have  just  been  describing,  namely,  those  whose 
blood  and  tissue  properties  favor  exudations  of  a  highly  pkstic  character, 
and  consequently  tending  to  permanent  organization. 

Cases  of  brcmcho-and  pleuro-pneuraonia  occurring  in  previ  usly  vigor- 
ous and  healthy  subjects,  and  still  more  in  those  of  a  rheumatic  diathesis, 
28 


434  CHRONIC  PNEUMONIA. 

are  the  ones  m  st  liable  to  have  some  part  of  the  pneumonic  exudation 
undergo  perman  nt  organization,  and  consequently  continue  to  fill  the 
alveoli  and  interstitial  spaces  after  the  acute  stage  of  the  disease  has 
passed  and  convalescence  is  apparently  established. 

The  majority  of  such  patients  so  far  recover  as  to  resume  t'leir  usual 
habits  and  business  of  life,  and  for  a  long  time  complain  only  of  shortness 
of  breath  when  exercising  or  making  any  extra  exertion;  of  undue  sen- 
sitiveness to  atmospheric  changes;  of  frequent  derangements  of  digestion 
chiefly  from  deficient  secretion  of  the  gastric  juice;  and  of  occasional 
wandering  pains  in  the  chest.  But  percussion  shows  less  than  the  natu- 
ral degree  of  resonance,  and  auscultation  detects  increased  fremitus  of 
voic  •  over  the  affected  part  of  the  lungs,  with  less  than  the  natural  res- 
piratory murmur. 

If,  after  six  or  twelve  months  have  passed  the  patient  comes  under  ex- 
amination, the  same  general  condi  ion  of  health  and  the  same  physical 
signs  will  be  found,  together  with  a  contraction  of  the  affected  side  of  the 
chest,  a  marked  difference  in  th-;  expansion  of  the  two  sides  during  or  li- 
nary  inspirations,  and  a  niore  constant  feeling  of  weariness  and  dull  pain 
or  oppression  in  the  chest.  The  latter  is  apt  to  be  increased  by  exercise 
of  the  arms  or  in  the  performance  of  maimal  labor;  and  at  such  times 
slight  feverishness  and  a  dry  hacking  cougli  are  sometimes  present.  Some 
persons  remain  in  this  condition  of  impaired  health,  yet  attending  more 
or  less  to  the  ordinary  duties  of  life  for  many  years.  But  the  long-con- 
tinued deficiency  in  the  performance  of  the  respiratory  function,  render- 
ing the  oxygenation  and  decarbonization  of  the  blood  defective,  in  most 
cases  ultimately  induces  fatty,  atheromatous,  or  caseous  degenerations 
■either  in  the  affected  part  of  the  lung  developing  all  the  phenomena  of 
pulmonary  phthisis,  or  in  the  liver,  kidneys,  or  heart,  giving  rise  to  some 
iform  of  dropsical  accumulations,  or  to  progressively  increasing  cardiac 
weakness  and  irregularity  ending  in  vertigo  and  sometimes  paralysis,  or 
sudden  death.  The  remaining  class  of  cases,  described  bv  Corrigin  and 
Bastian  as  constituting  true  pulmonary  cirrhosis,  but  regarded  by  Charcot, 
Wilson  Fox,  and  others  as  identical  with  chronic  pneumonia,  are  not  of 
frequent  occurrence.  You  will  find  the  same  class  of  cases  described  by 
Drs.  Flint,  Bartholow,  and  Palmer,  in  their  respective  works,  under  the 
name  oi  fibroid  phthisis.  Some  other  writers  have  called  them  cases  of 
interstitial  pneumonia  or  sclerosis  of  the  pulmonary  structure.  But  what- 
ever may  be  the  name  adopted,  a  careful  examination  of  the  clinical  his- 
tories, so  far  as  they  are  given,  show  that  nearly  all  the  cases  are  traceable 
to  primary  chronic  capilary  bronchitis,  becoming  complicated  in  some 
stage  of  its  progress  with  lobular  pneumonia,  as  I  described  when  speak- 
ing to  you  of  that  form  of  bronchitis  a  few  days  since. 

The  inflammatory  action  thus  extending  into  the  pulmonary  lobules 
causes  increased  irritability  and  growth  of  the  connective  tissue  and  cell 
walls  which,  added  to  the  obstructed  bronchioles,  diminishes  the  capacity 
for  air,  and  constitutes  a  pathological  condition  perhaps  more  analogous 
to  sclerosis  of  the  central  parts  of  the  nervous  structures,  than  to 
'cir.  hosis.  Yet  the  exclusion  of  air  which  it  involves  pretty  uniformly 
leads  to  marked  contraction  of  the  affected  lung.  Writers  generally 
claim  that  this  form  of  disease  is  met  with  almost  excKisively  in  adult 
life,  and  generally  between  the  ages  of  thirty  and  fifty  years.  Yet  some 
of  the  most  characteristic  cases  that  have  come  under  my  own  observa- 
tion have  been  in  children  between  five  and  ten  years  of  age.  My  own 
clinical  and  post  mortem  observations  have  led  me  to  the  conclusion  that 
the   usual   order  of  anatomical  changes  in  the  cases   under  consideration, 


SYMPTOMS.  435 

is,  first,  a  trvie  sclerosis  from  chronic  inflammation  of  the  connective  tissue 
constituting'  the  alveolar  and  lobular  septa  and  vascular  walls,  forming 
dense  bands  and  irregular  nodules  often  stained  with  dark  pigment;  sec- 
ond, exudations  from  the  congested  and  obstructed  vessels  filling  the 
alveoli  and  interstitial  spaces  with  fibrous  material  containing  lymphoid, 
spintlle-shaped  and  giant  cells  much  resembling  small  tuberculous  granu- 
lations; and  third,  the  same  exudative  material  accumulated  in  larger 
masses  and  presentinsf  various  stages  of  degeneration  either  calcareous, 
cheesy,  or  semi-purulent.  It  has  seemed  to  me  that  all  these  are  only 
different  stages  of  the  same  morbid  processes,  often  observable  at  differ- 
ent points  ill  the  same  section  of  diseased  lung;  and  differing  from  pri- 
mary tuberculosis,  in  having  originated  from  direct  inflamnntion  or 
hyperplasia  of  the  pulmonary  structure  and  often  preceded  by  capillary 
bronchitis,  pleurisy,  or  more  active  pneumonitis.  After  the  disease  has 
progressed  for  several  months,  the  imperfect  and  unequal  expansion  of 
the  chest  from  the  obstruction  or  obliteration  of  the  alveoli  and  the  ex- 
c  usion  of  air,  favors  dilation  of  many  of  the  smaller  bronchi,  and  general 
contraction  of  the  diseased  lung,  with  corresponding  contraction  of  that 
side  of  the  chest. 

Symptonis. — The  chief  symptoms  are  a  frequent  and  harassing  cough, 
accompanied  usually  in  all  the  earlier  stages  of  the  disease  by  onl})-  a 
scanty  mucous  expectoration,  later  becoming  muco-purulent,  and  some- 
times offensive  to  the  smell;  shortness  of  breath,  always  increased  by  ex- 
ercise; but  with  less  disturbance  of  the  pulse  and  less  emaciation  than  the 
other  symptoms  would  lead  us  to  expect.  Inspection  of  the  chest  shows 
marked  contraction  of  the  affected  side  laterally,  similar  to  that  which 
often  follows  attacks  of  acute  pleurisy,  and  not  the  flattening  or  reced- 
ing of  the  infra-clavicular  region,  which  is  generally  seen  in  ordiiaary  tu- 
berculosis. Percussion  reveals  increased  dullness  over  the  affected  side, 
with  here  and  there  tympanitic,  amphoric,  or  cracked  metal  sounds,  owing  to 
different  degrees  of  dilatation  of  the  bronchi,  the  last  named  sound  existing 
only  when  some  dilatation  has  become  sacculated  and  partly  filled  with 
muco-pus.  Auscultation  may  reveal  only  feeble  or  suppressed  respiratory 
murmur  with  increased  fremitus  of  voice  and  some  moist  bubbling  rales;  or 
there  m-iy  be  tubular  or  cavernous,  or  broncho-vesicular  sounds  according 
to  the  degree  of  the  bronchial  dilatations.  When  the  disease  has  existed 
for  several  years,  as  is  the  case  with  many  patients,  the  long  continued 
contraction  of  the  affected  lung,  retarding  the  flow  of  blood  through  it, 
causes  the  right  cavities  of  the  heart  to  become  dilated  and  the  tricuspid 
valve  insufficient,  allowing  regurgitation  or  double  cardiac  murmur  and 
jugular  pulse,  and  sometimes  general  drops\^  Although  the  disease  is 
generally  very  slow  in  its  progress,  in  some  instances  continuing  from 
five  to  twenty  years,  yet  sooner  or  later  the  structural  changes  reach  that 
degree  of  purulent  degeneration  which  afl"ords  abundant  expectoration, 
and  ends  in  extensive  emaciation,  hectic  fever  and  fatal  exhaustion. 

Pulmonary  hemorrhages  occur  during  the  progress  of  many  of  this 
class  of  cases,  but  not  in  all. 

Prognosis. — The  cases  belonging  to  the  class  of  chronic  pneumonia 
now  under  consideration,  are  seldom  recognized  by  accurate  examinations 
until  the  anatomical  changes  in  the  lung  tissue,  just  desci-ibed,  have  be- 
come well  established,  and  then  they  are  incapable  of  removal.  Conse- 
quently the  prognosis  is  very  unfavorable,  although  the  progress  of  the 
disease  may  be  retarded,  and  sometimes  kept  stationary,  for  a  long  period, 
by  judicious  treatment,  and  still  more  by  a  residence  in  a  mild  and  dry 
climate. 


436  CHRONIC  PNEUMONIA. 

Treatment. — As  I  have  just  remarked,  in  reference  to  the  prognosis  in 
the  last  variety  of  cases  described,  so  I  may  say  in  reference  to  all  the 
varieties  of  chronic  pneumonia,  when  they  have  progressed  so  far  as  to 
develop  well  established  structural  changes,  they  are  not  curable  in  the 
sense  of  complete  restoration  to  health.  Yet  much  may  be  done  through- 
oat  ail  stages  of  their  progress  to  palliate  the  more  distressing  symptoms 
and  to  prolong  the  lives  of  the  patients.  And  in  some  cases  when  the  di- 
agnosis is  made  early  and  the  treatment  adopted  judicious  and  faithfully 
pursued,  permanent  recoveries  have  taken  place.  To  give  each  patient 
the  full  benefit  which  his  case  is  capable  of  receiving  from  appropriate 
treatment,  you  must  have  an  accurate  knowledge  of  the  actual  patholog- 
ical conditions  existing  in  each  case,  which  can  be  gained  only  by  a  care- 
ful tracing  of  its  history,  its  present  general  symptoms,  and  a  thorough  ap- 
plication of  the  methods  of  physical  examination  and  diagnosis.  While 
attending  cases  of  acute  pneumonitis,  whether  of  the  lobar  or  lobular  vari- 
ety, in  which  hepatization  has  characterized  the  second  stage,  you  should 
regard  it  as  a  necessary  rule  of  practice  to  note  carefully  the  progress  of 
resolution  during  the  decline  of  the  disease.  And  when  convalescence 
appears  to  have  been  fairly  established  it  is  proper  to  give  the  aiFected 
side  of  the  chest  a  careful  examination  by  auscultation  and  percussion. 
If  the  continuance  of  well  marked  dullness  on  percussion  and  imperfect 
inflation  of  the  lung  in  ordinary  inspiration,  shows  that  the  resolution  or 
clearing  up  of  the  lung  structure  is  tardy  or  incomplete,  it  should  receive 
careful  attention.  If  the  patient  is  known  to  possess  a  scrofulous  or  tu- 
berculous tendency,  either  hereditary  or  acquired,  special  care  should  be 
taken  to  promote  healthy  nutrition  hy  a  sufficient  variety  of  easily  digest- 
ible food,  aided  by  such  remedies  as  the  syrup  of  lacto-phosphate  of  cal- 
cium, syrup  of  iodide  of  calcium,  compound  syrup  of  the  hypopbosphites, 
and  cod-liver  oil  when  it  is  well  received  by  stomach,  and  as  good  a  sup- 
ply of  pure  air  as  possible.  Exercise  is  also  important,  and  should  consist 
at  first  in  gentle  or  cautious  efforts  to  inflate  the  lungs  two  or  three  times 
a  dav,  but  may  be  gradually  extended  until  it  embraces  riding,  driving, 
and  moderate  walking,  ending  when  necessary  and  practicable  in  a  change 
to  a  milder  and  dryer  climate  at  moderate  elevations.  By  such  a  course, 
promptlv  adopted  and  judiciously  executed,  vou  may  arrest  the  further 
caseous  degeneration  of  the  exudate  in  the  lung  and  induce  its  ulti- 
mate calcification  or  disappearance  by  slow  disintegration  and  removal. 
But  if  in  spite  of  your  best  directed  efforts  the  deteriorative  changes  pro- 
gress until  caseous  and  purulent  products  are  completed,  with  rapid  emaci- 
ation and  hectic  fever,  you  can  do  but  little  more  than  palliate  the  more 
troublesome  symptoms  by  measures  which  will  be  more  fully  explained 
when  I  come  to  speak  of  the  management  of  the  advanced  stage  of  tuber- 
cular phthisis. 

When  the  exudate  in  the  acute  stage  of  pneumonitis  has  been  un- 
usually plastic,  leaving  after  convalescence  the  alveoli  and  interstitial  spaces 
filled  by  permanently  organized  false  tissues  as  I  have  previously  described, 
advantage  may  be  gained  by  a  somewhat  protracted  use  of  either  the 
iodide  of  potassium  or  muriate  of  ammonium  in  moderate  doses  three 
times  a  day,  and  the  daily  practice  of  cautious  but  full  inspirations  and 
such  training  of  the  chest  and  arms  as  is  calculated  to  re-establish  as  good 
a  capacity  for  air  as  possible.  In  those  cases  following  attacks  of  capillary 
bronchitis  complicated  with  lobularpneumonia,  which  I  have  described  as 
including  both  the  fibroid  or  catarrhal  phthisis  and  the  pulmonary 
cirrhosis  of  different  writers,  I  have  found  no  combination  of  remedies 
more  efficient  in  allaying  the  cough,  lessening  the  soreness  and  feeling  of 


PLEUKITIS.  437 

constriction  in  the  chest,  and  promoting  the  removal  of  the  exudntivo 
material  without  suppuration,  than  the  formulae  containino;  muriate  of  am- 
mon'um,  already  stated  to  you  during  the  present  lecture.*  To  adults  it 
may  be  g-iven  in  doses  of  four  cubic  centimeters  (fl.  3i)  from  ^vvo  to  four  times 
a  dav,  according  to  the  severity  of  the  symptoms.  The  functions  of  the 
digestive  organs,  including  regular  evacuations,  should  be  sustained  by 
the  use  of  mildly  laxative  and  tonic  remedies,  and  by  such  judicious 
exercise  daily  in  the  o^jen  air  as  the  patient  is  able  to  endure  without 
fatigue.  Many  of  the  cases  belonging  to  this  class  are  much  benefitted 
by  the  inhalation  of  resinous  and  anodyne  vipors.  Perhaps  the  best  of 
tliese  is  the  combination  of  carbolic  acid,  oil  of  scotch  pine,  and  camphor- 
ated tinccure  of  opium,  which  I  mentioned  when  speaking  of  the  treat- 
ment o'f  certain  conditions  in  the  progress  of  chronic  capillary  bronchitis.f 
But  the  most  important  of  all  remedies  for  this  class  of  patients,  is  an  early 
and  judicious  choice  of  a  residence  in  a  mild  and  genial  climate.  The 
soutiiern  part  of  California,  the  district  of  Texas  represented  by  San 
Antonio,  some  places  in  New  Mexico,  and  many  in  Mexico,  afford  resi- 
dences of  the  greatest  value  to  a  large  proportion  of  thesj  cases,  if  made 
available  before  the  structural  changes  have  advanced  too  far.  It  is  the 
mild,  dr}^  and  pure  air  at  moderate  elevations  (from  1,500  to  3,000  feet)  in 
these  districts  of  country  that  is  most  beneficial.  For  a  temporary  resi- 
dence during  the  winter  months,  the  orange  grove  regions  of  the  interior 
of  Florida,  and  many  other  places  in  the  interior  and  moderatelv  elevated 
districts  of  Georgia,  Alabama,  and  South  Carolina,  afford  good  advantages. 
For  such  as  need  the  influence  of  sea-air  in  connection  with  mildness  of 
climate,  the  Bermuda  and  Sandwich  Islands  are  well  adapted;  and  the 
Bermudas  especially  are  easy  of  access  lor  the  citizens  of  this  country. 


LECTUKE  XLV. 


Pleuritis— Acute  and  Chronic :  Th2ir  Clinical  History,  Anatomical  changes,  Diagnosis,  Prognosis 
and  ireatment. 

GENTLEMEN:  The  remaining  important  structure  constituting  a  part 
of  the  respiratory  organs,  the  inflammations  of  which  I  have  now  to 
CO  sider,  is  the  serous  membrane  called  the  pleura,  which  forms  both  an 
external  covering  of  the  lungs  and  an  internal  lining  of  the  parieties  of 
the  chest.  Consequently  the  mambrane  on  each  side  constitutes  a  closed 
or  complete  sac,  the  smooth,  free  surface  of  which  is  covered  with  a  single 
layer  of  endothelial  cells  and  is  everywhere  in  contact  with  itself.  In 
the  natural  condition  the  surface  is  constantly  moistened  by  a  small  quan- 
tity (  f  serous  flui(J.  In  addition  to  the  layer  of  endothelial  cells  on  the 
surface,  the  nKMnbrane  is  composed  of  white  connective  and  elastic  fibers; 
a  net  work  of  capillaries  derived  from  the  larger  vessels  in  the  sub- 
serous layer  of  tissue,  and  lymphatics.  The  pleural  membrane  may  be 
attacked  with  inflammation   at   any  period  of  life,  and   at   any  season   of 

*  See  page  429. 
t  See  page  409. 


438  PLEURITIS. 

the  year;  althouj^h  much  the  larger  number  of  cases  occur  in  the  colder 
months  of  the  year,  and  in  such  climates  as  are  characterized  by  sudden 
and  extreme  changes  in  the  thermometric  and  hygrometric  conditions  ol 
the  atmosphere.  Males  appear  to  be  more  liab!e  to  the  disease  than 
females.  The  great  majority  of  attacks  are  unilateral,  but  in  some  rare 
instances  the  inflammation  invades  both  membranes  at  the  same  time  and 
is  called  double  pleuritis.  On  the  other  hand  it  may  be  limited  to  only  a 
small  part  of  one  pleura,  constituting  circumscribed  pleuritis. 

The  grade  of  the  inflainma'.ion  may  be  acute  and  rapid  in  its  progress, 
or  chronic  and  persistent  in  duration. 

Symptoms  of  Acute  Pleuritis. — An  attack  of  acute  pleurisy  is  gener- 
ally abrupt  in  its  beginning  and  characterized  by  well  marked  symptoms. 
In  some  cases,  however,  slight  pains  and  feelings  of  depression  are  noticed 
for  two  or  three  days  prior  to  the  commencement  of  the  more  severe 
symptoms. 

Most  of  the  acute  cases  are  ushered  in  by  a  chill  or  brief  period  of 
rigors,  accompanied  by  paleness  and  coolness  of  the  surface,  small  pulse, 
short  and  unsteady  respiratory  movements,  and  sharp  piercing  pains  in 
one  side  of  the  chest,  more  frequently  in  the  sub-axillary  region  than  else- 
where. The  coldness  soon  gives  place  to  heat  and  dryness  of  the  sur- 
face; some  flush  of  redness  in  the  face;  a  full  iiim  pulse  accelerated  in 
frequency  to  90  or  100  per  minute;  respirations  short  and  frequent  being 
voluntarily  stifled  as  much  as  possible  to  prevent  the  increase  of  pain  in 
the  side;  a  short,  dry  cough  which,  like  the  respiratory  movements  is  sup- 
pressed as  much  as  possible  to  prevent  increase  of  pain. 

The  secretions  generally  are  diminished,  as  in  other  acute  inflammations, 
and  the  tongue  in  mos^  cases  covered  with  a  thin  white  fur.  If  the 
afi"ected  side  of  the  chest  is  examined  within  eighteen  or  twenty-four 
hours  after  the  initial  symptoms  by  auscultation  and  percussion,  the  only 
unnatural  sign  discoverable  will  be  a  rubbing  or  friction  sound  synchro- 
nous with  the  respiratory  movements.  If  the  examination  is  made  at  any 
later  period  during  the  progress  of  the  disease,  in  most  cases  the  friction 
sound  will  have  ceased,  and  in  its  stead  you  will  find  marked  dullness  on 
percussion,  increased  vibration  of  voice,  in  some  cases  amounting  to 
(jegophony,  and  absence  of  respii-atory  murmur.  These  signs  indicate  the 
commencement  of  the  second  or  exudative  stage  of  the  inflammatory 
process  with  sufficient  efi'usion  of  serous  fluid  to  separate  the  surfaces  of 
the  pleura  by  compressing  the  lung,  and  to  some  extent,  increasing  the 
size  of  the  afi"ected  side  of  the  chest.  In  all  the  more  acute  cases,  the 
symptoms  of  general  irritative  fever,  sharp  local  pains,  and  stifled  respira- 
tions, continue  without  abatement  from  three  to  five  days,  or  until  the 
accumulation  of  inflammatory  products  in  the  cavity  of  the  pleura  and 
its  consequent  distension  with  serous  or  sero-purulent  fluid,  has  become 
sufficient  to  render  the  oxygenation  and  decarbonization  of  the  blood  de- 
fective. Then,  the  temperature  begins  to  diminish;  the  pains  to  be  less 
acute  and  less  frequent;  but  the  shortness  of  breath  and  sense  of  oppres- 
sion in  the  chest  have  increased,  the  pulse  has  become  smaller  and  more 
frequent,  and  the  patient  complains  much  of  weariness,  yet  is  wholly 
unable  to  rest  in  any  other  than  the  sitting  or  semi-erect  position. 

In  some  of  the  most  severe  cases,  by  the  end  of  the  first  week  the  sac 
of  the  inflamed  pleura  has  become  fully  distended  rendering  the 
whole  affected  side  of  the  chest  completely  dull  on  percussion,  consider- 
ably enlarged  with  the  intercostal  spaces  bulging  or  convex,  and  the  lung 
compressed  into  the  upper  and  back  part  ol  the  chest,  thereby  suppressing 


SYMPTOMS.  439 

all  respiratory  sounds  and  restricting  the  motions  of  the  chest  in  inspira- 
tion and  expiration  to  the  well  side.  If  the  left  pleura  is  the  seat  of  the 
disease  its  distension  to  the  extent  just  described  will  push  the  heart  from 
its  natural  jwsition  further  to  the  right  until  its  impulse  and  natural 
sounds  are  both  felt  and  heard  to  the  right  of  the  sternum.  As  a  general 
rule  the  crisis  of  the  disease  is  reached  by  the  end  of  the  first  or  during 
the  first  half  of  the  second  week  of  its  progress,  after  which  tlie  febrile 
symptoms  and  local  pains  soon  cease.  But  the  shortness  of  breath  and  all 
other  symptoms  and  physical  signs  caused  by  the  mechanical  distension  of 
the  pleural  sac  will  abate  more  slowly,  and  may  keep  the  patient  confined 
several  weeks  before  the  accumulated  inflammator}'  products  will  have 
been  entirely  removed  and  the  respiratory  function  freed  from  embarrass- 
ment. In  the  milder  cases,  however,  the  first  or  stage  of  vascular  en- 
gorgement will  occupy  from  one  to  two  days;  the  second  or  stage  of  ex- 
udation and  effusion  from  three  to  five  days;  and  the  t'hird  or  stage  of 
resolution  and  re-absorption  of  inflammatory  products  only  from  seven  to 
nine  days  more,  making  the  average  duration  of  such  cases  from  eleven  to 
sixteen  days. 

The  symptoms  and  clinical  history  I  have  thus  far  given  you  apply  with 
sufficient  accuracy  to  the  great  majority  of  cases  of  acute  pleutitis  as  they 
are  met  with  in  general  piactice.  But  there  are  several  deviations  from  the 
usual  course  of  the  disease,  of  sufficient  importance  to  require  attention. 
In  a  few  instances,  even  of  unilateral  pleuritis,  the  serous  effusion  into  the 
pleural  sac  accumulates  so  rapidly  during  the  second  stage  of  the  inflam- 
matory process  as  to  completely  compress  the  one  lung  and  crowd  the  me- 
diastinum so  far  to  the  opposite  side  as  to  materially  lessen  the  expansion 
of  the  other.  In  such  cases  the  patient  feels  a  most  distressing  sense  of 
suffocation  and  exhaustion  from  want  of  air;  his  extremities  become  cold, 
ard  the  whole  cutaneous  surface  passively  congested  or  cyanozed;  the 
pulse  is  small,  frequent  and  feeble,  and  unless  speedily  relieved  by  surgi- 
cal interference,  the  patient  dies  from  apnoea  or  insufficient  supply  of  air 
to  the  pulmonary  alveoli. 

A  case  of  this  kind  was  received  into  the  medical  department  of  the 
Mercy  Hospital  a  few  years  since,  in  which  the  symptoms  of  suffoca- 
tion were  so  urgent  that  I  deemed  it  necessary  to  diminish  the  amount  of 
effused  fluid  by  tapping  the  affected  side  of  the  chest,  at  once,  with  an 
ordinary  trochar.  Four  liters  (between  8  and  9  pints)  of  serum  were 
drawn  off,  much  to  the  relief  of  the  patient,  who  subsequently  recovered. 
The  danger  of  death  from  compression  of  the  lungs  during  the  second 
stage  of  the  disease  is  much  greater  when  the  inflammation  has  attacked 
the  pleural  membrane  in  both  sides  of  the  chest  at  the  same  time.  An- 
other deviation  from  the  ordinary  course  of  the  disease  is  manifested  by 
the  occurrence  of  one  or  more  chills  during  the  second  stage  followed  by 
higher  fever,  more  rapid  pulse,  shorter  breathing,  andgreater  restlessness, 
ending  in  from  six  to  twenty-four  hours  by  a  copious  sweat.  The  fever 
now  assumes  a  distinct  hectic  type,  with  rapid  loss  of  flesh  and  strength, 
while  the  signs  of  fluid  accumulating  in  the  pleural  sac  daily  increase, 
until  the  symptoms  of  exhaustion  and  approaching  apnoea  indicate  ex- 
treme danger  to  life.  The  occurrence  of  the  chills  and  more  decided 
hectic  symptoms  usually  indicate  the  commencement  of  the  suppurative 
process  in  the  inflamed  membrane,  and  the  consequent  intermixture  of 
pus  with  the  serous  effusion.  In  some  cases  the  accumulated  fluid  con- 
sists wholly  of  pus,  constituting  empyema,  as  distinguished  from  serous 
and  aqueous  accumulations  called  hydrothorax.  In  some  of  the  pleuritic 
inflammations  occurring  in  tuberculous  subjects,  the  inflammatory  affection 


440  PLEUKITTS. 

is  circumscribed  or  limited  to  a  small  portion  of  the  membrane,  is  slower 
in  its  progress,  accompanied  by  less  active  general  febrile  phenomena,  and 
yet  the  resulting  accumulation  of  sero- purulent  fluid  may  be  as  copious 
and  as  oppressive  to  the  respiratory  function  as  in  cases  involving  a  larger 
part  of  the  membrane. 

It  sometimes  happens  in  cases  of  suppurative  pleuritis,  especially  when 
connected  with  the  suppurative  stage  of  pulmonary  tuberculosis,  that  gases 
as  well  as  pus  are  formed  in  the  pleural  cavity  adding  to  the  distension 
of  the  side  and  embarrassment  of  respiration,  and  yet  giving  you  increased 
or  tympanitic  resonance  instead  of  dullness  over  a  large  part  of  the 
affected  side.  The  same  effect  is  capable  of  resulting  from  the  perfora- 
tion of  the  pleura  by  the  extension  of  superficial  tubercular  abscesses  or 
cavities  in  the  lung,  and  the  escape  of  air  as  well  as  matter  into  the 
pleural  sac.  One  more  deviation  which  you  may  occasionally  meet  with, 
results  from  the  unusually  plastic  quality  of  the  exudative  material  that 
accumulates  upon  the  surface  of  the  inflamed  membrane  during  the 
earlier  stages  of  the  disease.  In  some  rare  cases  the  exudate  will  be 
wholly  plastic,  and  by  undergoing  rapid  organization  into  a  layer  of  false 
membrane,  will  result  in  the  firm  adhesion  of  the  pulmonary  to  the  costal 
pleura.  In  such  cases  the  symptoms  of  the  first  stage  undergo  less 
change  during  the  second;  the  layer  of  plastic  exudate  not  occupying 
sufficient  space  to  either  compress  the  lung  or  perceptibly  enlarge  the 
affected  side  of  the  chest,  the  respiratory  murmur  and  even  some  friction 
may  continue  through  the  whole  of  the  second  stage,  and  the  dullness 
from  percussion  usually  so  strongly  marked  in  cases  attended  by  serous 
effusion,  does  not  supervene.  The  adhesions  formed  during  the  active 
stage  of  these  cases,  remain  after  convalescence  and  generally  thi'ough 
life.  During  the  first  few  months  they  are  apt  to  cause  some  feeling  of 
constriction  or  embarrassment  when  the  patient  takes  full  inspiration  or 
exercises  actively.  And  the  same  causes  often  occasion  slight  pains  or 
temporary  feelings  of  soreness  in  the  affected  side  of  the  chest.  But  in 
nearly  all  the  cases  the  layer  of  new  or  adventitious  tissue  which  consti- 
tutes the  bond  of  union  between  the  two  surfaces  of  the  pleura,  under  the 
constant  influence  of  the  respiratory  movements,  becomes  gradually  more 
smooth,  attenuated  in  structure,  and  its  fibers  elongated,  until  it  ceases  to 
produce  any  perceptible  embarrassment  or  inconvenience  to  the  patient. 
More  serious  results,  h  wever,  attend  and  follow  attacks  of  acute  pleu- 
ritis in  many  young  and  vigorous  subjects.  They  are  cases  in  which  the 
second  stage  of  the  inflammatory  process  gives  rise  to  both  copious  serous 
effusion  and  abundant  plastic  exudate.  The  former  rapidly  distends  the 
pleural  sac  and  compresses  the  lung,  producing  all  the  symptoms  and 
physical  signs  I  have  already  mentioned  when  giving  the  history  of  ordi- 
nary cases  of  the  disease;  while  the  latter,  continuing  to  accumulate  on 
the  surface  of  the  pleura  covering  the  compressed  lung,  becomes  so  firmly 
organized  during  the  protracted  period,  sometimes  intervening  before  the 
effused  fluid  is  re-absorbed  or  otherwise  removed,  that  it  eff^ectually  re- 
sists the  renewal  of  expansion  of  the  lung  in  proportion  to  the  removal 
of  the  serous  fluid.  This  not  only  subjects  the  patient  to  a  continuance 
of  shortness  of  breath  and  all  the  consequences  of  diminished  capacity 
for  air  after  the  establishment  of  convalescence,  but  the  ribs  and  walls  of 
the  affected  side  of  the  chest  yielding  to  atmospheric  pressure  become 
depressed  or  sunken  laterally  in  proportion  to  the  deficiency  of  expan- 
sion of  the  lung.  In  some  cases  this  permanent  lateral  contraction  of  the 
chest  is  sufficient  to  cause  a  lateral  curve  in  the  spine  and  tilting  of  the 
shoulders,  constituting  a  marked  deformity  of  the  chest. 


CHRONIC    PLEURITIS.  441 

Havino-  given  you,  thus  in  detail,  the  symptoms  which  characterize  the 
several  stages  of  acute  pleuritis  and  the  pathological  changes  accom- 
panying them  under  the  varying  circumstances  in  which  the  disease  may 
occur,  but  few  words  need  be  added  concerning  the  symptoms  and  prog- 
ress of  the  disease  in  its  chronic  form. 

Chronic  Pleuritis. — This  grade  of  the  disease  may  follow  as  the  sequel 
of  an  acute  attack,  but  is  much  more  frequently  chronic  or  subacute  from 
its  beginning.  Cases  liave  been  met  with  at  all  periods  nf  life,  though  very 
much  the  larger  number  occur  between  the  ages  of  fifteen  and  forty 
years.  Patients  suffering  from  pulmonary  tuberculosis  and  from  albu- 
minuria dependent  on  either  acute  or  chronic  renal  disease,  are  more 
liable  to  attacks  of  chronic  inflammation  of  the  pleura,  yet  the  larger 
number  of  cases  of  the  last  named  disease  occur  in  persons  previously 
in  fair  health,  and  without  any  recognized  cause.  I  have  seen  a  consider- 
able number  of  cases  that  were  ti'aceable  to  the  effects  of  mechanical 
violence  from  blows,  falls,  or  severe  strain  upon  the  chest;  and  some 
others  that  were  clearly  the  result  of   sudden   exposure   to  wet  and  cold. 

Symptoms. — In  the  chronic  form  of  pleurisy,  the  subjective  symptoms 
in  the  early  stage  are  generally  slight;  so  much  so  that  in  many  cases  the 
patients  neither  cease  attending  to  their  ordinary  business  nor  think  it 
necessary  to  consult  a  physician,  until  the  second  stage  is  far  advanced 
and  the  amount  of  the  serous  effusion  is  sufficient  to  compress  the  lung- 
and  render  the  respirations  uncomfortably  short.  Yet  on  close  exami- 
nation nearly  all  the  patients  acknowledge  that  they  have  had  more  or  less 
pains,  or  sense  of  soreness  in  the  affected  side  of  the  chest,  increased  by 
active  exercise  or  full  inspirations,  from  the  commencement  of  the  disease. 
And  in  addition  most  of  them  complain  of  having  had  slight  chills  al- 
ternately with  flushes  of  heat,  dryness  of  the  mouth,  variable  appetite, 
scanty  and  high  colored  urine,  and  imperfect  digestion  of  food.  After 
these  mild  and  apparently  unimportant  symptoms  have  continued  from 
two  to  four  weeks,  there  are  added  shortness  of  breath,  especially  when 
taking  active  exercise  or  when  lying  in  a  horizontal  position  on  the  well 
side;  a  short  dry  cough;  moderate  acceleration  of  pulse;  and  general  sense 
of  weariness.  The  objective  symptoms,  or  those  developed  by  direct 
physical  examination  of  the  patient,  are  more  characteristic  and  therefore 
important  in  making  a  correct  diagnosis.  In  nearly  all  the  cases  the 
clinical  thermometer  will  show  a  temperature  at  least  one  or  two  degrees 
above  the  natural  standard;  and  during  the  early  stage  auscultation  will 
reveal  some  degree  of  rubbing  or  friction  sound,  increased  by  full  inspi- 
rations, but  often  limited  to  a  small  space  on  one  side  of  the  chest.  At  this 
stage  no  changes  are  usually  detected  by  percussion  and  measurement. 
At  a  later  stage,  however,  when  the  patient  begins  to  be  embarrassed  from 
shortness  of  breath,  auscultation  will  reveal  neither  friction  nor  respiratory 
murmur  over  the  affected  side,  but  in  their  place  sometimes  tubular 
sounds  and  some  increased  fremitus  or  vibration  of  voice;  while  percus- 
sion will  elicit  decided  dullness  over  the  most  dependent  part  of  the 
chest  in  whatever  position  the  patient  may  be  placed,  accompanied  by  in- 
creased fullness  or  bulging  of  the  intercostal  spaces  and  diminished 
respiratory  movements.  These  signs  taken  together  with  the  subjective 
pymptoms  indicate  very  certainly  an  accumulation  of  fluid  in  the  cavity  or 
sac  of  the  pleural  membrane  sufficient  to  compress  the  lung;  and  the  sub- 
sequent progress  of  different  cases  may  develop  all  the  varied  conse- 
quences and  changes  that  1  have  already  described  as  liable  to  follow  ac- 
cumulations of  serum,  pus,  or  gases  resulting  from  attacks  of  acute 
j^leuritis.       When  the  effusion  resulting    from  chronic   pleuritis  is  serous, 


442  CHRONIC    PLEURITIS. 

constituting  one  of  the  forms  of  hydrothorax,  the  slower  progress  of  the 
accumulation  causes  less  embarrassment  to  the  respiration  than  when  it 
takes  place  more  rapidly  in  the  acute  form,  and  consequently  is  sometimes 
allowed  to  continue  until  the  quantity  of  fluid  and  degree  of  distension 
of  the  pleural  sac  is  greater  than  in  any  other  class  of  cases.  In  cases  in- 
volving suppurative  action  in  the  inflamed  membrane,  causing  the  effused 
fluid  to  be  pus,  constituting  pyothorax  or  empyema;  or  a  mixture  of  serum 
and  pus,  constituting  hydro- jiyothorax;  the  more  rapid  loss  of  flesh  and 
strength,  and  the  more  decided  febrile  movements  accompanying  such 
Ciises,  usually  lead  either  to  earlier  surgical  interference  for  the  removal 
of  the  pleural  accumulation  or  the  death  of  the  patient,  before  the  quantity 
accumulated  has  become  so  great  as  in  the  cases  of  serous  effusion. 
Gases  or  air  may  accumulate  in  the  pleural  sac  during  the  progress  of 
chronic  pleuritis  under  the  same  circumstances  as  I  mentioned  in 
relation  to  the  acute  form  of  the  disease. 

Pat/iolog leal  Anatomy . — The  structural  changes  which  accompany  the 
several  stages  of  acute  and  chronic  pleuritis  are  the  same  in  kind  as  take 
place  in  all  inflamed  structures.  At  first  the  blood  rapidlv  accumulating 
in  the  capillaries  and  smaller  vessels  gives  the  membrane  an  intensely  red 
and  tumefied  appearance.  A  few  hours  later  you  may  find  the  white  or 
migrating  corpuscles  and  liquor  sanguinis  passing  from  the  overdistended 
capillaries  into  the  interstitial  spaces  of  the  membrane  and  upon  the  free 
surface  where  its  fibrinous  element  rapidly  solidifies  into  patches  or  a  layer 
of  white  pseudo-membrane  adherent  to  the  endothelial  layer  of  cells  upon 
the  surface,  while  the  watery  element  of  the  effused  fluid  accumulates  in 
the  pleural  sac,  holding  in  solution  more  or  less  albumen  and  enough  leu- 
cocytes and  detached  endothelium  to  give  it  a  slightly  turbid  appearance. 
In  many  cases  you  may  also  find  red  corpuscles  entangled  in  the  meshes 
of  the  fibrinous  exudate,  both  in  the  structure  of  the  membrane  and  on  its 
free  surface. 

If  the  inflammatory  process  should  be  protracted  or  degenerate  into  the 
chronic  form  you  will  have  added  to  the  inflammatory  products  alreadji- 
mentioned,  lymphoid  cells  and  hyperplasia  of  the  connective  tissue,  caus- 
ing the  membrane  to  appear  thicker  and  harder  than  natural.  During  the 
third  or  declining  stage  of  the  disease,  all  these  inflammatory  products 
may  undergo  disintegration  and  removal  by  absorption,  constituting  reso- 
lution and  recovery;  or  the  cell  elements  may  degenerate  into  pus  cor- 
puscles, much  of  the  fibrin  into  fat  granules,  and  these  with  the  serous 
etFusion  continue  to  accumulate  until,  partly  by  mechanical  compression 
of  the  lungs  and  in  part  from  exhaustion,  the  case  reaches  a  fatal  termi- 
nation, as  ]  have  already  described. 

Prognosis. — A  very  large  majority  of  the  cases  of  uncomplicated  pleu- 
ritis, confined  to  one  side  of  the  chest,  terminate  favorably.  When  the 
inflammation  attacks  the  membrane  in  each  side  of  the  chest  at  the  same 
time,  and  is  accompanied  by  much  serous  effusion,  there  is  great  danger 
of  a  fatal  result  from  apiioea.  Cases  that  become  complicated  with  pneu- 
monia, pericarditis,  or  acute  nephritis  are  more  dangerous  than  when  un- 
complicated, and  still  more  so  are  those  that  occur  during  the  progress  of 
chronic  renal  diseases,  pulmonary  tuberculosis,  or  constitutional  syphilis. 
The  pleuritic  inflammation,  whether  acute  or  chronic,  when  occurring  in 
connection  with  the  last  named  constitutional  conditions,  is  very  liable  to 
take  the  suppurative  form  and  lead  to  purulent  or  sero-purulent  accumu- 
lation and  a  persistent  wasting  of  flesh  and  strength  until  death  results 
fiom  asthenia.  Early  evacuation  of  the  purulent  accumulations,  efficient 
drainage,  and  the  judicious  use  of  antiseptics,  tonics,  good  food  and  pure 


DIAGNOSIS.  443 

air  will  relieve  ninny  of  this  class  of  cases,  and  enable  them  to  live  many 
months,  or  until  the  further  development  of  the  coincident  constitutional 
disease  cuts  them  off. 

Diagnosis. — In  giving  the  clinical  history  of  acute  and  chronic  pleuritis 
I  have  already  directed  your  attention  to  the  symptoms  and  physical  signs 
that  characterize  each  stage  in  the  progress  of  all  grades  of  the  disease, 
close  attention  to  which  will  enable  you  not  only  to  determine  whether 
pleuritic  inflammation  exists  as  distinguished  from  other  aifections,  but 
also  the  stage  of  its  advancement  and  the  pathological  consequences 
which  may  have  resulted,  more  especially  as  regards  the  quality  and 
quantity  of  accumulated  inflammatory  products.  The  afl'ections  most 
liable  to  be  confounded  with  pleurisy  are  neuralgic  pains  in  the  inter- 
costal or  phrenic  nerves,  acute  and  subacute  rheumatic  inflammation  in 
the  intercostal  structures  and  diaphragm,  and  inflammations  of  the  peri- 
cardium, spleen  and  liver. 

If  vou  remember  that  the  tvvo  former  are  usually  unaccompanied  by 
increase  of  temperature  and  equally  free  from  any  abnormal  sounds  to  be 
obtained  by  auscultation  and  percussion  in  any  stage  of  their  progress, 
while  pleuritic  inflammation  involves  both,  you  can  hardly  fail  to  differ- 
entiate the  one  from  the  other.  The  rheumatic  inflammation  may  be  ac- 
companied by  some  acceleration  of  pulse  and  febrde  heat,  but  the  pain  is 
more  continuous,  less  lancinating  or  sharp,  and  auscultation  and  percus- 
sion yield  none  of  the  physical  signs  that  I  have  mentioned  as  accompany- 
ing the  first  and  second  stages  of  pleuritis.  Inflimmatory  afl'ections  of 
the  liver  and  spleen  not  oidy  present  symptoms  chiefly  located  below  the 
diaphragm  and  peculiar  to  those  organs,  but  they  fail  to  induce  any  phys- 
ical signs  of  disease  in  any  part  of  the  chest.  While  the  general  symp- 
toms, character  of  pain  and  physical  signs  are  similar  in  both  pericarditis  and 
pleuritis,  yet  in  the  one  they  are  synchronous  with  the  action  of  the  heart, 
and  in  the  other  with  the  respiratory  movements.  Very  rarely,  however, 
a  case  may  be  met  with  in  which  the  inflammation  will  occupy  that  part 
of  the  left  pleura  connected  with  the  pericardium  and  will  give  an  audible 
friction  with  the  movements  of  the  heart. 

Treatment. — The  olqects  to  be  accomplished  in  the  treatment  of  acute 
pleuiitis  are  the  same  that  are  presented  to  us  in  the  treatment  of  acute  in- 
flammation in  any  of  the  other  tissues  of  the  body.  As  I  have  explained 
in  previous  lectures  the  means  for  accomplishing  these  objects  may  vary 
t-ome  with  the  nature  of  the  structure  involved  in  the  inflammation. 
When  the  structure  involved  is  highly  vascular,  like  tliat  of  the  parenchyma 
of  the  lung,  the  indication  for  lessening  vascular  fullness  or  congestion  in 
the  first  stage  is  predominant  over  all  others.  But  when  the  structure 
involved  in  the  inflammation  is  less  vascular,  composed  more  largely  of 
connective  tissue,  like  the  serous  membranes  of  which  the  pleura  is  one,  the 
fulfillment  of  this  indication  is  of  less  relative  importance  than  that  which 
relates  to  the  removal  of  the  morbid  sensitiveness  of  the  structure  and 
the  intensity  of  the  pain.  While  in  pneumonia,  as  I  have  stated  in  pre- 
ceding lectures,  the  degree  of  vascular  engorgement  in  the  first  stage  de- 
termines the  amount  of  exudation  in  the  second,  which  may  directly  ob- 
struct the  function  of  oxyg'enation  and  decarbonization  of  the  blood  to 
such  a  degree  as  to  endanger  life;  in  pleuritis  the  exudation,  whether 
serous  or  plastic,  although  occasioning  inconvenience,  causes  no  direct 
danger  to  life  except  in  extreme  cases. 

The  intensity  of  the  pain  that  the  patient  suffers,  the  voluntary  stifling 
of  respiration,  and  restlessness,  are  all  effects  which  contribute  much  to 
prolong  the  disease.     And  yet,  the  practitioner   should   keep    both  these 


444  CHEONIC    PLEURITIS. 

indications  in  view;  namely,  that  of  relieving  the  vascular  fullness  in  the 
first  stage  of  the  inflammatory  process,  and  of  subduing  pain  and  the 
morbid  excitability  of  the  structures,  adjusting  his  remedies  to  the  re- 
moval of  both  in  accordance  with  their  relative  importance  in  each  indi- 
vidual case.  The  accomplishment  of  the  first  indication,  namely,  lessen- 
ing the  vascular  fullness,  may  be  efl'ected  by  three  classes  of  remedies; 
first,  direct  abstraction  of  blood  by  venesection  or  local  bleeding;  second, 
by  arterial  sedatives,  which,  by  diminishing  the  heart's  action,  lessen  the 
amount  of  blood  taken  to  the  inflamed  part  in  a  given  time;  third,  by  the 
use  of  evacuants,  which,  acting  upon  the  bowels  and  kidneys,  increase  the 
discharges  and  thereby  indirectly  deplete  the  circulation.  The  accom- 
plishment of  the  second  indication  is  most  promptly  and  efficiently  ob- 
tained by  the  judicious  use  of  opiates.  In  the  more  severe  cases  of 
acute  pleuritis,  occurring  in  subjects  previously  healthy,  and  in  the  active 
period  of  life,  characterized  by  sudden  development  of  acute  pain,  fol- 
lowed rapidly  by  pyrexia  or  increase  of  temperature,  full  pulse,  and  dry 
skin,  the  most  reliable  and  efficient  treatment  will  be  the  opening  of  a 
vein  and  the  abstraction  of  such  an  amount  of  blood  as  will  cause  a  de- 
cided diminution  of  pain,  lessen  the  fullness  and  tension  of  the  pulse, 
and  cause  a  little  paleness  of  the  features.  Thus  is  produced  within  a 
few  minutes  that  abatement  in  the  symptoms  and  arrest  of  determination 
of  blood  to  the  inflamed  part  whi(?h  would  require  several  hours  for 
accomplishment  by  the  best  cardiac  sedatives.  To  hold  the  advantage 
thus  gained,  however,  you  should  follow  the  venesection  as  speedily  as 
possible,  by  the  use  of  veratrum  viride  or  aconite  or  a  combination  of 
veratrum  viride  and  gelseminum  in  such  doses,  repeated  with  such  fre- 
quency as  to  induce  an  early  sedative  efi"ect — if  possible,  before  reaction 
has  taken  place  from  the  effects  of  the  venesection.  At  the  same  time  to 
relieve  the  pain  and  restlessness  of  the  patient  and  overcome  that  element 
of  the  inflammatory  p;03ess  which  consists  in  morbid  excitability  of  the 
tixtures,  such  doses  of  some  one  of  the  preparations  of  opium,  combined 
with  an  alterant,  should  be  given  between  each  of  the  doses  of  the  seda- 
tive, as  will  completely  control  jjain  and  keep  the  patient  moderately  at 
rest. 

For  these  purposes,  probably  a  combination  of  the  sulphate  of  morphia 
in  doses  of  two  centigrams  [gv.  -g-),  with  calomel  six  centigrams 
(gr.  i),  bicarbonate  of  sodium  three  decigrams  (gr.  v),  given  in  the 
form  of  a  powder  with  a  little  white  sugar,  and  repeated  everv  three  or 
four  hours,  would  accomplish  the  object  as  efficiently  as  anything  that 
could  be  used.  The  veratrum  viride  or  aconite  that  are  given  as  seda- 
tives alternately  with  these  powders,  may  generally  be  given  in  combina- 
tion with  nitrous  etlier  and  liquor  ammoniae  acetatis — which  not  on  y 
make  a  good  vehicle  for  the  sedative  but  also  exert  some  influence  in 
promoting  secretions  from  the  skin  and  kidneys.  In  the  great  majority 
of  cases,  even  of  the  most  severe  and  acute  attacks  of  pleurisy,  one  free 
bleeding,  sufficient  to  produce  the  effects  I  have  mentioned  (it  will  usually 
require  from  twelve  to  twenty-four  ounces  of  blood),  followed  by  the  rem- 
edies which  I  have  indicated,  will  be  found  sufficient  to  overcome  all  the 
more  active  symptoms.  It  will  make  the  patient  more  or  less  inclined 
to  sleep,  cause  the  pulse  to  become  softer  and  more  compressible.  The 
skin  will  become  somewhat  moist  by  the  end  of  the  first  twenty-four 
hours  of  the  treatment.  If  this  is  the  case,  and  on  careful  examination 
by  auscultation  and  percussion,  the  friction  sound  of  the  first  stage  is 
either  much  diminished  or  removed,  and  the  indications  of  effusion,  such 
as  increased  dullness  on  percussion    and  absence  of  respiratory  murmur 


TREATMENT.  445 

do  not  indicate  a  very  considerable  amount  of  exudation  or  effusion,  it 
will  be  sufficient  to  continue  the  cardiac  sedative  in  moderate  doses,  sus- 
pend tbe  use  of  the  powders  for  the  present  and  give  in  thei.  place  a 
saline  laxative  sufficient  to  produce  a  moderately  free  movement  of  tiie 
bowels.  After  the  bowels  have  been  freely  moved,  if  there  is  no  returi 
of  acute  pain  or  restlessness,  the  patient  may  be  put  upon  a  prescription 
composed  of  nitrous  ether,  liquor  ammonii  acetatis  and  camphorati^d  tinc- 
ture of  opium,  each  sixty  cubic  centimeters  (^ii),  and  tincture  of  digitalis 
thirty  cubic  centimeters  (~i),  of  which  four  cubic  centimeters  or  an  ordi- 
nary teaspoonful  may  be  given  every  three  hours  in  place  of  the  previous 
cardiac  sedative,  and  a  dose  of  the  compound  powder  of  opium,  ipecacu- 
anha and  nitrate  of  potassium  five  decigrams  (gr.  viii),  given  at  bed- 
time. These  remedies,  by  continuing  the  action  upon  the  skin  and 
kidneys,  and  the  powder  at  bed-time,  by  prosuring  rest,  will  usually  ren- 
der the  patient  comfortable  through  the  third,  fourth  or  fifth  days,  while 
the  moderate  amount  of  effusion  that  had  taken  place  is  re-absorbed,  leav- 
ing but  little  physical  evidence  of  any  accumulation  in  the  cavity  of  the 
pleura.  The  patient  is  now  convalescent,  requiring  but  little  additional 
care  except  to  avoid  exposure,  subsist  vipon  a  mild  diet,  and  avoid  active 
physical  exercise,  until  an  ordinary  degree  of  strength  is  regained. 

I  have  seen  many  cases  of  acute  pleurisy  occupying  but  one  side  of  the 
chest,  that  under  this  management  were  completely  relieved,  and  the 
amount  of  exudation  either  plastic  or  serous  so  limited  as  to  lead  to  no 
serious  embarassment  of  the  respiratory  function  in  any  part  of  its  prog- 
ress. But  to  insure  this  success  it  is  necessary  that  the  treatment  be 
commenced  actually  during  the  first  stage  of  the  inflammatory  process, 
which,  as  I  have  already  stated  in  giving  the  clinical  history,  lasts  usually 
not  more  than  twelve  or  eighteen  hours  after  tiie  initial  chill  and  symp- 
toms of  the  attack.  But  in  some  cases,  notwithstanding  the  early  and 
judicious  use  of  the  remedies  I  have  indicated,  on  the  second  and  third 
days  of  the  treatment  it  will  be  found  that  the  pain,  although  much 
abated,  is  nevertheless  quite  sharp  whenever  the  patient  attempts  full 
breathing  or  any  freedom  of  bodily  motion;  that  the  temperature  con- 
tinues more  elevated  and  the  physical  signs  of  exudation  and  effusion 
rather  more  marked.  Where  this  is  the  case  I  add  to  the  foregoing  treat- 
ment counter  irritation  by  blisters.  The  application  of  a  blister  four  by 
six  inches  over  the  most  painful  part  of  the  affected  side  will  very  fre- 
quently afford  great  relief,  and  in  conjunction  with  the  other  remedies  will 
arrest  the  further  progress  of  the  inflamtnatory  process,  leading  to  the 
early  re-absorption  of  the  effusion  that  exists  in  the  cavity  of  the  pleura. 
In  the  milder  cases  of  acute  pleurisy,  cr  those  occurring  in  subjects  less 
vigorous,  or  weakened  by  any  previous  constitutional  impairment,  the 
abstraction  of  blood  by  venesection  is  usually  unnecessary  and  inexv'edient. 
In  some  of  them  local  bleeding  by  leeches  or  by  cupping  may  still  afford 
decided  aid  in  the  early  stage  of  the  disease,  but,  omitting  the  bleeding, 
such  cases  may  be  overcome  sufficiently  early  by  the  use  of  the  other 
agents  that  have  been  recommended. 

Again,  the  cases  in  which  you  will  be  called,  where  the  first  stage  of  the 
disease  has  already  passed  by,  and  when  you  find  on  your  first  examina- 
tion of  the  patient  that  instead  of  the  friction  sound  you  have  decided 
dullness  on  percussion,  in  most  of  them  increased  fremitus  of  voice  and 
absence  of  the  respiratory  murmur,  constituting  evidence  of  decided 
effusion,  no  idea  of  abstraction  of  blood  either  by  venesection,  leeches  or 
cupping  should  be  entertained,  as  that  would  only  serve  to  deplete  the 
patient  withf^at  any  beneficial  effect   upon  the  progress  of  the    disease. 


446  CHRONIC    PLEURITJS. 

The  treatment  now  should  be  commenc:^d  with  a  view  of  arresting  the 
further  efFus  on  of  serum  or  exudation  of  plastic  material  on  the  one  hand, 
and  of  hastening  the  re-absorption  or  removal  of  what  has  already  taken 
place  on  the  other.  For  these  purposes  open  the  bowels  by  a  mild  saline 
laxative,  administer  every  three  or  four  hours  the  mixture  which  we 
have  already  mentioned,  consisting  of  nitrous  ether,  liquor  ammonii 
acetatis,  camphorated  tincture  of  opium  and  digitalis,  to  which  we  mav 
now  add  iodide  of  potassium  in  such  proportions  that  the  patient  will  got 
three  decigrams  (gr.  v)  of  the  latter  in  each  dose.  Apply  a  blister  at 
once  to  the  affected  side  of  the  chest,  and  if  the  effusion  appears  slow  in 
diminishing,  the  blistering  may  be  repeated  two  or  three  times  at  inter- 
vals of  three  or  four  days.  Under  these  measures  the  great  majority  of 
cases,  although  having  passed  the  first  stage  before  they  are  brought  un- 
der treatment,  will  begin  to  improve  and  continue  slowly  to  do  so,  until 
the  removal  of  the  effused  fluid,  the  re-expansion  of  the  compressed  lung 
and  the  establishment  of  convalescence  have  taken  place.  But  in  many 
of  them  it  will  require  two  to  four  and  sometimes  six  weeks  to  accomplish 
this  end.  In  those  cases  which  are  sometimes  met,  in  which  the  amount 
of  the  effused  fluid  in  the  cavity  of  the  pleura  is  so  great  as  not  onlj-  to 
completely  compress  the  lung  on  the  afi'ected  side,  but  to  crowd  the 
mediastinum  in  the  opposite  direction,  lessening  also  the  space  for  the 
expansion  of  the  other  lung,  thus  causing  the  patient  to  suffer  the  severe 
consequences  of  imperfect  oration  of  the  blood,  causing  a  distressing  sense 
of  suffocation  and  inability  to  lie  down,  it  is  not  proper  to  wait  for  the 
slow  process  of  absorption  of  the  eff"used  fluid.  The  practitioner  should 
proceed  at  once  to  relieve  the  suffering  and  danger  to  which  the  patient 
is  exposed  by  the  removal  of  the  efi"used  fluid  with  the  aspirator;  a 
method  which  is  usually  safe  and  easily  practiced.  There  is  another  mo- 
tive in  such  cases  for  proceeding  at  once  to  withdraw  the  effused  liquid, 
and  that  is  to  avoid  the  danger  that  would  occur  from  keeping  the  lung 
long  compressed  until  it  had  become  bound  in  this  position  b}?^  a  covering 
of  false  membrane.  If  this  is  permitted,  there  would  remain  after  the 
patient's  recovery  in  other  respects,  a  permanent  impairment  of  the 
capacity  of  that  lung,  a  shrinking  of  that  side  of  the  chest,  constituting  a 
deformity,  and  making  the  patient  more  lial)le  to  subsequent  degener- 
ation of  the  lung,  and  would  ultimately  shorten  life. 

There  is  another  class  of  cases  in  which,  though  the  eff'used  fluid  is  not 
so  much  in  quantity  as  to  produce  direct  danger  from  suffocation,  yet  is 
sufficient  to  closely  compress  the  lung  on  the  affected  side,  and  in  which, 
from  the  previous  healthy  condition  of  the  patient,  we  have  reason  to 
suppose  that  there  is  a  liberal  amount  of  plastic  exudation  covering  the 
compressed  lung  in  addition  to  the  eff'used  fluid. 

In  these  cases  re-absorption,  under  ordinary  treatment,  takes  place  very 
slowly,  thereby  indicating  clearly  that  to  wait  fur  the  completion  of  the 
process  would  require  several  weeks  of  time  and  as  has  been  explained, 
would  render  probable  the  permanent  Vjindingof  the  lung  in  this  compressed 
condition.  Under  these  circumstances  it  is  the  duty  of  the  practitioner  to 
aspirate  the  chest.  This  may  be  done  slowly  at  one  operation,  giving  fhe 
patient  time  to  inflate  the  lungs  as  the  process  of  drawing  off  the:  fluid  is 
very  gradual,  or  only  a  part  of  the  fluid  be  removed  at  one  time;  delay 
twenty  four  hours  and  then  another  part  may  be  taken,  until  the  whole  is 
removed  in  successive  punctures  thus  giving  opportunity  for  the  com- 
pressed lung  to  regain  its  expansion  in  proportion  to  the  removal  of  the 
comijression.  You  will  notice  that  in  speaking  of  the  most  active  and 
Severe  cases  in  the  first  stage,  I  have  mentioned  the  use  of  a  powder  con- 


TREATMENT.  447 

sistirify  of  tlie  sulphate  of  morphia,  calomol  and  bi-carbonatc  of  sodiuin. 
The  cliiof  object  of  giving  that  jjowder,  aside  from  the  anodyne  edects  of 
the  morpliia,  was  to  induce  the  early  effect  of  the  mercurial  in  conjunc- 
tion witli  the  bi-carbonate,  in  lessening  tlie  plasticity  of  the  inflammatory 
exudate.  In  other  cases  which  are  sometimes  met  with,  though  rarely, 
in  which  the  exudation  is  almost  entirely  plastic,  there  is  not  apt  to  be  in 
the  second  stage  of  the  disease  sufficient  serous  exudation  or  material  to 
compress  the  lung,  but  a  copious  plastic  exudation  continues  to  modify 
the  friction  in  the  second  stage,  usually  leading  to  extensive  adhesions  of 
the  two  surfaces  of  the  pleura  together.  In  sue  i  cases  the  free  use  of 
the  carbonated  alkalies  internally,  and  efficient  alterative  doses  of  th(i 
mercurial  as  far  as  will  be  borne  without  producing  a  visible  effect  upon 
the  patient's  gums  or  breath,  and  then  following  the  mercurial  by  moder- 
ate doses  of  the  iodide  of  potassium  in  addition  to  the  carbonated 
alknlies  will  be  more  efficient  than  any  other  treatment  in  first  ar- 
resting the  accumulation  of  these  plastic  exudates,  and  subsequently  in 
h  stening  their  disintegration  or,  at  least,  partial  removal.  But  most  of 
such  cases  to  which  we  give  efficient  alterant  and  alkaline  treatment,  witli 
blisters  externally,  though  recovering  well,  will  leave  more  or  less  perma- 
nent adhesion  of  the  surfaces  of  the  pleura  to  each  other.  These  adhesions 
usually  cavise  a  feeling  of  constraint  en  taking  a  full  inspiration  and 
sometimes  a  slight  sense  of  soreness  for  a  considerable  time  after  conva- 
lescence, hut  ultimately  become  attenuated  and  smooth  by  the  continued 
motions  of  the  chest.  And  although  they  may  continue  through  the  subse- 
quent life  of  the  patient  they  will  usually  create  little  or  no  inconven- 
ience. 

In  the  management  of  ordinary  cases  of  acute  pleurisy  the  patient 
should  be  kept  at  rest  in  the  first  stage,  and  a  very  mild,  simple  diet,  con- 
sisting chiefly  of  milk  and  animal  broths  given  in  small  quantities.  In 
the  second  stage,  a  little  more  liberal  amount  of  nourishment  and  simple, 
cooling  drinks  are  all  that  are  required.  Occasionally  one  of  the  most 
acute  class  of  cases,  during  the  first  two  or  three  days,  will  present  a 
temperature  so  high  that  antipyretic  measures,  more  especially  free 
sponging  of  the  surface  with  cold  water,  or  even  wrapping  the  chest  and 
body  in  a  wet  sheet,  will  be  advisable  and  productive  of  much  relief. 
But  in  the  great  majority  of  cases  these  special  antipyretic  measures  are 
not  necessary.  As  you  are  aware,  during  the  last  quarter  of  a  century,  the 
pi-actice  of  venesection  in  almost  all  diseases  has  been  so  nearly  abandoned 
and  the  use  of  opium  for  overcoming  inflammations,  even  of  an  acute 
character,  so  generally  commended,  that  you  may  diubt  the  expediency 
of  the  recommendation  I  have  made,  to  commence  the  treatment  of  the 
more  acute  cases  in  the  first  stage  with  a  free  venesection.  You  may  be 
induced  to  disregard  that  full,  tense  pulse,  rapid  development  of  temper- 
ature, giving  severe  pain  and  stifiinl  breathing,  which  indicate  the  true 
sthenic  acute  inflammatory  process,  and  attempt  to  subdue  such  cases 
simply  with  opiates  and  cardiac  sedatives  without  the  abstraction  of  blood. 
In  the  larger  proportion  of  cases  I  admit  that  you  can  succeed;  but  in 
many  of  them,  while  you  succeed  in  the  end,  the  time  required  is  much 
longer,  the  amount  of  effusion  and  compression  of  the  lung  is  greater,  the 
patient  is  subjected  to  greater  danger  of  secondary  consequences  of  a 
bad  character,  and  occasionally  an  instance  is  met  with  in  which  the  at- 
tempt to  administer  full  doses  of  opium,  without  first  lessening  the  arterial 
tension,  is  followed  hy  direct  aggravation  and  increase  of  all  the  symp- 
toms. A  case  of  this  kind  occurred  under  my  own  observation  many  years 
since.     A    strong    laboring    man,    about    twenty-five    years    of   age,  of  a 


448  PLEURITIS. 

sanguine  temperament,  accustomed  to  daily  labor,  was  attacked  with  all 
the  symptoms  of  acute  pleurisy  in  the  latter  part  of  the  afternoon  while  at 
his  work.  The  pain  was  so  severe  that  it  was  with  difficulty  he  could 
reach  his  home.  On  his  way  he  stopped  at  my  office  for  advice.  Having 
just  read  some  accounts  from  high  authority  of  the  ability  to  subdue  acute 
inflammation  of  the  serous  membranes  by  full  doses  of  opium,  I  or- 
dered for  this  patient  six  powders,  each  containing  thirteen  centigrams 
(gr.  ii)  of  powdered  opium  and  three  decigrams  (gr.  v)  of  nitrate  of  potas- 
sium, with  instructions  to  take  one  of  them  as  soon  as  he  reached  his 
home,  and  to  repeat  the  dose  every  two  hours,  till  his  pain  was  subdued. 
In  about  eight  hours  I  was  called  in  great  haste  to  see  him,  and  found 
the  patient  wildly  delirious,  face  deeply  suffused  with  redness,  pupils 
small,  head  hot,  pulse  full,  and  requiring  two  persons  to  keep  him  in  his 
bed.  He  had  taken  the  fourth  powder  of  his  opium  and  nitrate  of  potas- 
sium with  no  other  effect  than  to  have  each  powder  followed  by  increase 
of  the  delirium  and  fever,  I  immediately  opened  a  vein  in  his  arm,  letting 
the  blood  flow  in  a  full  stream,  and  when  1  had  taken  about  one  liter 
(?xxx)  of  blood  he  became  calm,  free  from  delirium,  pulse  soft,  and  a 
little  moisture  started  out  upon  his  forehead  and  face. 

As  I  stopped  the  flow  of  blood  some  sensation  of  syncope,  sufficient 
to  bring  a  full  sweat  over  the  surface,  ensued,  I  told  the  attendants 
to  continue  his  powders,  one  every  four  hours,  and  left  him.  The  result 
was,  he.  passed  into  a  quiet  sleep,  remained  so  for  four  or  five  hours, 
sweating  freely,  and  the  following  day  was  found  almost  free  from  fever, 
no  continuous  pain  in  his  side,  and  but  moderate  stitches  of  pain  in  at- 
tempting to  take  a  full  breath,  but  there  was  some  degree  of  dullness  of 
the  left  side  of  the  affected  part  of  the  chest  and  absence  of  respiratory 
murmur  sufficient  to  indicate  a  moderate  degree  of  effusion.  His  bowels 
were  opened  by  a  saline  laxative,  light  counter-irritation  applied  over  the 
affected  side,  the  patient  kept  at  rest  for  two  days,  and  his  convalescence 
was  complete.  I  relate  this  case  to  show  the  difference  between  the  effects 
of  administering  opiates  at  once  with  a  tense,  hard  pulse,  in  the  beginning 
of  acute  inflammation,  and  the  effects  of  the  same  remedy  when  through 
lessening  the  amount  of  blood  in  the  vessels,  that  arterial  tension  has  been 
removed  and  the  whole  tone  of  the  vascular  system  put  in  a  different  re- 
lation. I  have  seen  the  same  practical  point  illustrated  a  hundred  times 
in  an  equally  striking  manner,  and  I  feel  entirely  safe  in  assuring  you 
that  you  will  do  far  better  justice  to  your  patient  in  all  similar  cases  of 
inflammation,  if  you  sacrifice  a  sufficient  amount  of  blood  by  venesection 
when  he  comes  under  your  care  in  the  early  period  of  the  most  acute 
stage,  and  in  milder  cases  procure  free  evacuation  of  the  bowels  and  give 
cardiac  sedatives  for  a  sufficient  time  to  lessen  the  vascular  tension  before 
full  anodyne  doses  of  the  opium  are  administered.  The  directions  I  have 
given  you  thus  far  relate  to  the  management  of  acute  pleurisy  as  it  is 
met  with  usually,  in  the  field  of  general  practice;  but  there  are  some  de- 
viations from  the  ordinary  class  of  cases  which  will  require  modification 
in  the  treatment.  When  the  inflammation  occurs  in  subjects  previously 
in  bad  health,  either  from  scrofulous,  tuberculous  or  syphilitic  influences, 
or  constitutional  impairment,  there  is  much  tendency  "to  exudative  mate- 
rial of  a  purulent  character,  which  may  fill  the  pleural  cavity  with  a 
sero-purulent  or  purulent  fluid,  neither  of  which  would  be  capable  of 
absorption. 

The  occurrence  of  suppuration  in  the  progress  of  pleuritic  inflammation 
of  an  acute  character  is  usually  indicated  by  the  occurrence  of  chills  during 
the  third,  fourth  or  fifth  days,  followed  by  a  brief  exacerbation  of  fever  and 


TREATMENT.  449 

copious  sweating.  These  periods  of  sweating  are  apt  to  recur  at  irregular 
intervals.  The  patient  loses  strength  and  flesh  rapidly,  the  pulse  becomes 
soft,  weak,  quick,  and  we  have  all  the  physical  signs  of  pretty  rapidly  in- 
creasing accumulation  of  fluid  in  the  pleural  cavity.  The  supervention 
of  such  symi)toms  should  always  lead  to  the  suspicion  of  suppuration,  and 
consequencly  either  an  entire  pus  accumulation  in  the  pleural  cavity  con- 
stituting empyema  or  pyothorax,  or  an  accumulation  of  a  mixture  of  serum 
and  pus,  which  in  either  case  will  not  be  absorbed  or  removed  by  any 
spontaneous  process.  Consequently  it  is  in  vain  to  lose  time  by  the  use 
of  remedies  calculated  to  promote  absorption.  It  is  not  only  in  vain,  but 
the  delay  thus  occasioned  greatly  increases  the  risk  of  loss  of  life.  Just 
as  soon,  therefore,  as  the  evidences  of  accumulation  are  sufficient  to  indi- 
cate any  considerable  compression  of  the  lung,  the  aspirator  needle  should 
be  introduced  for  the  purpose  of  making  certain  the  diagnosis.  If  on 
withdrawing  a  small  amount  of  the  fluid,  it  is  found  to  contain  a  large 
proportion  of  pus,  the  only  safe  practice  is  to  freely  aspirate  what  can 
be  drawn  off  with  the  aspirator,  and  to  enlarge  the  opening  so  as  to  allow 
judicious  drainage,  accompanied  by  the  use  of  antiseptics,  as  you  will 
tind  described  in  all  your  surgical  works,  for  the  treatment  of  empyema 
and  other  internal  collections  of  pus.  At  the  same  time  the  patient 
must  be  supported  by  mild  tonics,  easily  digestible  nourishment,  rest  and 
pure  air.  Such  measures,  judiciously  applied,  will,  in  many  cases,  lead  to 
the  recovery  of  the  patient.  But  in  some,  especially  when  complicated, 
as  they  are  apt  to  be  with  tubercular  deposits  in  the  lungs,  the  recovery 
will  be  only  partial.  The  patient  will  linger,  in  some  cases,  for  many 
months  in  a  feeble  condition,  while  the  disease  in  the  lung  tissues  pro- 
gresses through  its  successive  stages,  and  aids  materially  to  reduce  the 
patient  and  hasten  the  fatal  result. 

The  same  remarks  in  regard  to  treatment  are  applicable  to  those  cases 
of  circumscribed  pleuritis  of  a  subacute  character  that  are  apt  to  recur, 
sometimes  rapidly,  in  the  progress  of  cases  of  tuberculosis  in  which  the 
tubercular  deposits  are  near  the  surface  of  the  lung.  Some  of  these  are 
mild  and  will  rapidly  yield  to  the  prompt  use  of  anodynes,  aided  by  the 
cautious  use  of  cardiac  sedatives,  but  will  generally  recur  from  time  to 
time  until  they  end  in  suppuration,  frequently  leading  to  a  communication 
of  the  softened  tubercular  abscess  in  the  lung  through  the  pleural  mem- 
brane so  as  to  make  a  communication  between  the  tuberculous  abscess 
and  the  pleural  cavity.  In  these  cases  free  opening,  drainage  and  anti- 
septics, with  supporting  measures  internally,  constitute  the  only  means 
of  palliating  the  condition  of  the  patient  and  prolonging  life.  In  some 
of  this  class  of  cases  the  communication  between  the  suppurative  cavities 
in  the  lung  and  the  cavity  of  the  pleura  allows  of  the  escape  of  air,  and 
we  get  complicating  what  was  otherwise  a  pyothorax  or  accumulation 
of  pus,  a  pneumothorax,  or  accumulation  of  air,  in  the  pleural  cavity, 
giving,  at  the  more  dependent  part  of  the  afi'ected  side,  dullness  on  per- 
cussion, and  symptoms  of  accumulation  of  fluid,  while  we  have  tympanitic 
resonance  from  the  presence  of  air  above.  Unless  the  accumulation  of 
air  and  matter  is  so  great  as  to  threaten  the  life  of  the  patient  by  the  de- 
gree of  compression,  it  is  better,  in  most  such  cases,  to  palliate  the  pa- 
tient's condition  as  much  as  possible  by  tonics,  anodynes  and  rest,  without 
attempting  the  more  radical  measure  of  incision  and  drainage  on  account 
of  the  possibility  of  making  a  communication  between  the  air  that  enters 
the  lungs  and  the  exterior,  a  means  of  encouraging  collapse  and  sudden 
death:  although  such  results  do  not  by  any  means  always  follow  when  the 
communication  exists. 

29 


450  PHTHISIS. 

The  treatment  of  chronic  pleurisy  may  be  summed  up  in  a  very  few 
words.  x\ll  that  I  have  said  in  regard  to  the  measures  reouired  for  limit- 
ing the  amount  of  effusion  and  exu  latioii  in  the  second  stage  of  an  acute 
attack,  and  for  the  subsequent  removal  of  such  eifusion  either  by  absorp- 
tion or  by  aspiration  in  cases  of  moderate  effusion,  and  free  openings  and 
drainage  when  the  effusions  are  purulent,  are  equally  apph'cable  to  the 
treatment  of  chronic  pleurisy;  the  difference  being  mostly,  that,  in 
chronic  cases  the  pi-ogress  is  slower,  the  accumulations  take  place  much 
less  rapidly,  accompanied  by  little  fever;  and  although  the  measures  of 
relief  are  the  same  in  kind  so  far  as  the  administration  of  medicines  is 
concerned,  they  require  to  be  given  with  a  less  degree  of  energy. 


LECTURE  XLVI. 


Phthisis  Pulmonalis  or  Pulmonary  Consumption— Its  varieties— Their  clinical  history,    Anatom- 
ical changes,   Diagnosis,  and  Prognosis  and  Treatment. 

GENTLEMEN:  Varieties. — Under  the  head  of  phthisis  pulmonalis,  or 
wasting  disease  of  the  lungs,  are  included  at  the  present  time  sev- 
eral diseases  essentially  distinct  from  each  other  in  their  origin  and 
the  causes  which  produce  them,  although  leading  to  very  nearly 
the  same  ultimate  results.  If  we  keep  in  view  the  different  patho- 
logical conditions  which  give  rise  to  those  symptoms  and  lesions 
usually  denominated  consumption  or  phthisis  pulmonalis,  we  shall 
•find  three  distinct  varieties  of  disease.  First,  those  cases  which 
are  accompanied  by  primary  deposits  in  the  pulmonarv  tissues  con- 
sisting either  of  small  miliary  granules,  called  miliar}^  tubercles,  of  a  gray- 
ish color,  or  of  larger  masses  of  a  more  yellow  hue,  and  beginning  in- 
siduously  without  s^'mptoms  of  an  inflammatorv  character,  and  even  with 
so  little  local  feelings  of  irritation  or  annoyance  to  the  patient  that  their 
existence  is  not  suspected  until  considerable  progress  has  been  made. 
This  variety  of  disease  is  jDroperly  styled  pulmonary  tuberculosis.  The 
second  variety  includes  those  cases  in  which  the  deposits  or  accumulations 
in  the  lung  tissue  date  their  beginning  either  from  pulmonary  hemor- 
rhage or  more  frequently  from  an  attack  of  pneumonia.  Tliere  is  a  class 
of  patients  not  infrequently  met  with  who  are  hereditarily  predisposed  to 
tuberculous  or  scrofulous  disease,  or  having  the  predisposition  acquired 
from  circumstances  relating  to  habits  of  life  and  sanitary  conditions,  who, 
although  not  having  any  deposits  or  change  in  the  lung  tissue  at  the  time 
that  they  are  attacked  with  acute  pneumonia,  nevertheless  when  thus  at- 
tacked, the  exudation  which  accompanies  the  pneumonic  inflammation 
partaking  of  the  abnormal  properties  belonging  to  the  previous  diathesis, 
fails  to  be  disintegrated  and  removed  by  resolution  on  the  subsidence  of 
the  inflammatory  process.  The  exudative  material  which  is  thus  left  in 
the  lung  in  such  cases  very  generally,  within  a  period  ranging  from  three 
to  four  weeks  to  as  many  months,  is  found  to  be  undergoing  a  deteriora- 
tive change  called  caseous  degeneration.  In  the  progress  of  this  change, 
the  patient  begins  to  manifest  quickness  of  pulse,  increase  of  temperature 


VARIETIES.  4/>l 

especially  in  the  afternoon  and  evenins;,  renewal  of  cough  and  often  early- 
supervention  of  night  sweats.  This  class  of  cases  are  liable  to  run  a  more 
rapid  course,  both  in  the  conversion  of  the  caseous  deposit  into  purulent 
material,  and  in  the  establishment  of  suppurative  inflammatory  action  in 
the  contiguous  lung  tissue,  than  the  cases  which  are  of  a  primary  tuber- 
culous orijj'in,  and  we  may  distinguish  them  from  the  first  by  designating 
them  caseous  phthisis. 

The  other  variety  of  disease  generally  included  under  the  head  of 
phthisis  pulmonalis  is  strictly  of  a  fibroid  character;  and  generally,  if  not 
always,  originates  from  primary  capillary  bronchitis.  The  capillary  form 
of  bronchitis  in  which  the  congestion,  thickening  and  hardening  of  the 
lining  membrane  of  the  smaller  bronchial  ramifications  is  sufficient  to  close 
many  of  those  tubes  and  to  exclude  the  air  from  the  alveoli  or  cluster  of 
cells  at  their  termini,  causing  the  latter  to  collapse,  thereby  tends  to  dimin- 
ish the  capacity  of  the  lung  for  air,  and  more  or  less  to  interfere  with  the 
movement  of  the  blood  in  tlie  capillary  net- work  surrounding  the  collapsed 
cells.  This  frequently  leads  to  more  or  less  exudation  from  the  obstructed 
capillaries  and  increased  irritability  of  the  connective  tissue  of  the  lung, 
constituting  a  grade  of  inflammatory  action,  similar  to  that  in  the  lining 
of  the  bronchioles,  which  constituted  the  original  disease.  At  first  the 
number  of  the  alveoli  thus  deprived  of  air  and  collapsed  may  be  small 
and  lead  to  but  little  inconvenience.  As  this  grade  of  bronchitis  is 
generally  renewed  with  every  cold  season  of  the  year  or  exposure  of  the 
patient  to  cold  and  damp  air,  and  as  each  renewal  is  liable  to  obstruct  an 
additional  number  of  the  smaller  bronchial  ramifications,  thereby  increas- 
ing the  number  of  collapsed  cells  and  the  amount  of  exudation  and  scle- 
rosis of  the  connective  tissue  surrounding  them,  in  the  end,  the  whole  side 
of  the  chest  involved,  or  both  sides  if  the  bronchitis  involves  both  lungs, 
becomes  shrunken,  and  from  the  diminished  amount  of  air,  gives  less  res- 
onance on  percussion  than  natural,  increased  fremitus  of  voice,  not  in- 
frequently hemorrhages  and  the  establishment  in  the  sclerosed  connective 
tissue  of  a  suppurative  process,  which  causes  a  muco-purulent  expec- 
toration, general  wasting  of  the  flesh  and  strength,  and  the  final  estab- 
lishment of  hectic,  night  sweats,  and  all  the  phenomena  of  the  advanced 
stage  of  phthisis,  or  consumptive  disease. 

In  a  preceding  lecture,  when  discussing  the  difi'erent  grades  of  bron- 
chitis, their  clinical  history,  pathological  changes  and  treatment,  I  stated 
all  that  may  be  necessary  in  regard  to  this  latter  class  of  cases  (see  pp.  39(J- 
7),  and  in  the  lecture  ujjon  pneumonia  and  its  results,  I  gave  sufficient  ac- 
count of  the  symptoms  and  progress  of  the  caseous  form  of  phthisis.  (See 
p.  433.)  It  remains,  therefore,  at  the  present  hour,  to  direct  your  attention 
chiefly  to  the  tubercular  phthisis,  as  we  have  indicated,  originating  from 
the  tubercular  diathesis,  either  hereditary  or  acquired,  and  without  any 
necessary  connection  with  inflammatory  attacks.  The  scrofulous  and  tu- 
berculous diatheses,  so  far  as  regards  their  etiology,  general  symptoms,  and 
the  treatment  which  they  require,  both  hygienic  and  medical  I  presented 
to  you  in  sufficient  detail  when  speaking  of  the  chronic  general  diseases 
(see  Lectures  XXVII,  XXVIII),  ani  consequently  I  need  not  repeat  with 
any  degree  of  fullness  the  primary  causes  which  lead,  first,  to  the  formation 
of  the  diathesis  and  the  alteration  of  the  constitutional  condition,  and  sec- 
ondly, to  the  establishment  of  local  manifestations  of  disease  in  the  form  of 
caco-plastic  deposits  in  the  lungs.  It  is  sufficient  to  recall  your  attention 
to  the  fact  that  when  the  diatheses,  which  are  denominated  scrofulous  and 
tuberculous,  are  once  established,  tl.ere  is  a  tendency  to  the  development 


452  PHTHISIS. 

of  imperfectly  elaborated  material  constituting  imperfectly  formed  cells, 
granules,  more  or  less  amorphous  niatter,  accompanied  by  certain  inor- 
ganic material,  and  when  these  materials  are  thus  elaborated  in  the  sys- 
tem they  appear  to  be  incapable  of  disintegration  and  elimination  as  ex- 
cretory matter  on  the  one  hand,  and  equally  incapable  of  being  added  to 
any  of  the  normal  tissues  of  the  body  so  as  to  form  natural  repair  or 
growth.  Being  neither  used  to  increase  the  growth  of  any  natural  tissue 
nor  susceptible  of  elimination,  the  tendency  is  to  find  lodgment  or  de- 
posit in  some  of  the  structures  of  the  body.  As  a  general  rule  they  will 
be  more  likely  to  be  found  deposited  in  such  structures  as  are  most  highly 
vascular,  and  at  the  same  time  subject  to  the  greatest  variations  in  the 
movement  of  the  blood  through  the  vascular  tissue. 

In  very  early  childhood,  while  the  brain  is  less  mature  in  its  develop- 
ment than  most  of  the  other  organs,  strong  hereditary  diatheses  in  this 
direction  often  result  in  the  deposit  of  the  granular  tubercle  in  the  mem- 
branes and  periphery  of  the  brain.  A  little  later,  anywhere  between 
childhood  and  puberty,  perhaps  the  greater  tendency  is  to  find  lodgment 
in  the  lymphatic  glands  and  adenoid  structures  of  the  body.  From  the 
period  of  puberty  to  the  middle  period  of  adult  life,  far  the  greater  tend- 
ency is  to  find  lodgment  for  this  material  in  the  pulmonary  structure. 
And,  as  abundant  clinical  observation  has  shown,  the  deposition  com- 
mences, in  far  the  larger  proportion  of  cases,  at  or  near  the  apex  ot  the 
lung.  It  may  commence  simultaneously  upon  both  sides,  or  it  may  in- 
vade but  one  side  first,  subsequently  involving  the  other,  or  it  may  attack 
but  one  side  in  any  part  of  its  course.  Having  already  described  suffi- 
ciently the  symptoms,  progress  and  diagnostic  features  of  the  tuberculous 
diathesis  prior  to  the  actual  deposit  of  the  tubercular  materials,  I  will 
direct  your  attention  at  once  to  the  symptoms  and  clinical  history  of  the 
local  development  and  progress  of  tubercular  disease  of  the  lung. 

Sympfxjms. — A  great  majority  of  these  cases  are  characterized  during 
the  first  weeks,  and  sometimes  months,  of  their  progress  by  no  other  re- 
cognizable symptoms  than  a  very  gradual  loss  of  flesh,  diminution  of  color 
or  increasing  paleness,  slight  shortness  of  breath  on  active  exercise  or 
going  quickly  up  stairs,  slight  increase  in  the  frequency  of  the  pulse  in 
the  afternoon  and  even'ng,  and  an  increase  of  one  or  two  degrees  of 
temperature  during  the  same  periods  of  the  day.  These  changes  are  so 
gradual  in  their  development,  give  rise  to  so  little  inconvenience  to  the 
patient  that  they  often  attract  from  him  no  attention.  But  after  a  period 
varying  from  six  weeks  to  six  or  eight  months  in  some  instances,  an  acci- 
dental exposure  to  cold  and  wet  induces  a  mild  attack  of  bronchitis  ac- 
companied by  the  usual  symptoms  of  cough,  soreness  in  the  chest,  slight 
fever  and  the  ordinary  characteristic  expectoration.  The  patient  and  his 
friends  regard  it  as  a  simple  cold.  It  passes  through  its  usual  stages  to 
the  period  when  an  ordinary  bronchitis  declines  and  disappears.  But  the 
cough,  instead  of  disappearing,  becomes  less  active  and  less  frequent,  and 
genei-alh^  is  restricted  to  the  time  that  the  patient  rises  from  bed  in  the 
morning  or  first  lies  down  at  evening.  The  expectoration  which  had  been 
the  usual  expectoration  of  moderate  bronchitis  begins  to  show  more  of  a 
yellowish  tinge,  especially  in  the  central  part  of  the  expectorated  matter 
whenever  deep  coughing  occurs  or  when  the  patient  coughs  freely  after 
sleeping  through  the  night.  The  soreness  in  the  chest,  that  had  charac- 
terized the  attack  of  bronchitis,  disappears. 

But  in  addition  to  the  continuance  of  cough,  the  patient  gradually, 
from  week  *a  week,  loses  color  and  flesh,  and  becomes  more  conscious  of 
sortie  shortness  of  breath  on  active  exercise.     If  the  case  is  allowed  to 


SYMPTOMS.  453 

take  its  own  natural  course,  the  cough  will  increase  moderately  from  week 
to  week,  and  the  expectoration,  especially  in  the  niornin<r,  will  become 
more  and  more  of  a  purulent  character,  some  portion,  if  not  all,  tendino-  to 
sink  ii)  water.  Not  infrequently  slight  hemorrhages  occur.  The  patient's 
a]>petite  becomes  less,  bowels  often  incline  to  be  costive,  pulse  in  the 
morning  soft,  easily  compressed,  but  little  if  any  more  frequent  than  nat- 
ural, face  and  lips  pale,  but  in  the  last  half  of  the  day  and  evening  more 
color  appears  in  the  face,  pulse  becomes  accelerated  to  ninety-five  or  a  hun- 
dred in  the  minute,  respirations  a  little  more  frequent  than  natural,  but 
shorter  and  of  less  depth  in  proportion  to  their  frequency.  The  patient 
somewhat  troubled  with  cough  on  lying  down,  gets  quiet  after  a  little  and 
usually  sleeps  without  much  disturbance  till  between  four  and  six  in  the 
morning,  when  he  awakes  with  increase  of  coughing  and  expectoration, 
and  sometimes  finds  that  during  the  last  of  his  sleeping  hours  a  general 
.perspiration  had  supervened.  Sometimes  this  morning  paroxysm  of 
coughing  comes  as  early  as  three  o'clock,  and  after  lasting  half  or  three 
quarters  of  an  hour,  the  patient  will  fall  asleep,  and  if  left  undisturbed 
may  then  rest  till  seven  in  the  morning,  when,  on  attempting  to  rise,  he 
will  suffer  more  paroxysms  of  coughing  and  expectoration  of  a  purulent 
character. 

These  are  the  general  symptoms  which  accompany  the  early  stage  of 
tuberculosis  up  to  the  time  of  what  is  denominated  the  commencement  of 
the  second  stage  of  the  diseas3.  Bat  if  its  progress  is  not  interfered  with, 
from  this  time  the  symptoms  I  have  last  described  consisting  of  paleness, 
weakness,  languor  and  1  )W  temperature  in  the  morning,  followed  by  flush 
of  the  cheeks,  increased  temperature,  acceleration  of  pulse,  shorter  and 
more  frequent  respiration,  with  steadily  increasing  emaciation  and' diminu- 
tion of  strength,  will  continue  with  accelerated  pace  from  week  to  week 
and  from  month  to  month.  At  the  same  time  the  expectoration  increases 
in  quantity,  and  a  larger  proportion  of  it  is  of  a  purulent  character,  some- 
times mixed  with  a  little  blood.  The  patient  may  have  hemorrhages  of  a 
greater  or  less  amount  of  clear  blood,  unmixed  with  mucus  or  matter,  at 
any  part  of  this  or  the  jjreceding  stage;  and  the  occurrence  of  night 
sweats  usually  becomes  more  frequent  and  copious,  till  at  the  end  of  from 
three  to  six  months,  as  an  average,  the  patient  is  obliged  to  forego  further 
exercise  and  take  to  his  bed,  or  at  least  to  his  room.  The  subsequent 
history  is  simply  a  continuance  of  the  prominent  symptoms  of  emacia- 
tion, hectic  fever,  night  sweats,  often  accompanied  after  awhile  by  en- 
tire loss  of  appetite,  the  occurrence  of  apthous  ulcerations  in  the  mouth 
and  fauces,  short  frequent  turns  of  diarrhoea  generally  without  griping  or 
pain,  more  rapid  exhaustion,  cold  extremities,  loss  of  volee^  or  feebleness 
of  articulation,  extremely  rapid  and  weak  pulse,  breathing  short,  hurried, 
imperfectly  inflating  the  lungs,  and  finally  collapse  and  death — the  history 
covering  a  period  of  time  varying  from  six  months  to  tvi^o  or  three  years. 
You  will  notice  from  the  history  I  have  given  you  that  the  clinical  prog- 
ress of  the  disease  may  be  divided  into  three  stages.  The  first  is  that  of 
simple  crude  tubercular  deposit,  occasioning  but  slight  symptoms  of  any 
local  trouble,  and  varies  in  its  duration  from  four  weeks  to  double  that 
number  of  months. 

The  commencement  of  the  second  stage  is  marked  by  evidences  of  in- 
creased inflammatory  action  and  hypereemia  in  the  lung,  causing  more 
cough,  temporary  periods  of  soreness  in  the  chest,  acceleration  of  pulse, 
and  moie  expectoration.  The  supervention  of  the  symptoms  are  usually 
attributed  by  the  patient  to  taking  cold  and  if  they  are  mitigated  by 
treatment  for  a  time  they  are  renewed;  and  each  renewal  will  be   attrib- 


454  PHTHISIS. 

uted  as  the  first  to  some  accidental  cause,  but  generally  they  are  owing 
merely  to  the  natural  progress  of  the  disease  in  the  lung.  This  second 
stage,  commencing  as  I  have  indicated,  continues  till  the  suppurative  proc- 
ess, softening  of  the  tubercular  masses,  and  establishment  of  the  suppu- 
rative process  in  the  contiguous  lung  tissue  is  complete;  as  indicated  by 
decided  purulent  expectoration,  hectic  fever  and  night  sweats.  This  sec- 
ond stage  pathologically  is  the  stage  of  softening  disintegration  of  the 
tubercular  masses,  and  the  establishment  of  the  suppurative  process.  The 
third  stage  commences  with  the  completion  of  this  suppurative  process, 
the  excavation  of  one  or  more  tuberculous  cavities,  and  well  marked 
hectic  fever.  Thus  far  I  have  given  you  only  the  subjective  symptoms 
that  accompany  the  progress  of  the  disease  and,  although  in  most  cases 
sufficient  by  themselves  to  render  the  diagnosis  reasonably  certain,  they 
should  never  be  relied  upon  to  the  neglect  of  physical  examination  of  the 
chest.  In  the  first  stage,  that  of  primary  tuberculosis  of  the  lung,  in- 
spection of  the  chest  will  usually  show  some  degree  of  flattening  in  the 
infra-clavicular  region  or  lessening  of  the  antero-posterior  diameter  of  the 
upper  part  of  the  chest.  This,  in  the  very  early  stage,  is  often  hardly  per- 
ceptible. But  if  the  tubercular  deposits  have  continued  even  in  an  entire- 
ly latent  condition  for  a  few  months,  this  change  is  almost  always  easily 
observable  on  inspection,  and  is  made  still  more  apparent  by  stretching  a 
tape  line  from  the  most  prominent  part  of  the  clavicle  to  the  nipple,  which 
will  show  a  receding  or  flattening,  from  the  fact  that  the  skin  over  the 
second  and  third  ribs  will  not  reach  the  tape  litje,  but  fall  from  it  enough 
to  indicate  a  concavity,  where  there  should  be  a  convexity  of  the  chest. 
When  the  tubercular  deposit  exists  in  only  one  lung  the  contrast  between 
the  aft'ected  side  in  this  respect  and  the  other  is  usually  well  marked. 

Percussion  carefully  practiced  in  such  manner  as  to  elicit  the  tone 
of  sound  distinctly  and  clearly,  will,  in  almost  all  cases,  indicate  an  ap- 
preciable diminution  in  the  resonance  of  the  affected  side  of  the  chest,  in 
the  infra-clavicular  space.  In  cases  where  the  tubercular  deposit  is  small 
or  diffused  through  a  considerable  portion  of  the  upper  lobe  of  the  lung, 
the  diminution  of  the  resonance  may  be  so  slight  as  to  leave  you  in  doubt 
as  to  whether  it  is  less  than  natural.  But,  even  in  those  cases,  if  in  ad- 
dition to  testing  the  resonance  carefully  by  percussion,  you  examine  the 
degree  of  fremitus  of  voice  with  the  aid  of  a  double  tube  stethoscope  you 
will  be  able  to  detect  increased  fremitus  or  vibration  through  the  walls 
of  the  chest  sufficiently  to  corroborate  even  the  slightest  diminution 
of  resonance  by  percussion.  Of  course,  the  more  the  deposit  accu- 
mulates in  the  lung,  the  greater  will  be  the  fremitus  and  the  less 
will  be  the  resonance.  Auscultation  in  this  first  or  primary  stage 
of  tuberculosis  seldom  gives  to  the  ear  any  new  sounds  or  rales, 
but  simply  modifications  of  the  natural  respiratory  or  vesicular 
murmur.  These  modifications  of  the  natural  murmur  consist  chiefly  in 
altering  the  uniformity  of  the  inspiratory  sound,  rendering  it  often  irreg- 
ular in  its  development,  and  causing  a  renewal  of  the  murmur  in  each 
expiratory  act.  In  some  instances  the  change  consists  in  simply  shorten- 
ing and  rendering  the  natural  murmur  deficient.  On  the  other  hand, 
when  the  mass  of  tubercular  deposit  is  larger,  the  sounds  transmitted 
through  the  condensed  pulmonary  tissue  will  be  increased  above  the 
natural  intensity,  and  not  infrequently  present  the  quality  that  is 
called  tubular.  The  physical  signs  of  the  first  stage  of  tuberculosis, 
therefore,  are  not  the  production  of  new  sounds,  but  simply  alteration  of 
the  natural  respiratory  murmur,  increased  fremitus  of  voice  and  dimin- 
ished resonance  on  percussion. 


SYMPTOMS.  455 

These  pliysical  signs,  taken  by  themselves,  do  not  prove  the  existence 
of  tuberculosis,  they  simply  prove  the  existence  of  something  which  has 
diminished  the  amount  of  air  in  the  lung  under  examination,  and  thereby 
rendered  its  structure  more  dense.  Whether  that  density  is  from  tubercular 
deposit,  pneumonic  exudation,  pulmonary  oedema,  or  compression  from 
pleuritic  effusion,  must  be  determined  by  the  history  of  the  case,  and  the 
associate  general  symptoms,  as  we  shall  see  when  we  come  to  speak  more 
particularly  of  diagnosis.  In  the  second  stage  of  tuberculosis,  auscul- 
tation still  gives  alterations  in  the  respiratory  murmur,  especially  that 
which  consists  in  irregularity  in  the  development  of  inspiratory  sound,  or 
its  renewal  in  expiration,  and  usually  there  are  added  more  or  less  moist 
rales.  At  first  these  rales  will  be  movable,  caused  by  mucus  accumulat- 
ing more  or  less  in  the  bronchial  tubes  and  the  passage  of  air  to  and 
fro  through  it.  The  rales  consequently  will  differ  much  in  the  amount 
present  or  absent  at  any  particular  moment,  depending  upon  the 
fact  as  to  whether  the  patient  had  been  long  without  coughing  and  clear- 
ing the  air  passages,  or  had  just  before  the  'examination,  by  such  act,  re- 
moved what  mucus  had  accumulated.  But  as  the  second  stage  progresses 
and  the  tubercular  mass  becomes  softened  and  the  surrounding  lung  tis- 
sue filled  partially  by  a  low  grade  of  pneumonic  engorgement,  a  sub- 
mucous rale  is  developed  of  a  more  fixed  character,  that  is  not  removed 
temporarily  by  the  act  of  coughing,  but  is  developed  regularly  near  the 
end  of  each  ino;lerate  attempt  at  inspiration;  showing  that  it  depends 
upon  the  entrance  of  air  into  texture  filled  more  or  less  with  a  viscid 
fluid. 

It  is  especially  distinctive  of  the  early  stage  of  suppurative  softening 
in  the  progress  of  tubercular  diseases.  While  auscultation  reveals  these 
changes  in  the  second  stage  of  the  disease,  percussion  elicits  a  greater 
degree  of  dullness  than  in  the  first  stage,  and  there  is  also  a  corresponding 
increased  vibration  of  voice,  making  what  was  slight  and  perhaps  a  little 
obscure  in  the  first  stage,  plain  and  unmistakable  in  the  second.  In  the 
third  stage  of  the  disease,  when  the  suppurative  process  is  complete,  when 
some  of  the  abscesses  now  in  the  lung  are  evacuated,  forming  the  com- 
mencement of  suppurative  cavities,  auscultation  still  will  leveal  a  fixed 
moist  rale  that  sounds  still  more  like  forcing  air  into  a  porous  body  filled 
with  a  viscid  fluid,  accompanied  by  an  occasional  drop,  as  though  two 
surfaces  moistened  with  thick  fluid  had  been  separated  from  each  other. 
Over  these  places  the  voice  now  instead  of  giving  simple  fremitus  or  in- 
creased vibration  gives  more  or  less  distinct  pectoriloquy  or  direct 
transmission  of  the  voice  into  the  ear  or  funnel  of  the  stethoscope. 
Percussion  over  most  of  the  affected  part  of  the  lung  will  still  be  decid- 
edly dull.  If,  however,  cavities  have  formed  near  the  surface  of  the  lung 
it  will  sometimes  happen  that  directly  over  the  cavity,  instead  of  dullness, 
there  will  be  a  modified  tympanitic  resonance.  This  is  only  when  the 
cavity  is  large  and  near  the  surface.  In  other  instances  the  cavity  thus 
formed  and  communicating  by  a  pretty  free  opening  with  one  of  the 
larger  bronchial  tubes,  will  yield  on  percussion  directly  over  it,  jiot  a 
tympanitic  resonance,  but  a  peculiar  sound  denominated  '•'•Bruit  du 
pot  fele^''  or  cracked  metal  sound. 

These  are  the  physical  signs  which  characterize  the  advanced  or  com- 
plete suppvirative  stage  of  tuberculosis.  They  are  almost  always  most 
marked  in  the  upper  part  of  the  chest.  Rare  cases  occur,  however,  in 
which  the  tubercular  deposits  have  taken  place  in  the  middle  lobe  of  the 
lungs,  and  still  rarer  instances  where  they  have  been  found  to  commence 
in  the  lower  lobes  and  to  produce  the  same  successive  changes  in  the  gen- 


453  PHTHISIS. 

oral  symptoms  and  physical  signs  as  I  have  described,  except  that  the 
sinking  or  flattening  of  the  chest  at  the  upper  part  would  not  be  notice- 
able so  much  as  the  parallel  changes  in  the  middle  and  lower  portions. 

I  have  thus  traced  the  symptoms  and  physical  signs  of  the  different 
stages  of  tubercular  disease  with  sufficient  minuteness  to  give  vou  a 
fair  outline  of  its  progress.  There  are  some  individual  symptoms, 
however,  to  which  it  may  be  well  to  refer  a  little  more  in  detail. 
Chief  among  these  are  hemorrhages.  Hemorrhage  as  a  symptom  of 
tuberculosis  is  of  importance,  both  in  its.  effects  upon  the  patient  and  as 
an  aid  to  diagnosis.  So  far  as  my  observation  goes,  pulmonary  hemor- 
rhage is  of  very  rare  occurrence  disconnected  from  prior  tubercular  de- 
posit, I  am  well  aware  that  Niemeyer  and  some  other  recent  writers, 
claim  that  pulmonary  hemorrhage  not  infrequently  precedes  tubercular 
deposit,  and  is  the  cause  of  such  deposit  instead  of  being  always  second- 
ary. These  writers  claim  that  the  hemorrhage  is  liable  to  occur  without 
being  preceded  by  any  mechanical  impediments  from  tubercular  deposits, 
and  when  the  hemorrhage  takes  place,  more  or  less  of  the  blood  extrav- 
asates  into  the  interstitial  spaces  of  the  tissue  and  part  of  it  fails  to  be 
disintegrated  and  removed  by  absorption.  Remaining,  it  undergoes 
caseous  degeneration  associated  with  more  or  less  inflammatory  conges- 
tion of  the  surrounding  pulmonary  tissue.  These  primary  deposits  soon 
change  still  further  into  a  purulent  condition,  and  the  hypersemia  of  the 
surrounding  tissue  assumes  the  form  of  suppurative  inflammation,  thus 
giving  you  all  the  phenomena  of  a  tubercular  development  in  the  second 
stage  of  its  progress.  I  must  acknowledge,  that  through  a  long  period 
of  observation,  with  the  attention,  during  the  later  years,  directed  to  this 
particular  point,  I  have  not  been  able  to  satisfy  mj^self  that  a  single  case 
has  come  under  my  observation  in  which  the  hemorrhage  preceded  evi- 
dences of  more  or  less  tubercular  deposit.  And  I  am  strongly  inclined  to 
think,  that  if  such  cases  occur,  they  are  extremely  rare,  and  that  the  oc- 
currence of  hemorrhage  without  any  traumatic  lesion  or  other  sjDCcial 
known  cause,  spontaneously  proceeding  from  the  pulmonary  tissue,  con- 
stitutes very  strong  presumptive  evidence  of  latent  tubercular  disease.  I 
have  yet  to  find  a  patient  whose  subsequent  history  did  not  corroborate 
the  position  that  hemorrhage  is  secondary  and  not  primary  to  the  tuber- 
cular formation. 

There  are  three  pathological  conditions  connected  with  tuberculo- 
sis, that  give  rise  to  hemorrhage.  The  first  would  appear  to  be  simply 
obstruction  of  the  capillary  or  smaller  blood  vessels  by  the  mechanical 
pressure  of  a  primary  tubercular  deposit,  damming  the  blood  and  causing 
the  coats  of  the  engorged  vessels  to  rupture,  thus  allowing  the  blood  to 
escape  into  the  air  cells  and  alveoli,  from  these  through  the  bronchial 
ramifications  to  appear  in  the  expectoration.  Hemorrhage  from  this 
pathological  condition  usually  takes  place  early  in  the  progress  of  the  tu- 
bercular disease,  and  is  quite  as  apt  to  occur  when  the  patient  is  entirely 
at  rest,  occasionally  waking  him  from  sleep  in  the  night.  Sometimes  it 
appears  while  he  is  sitting  at  ease,  at  others  while  walking  or  standing,  and 
not  infrequently  it  is  the  first  symptom  that  alarms  the  patient  and  cre- 
ates the  suspicion  that  he  has  serious  ailment.  In  most  instances 
the  quantity  of  blood  lost  is  slight.  It  may  be  but  a  single 
mouthful,  but  in  rarer  instances  it  may  come  up  mouthful  after  mouthful 
as  fast  as  the  patient  is  capable  of  spitting  it  out,  with  but  little  eflort  at 
coughing,  till  from  two  to  four  or  six  ounces  are  lost.  Very  much  more 
frequently,  however,  the  quantity  will  not  exceed  two  or  three  drachms. 

The  second  pathological  condition  liable  to  give    rise   to  hemorrhage 


SYMPTOMS.  457 

usually  develops  with  ths  early  part  of  the  second  stage  of  the  tubercular 
disease,  when  the  tissues  surrounding  the  tubercular  deposit  f.rst  begin 
to  take  on  inflammatory  action  and  the  vessels  become  engorged  with  blood 
or  hvpertemic.  It  not  infrequently  happens  that  at  this  stage  some  of 
the  vessels  immediately  surrounding  the  tubercular  mass  have  become 
weakened  by  more  or  less  degeneration  of  the  connective  tissue  entering 
into  their  coats.  Consequently  with  the  accumulation  of  blood  at  this 
stage  the  weaker  points  of  the  vessel  yield  to  the  distension  and  allow 
more  or  less  escape  of  blood,  and  consequently  of  hemorrhage  similar  to 
that  I  have  already  described.  These  turns  of  hemorrhage  also  usually 
come  without  any  special  cause  or  physical  exercise  on  the  part  of  the  pa- 
tient. The  hemorrhage  may  be  but  a  single  one  that  marks  this  stage,  or  thq 
escape  of  blood  may  take  place  rapidly  at  short  intervals  lasting  through 
three  or  four  days  at  a  time  and  be  renewed  again  in  one  or  two  weeks,  or 
it  may  occur  but  once  in  the  whole  progress  of  the  case.  The  third 
pathological  condition  liable  to  give  rise  to  hemorrhage  is  the  impairment 
and  destruction  of  vessels  in  connection  with  the  completion  of  the  sup- 
purative stage  and  the  formation  of  suppurative  cavities  in  the  lung. 
Hemorrhages  at  this  stage  are  not  so  frequent  as  at  either  of  the  other 
stages  mentioned;  but  when  it  does  occur  it  is  liable  to  be  much  more 
copious  and  sometimes  by  its  quantity  and  the  previously  debilitated  con- 
dition of  the  patient  directly  induces  a  dangerous  degree  of  exhaustion. 
It  is  rare  that  it  induces  a  direct  and  positively  fatal  result;  yet  it  adds  so 
much  to  the  exhaustion,  and  is  liable  to  be  repeated,  in  some  instances, at 
such  short  intervals  that  it  results  in  bringing  on  complete  collapse  and 
death.  The  hemorrhages  which  occur  in  the  first  and  second  stages  of  tu- 
berculosis, when  moderate  in  amount,  not  infrequently  leave  the  patient 
feeling  more  comfortable  and  free  from  oppression  than  he  was  for  several 
days  before  the  hemorrhage  occurred.  But  in  the  majority  of  instances 
hemorrhages,  whether  slight  or  more  copious,  not  only  greatly  alarm  the 
patient  and  the  friends,  creating  a  mental  anxiety  that  of  itself  is  depress- 
ing to  the  patient  and  calculated  to  hasten  the  further  development  of  the 
disease,  but  they  are  usually  followed  by  some  degree  of  increase  of  all 
the  more  important  symptoms.  Another  symptom  which  needs  perhaps 
an  additional  word  of  explanation  is  that  of  indigestion.  A  large  pro- 
portion of  tubercular  patients  complain  but  little  of  the  digestive  organs, 
but  you  will  meet  here  and  there  one,  who  from  an  early  stage  of  the  dis- 
ease has  suffered  from  loss  of  appetite,  sense  of  heaviness  in  the  epigas- 
trium followed  by  gaseous  and  sometimes  acid  eructations  during  the 
next  two  hours  after  taking  food. 

The  gastric  symptoms  often  occasion  more  suffering  to  the  patient  and 
occupy  more  of  his  attention  than  any  of  the  symptoms  belonging  to  the 
pulmonary  disease.  This  deprives  the  patient  of  good  assimilation  and 
nutrition  and  usually  increases  the  rapidity  of  his  failure  in  flesh  and 
strength,  and  by  exhausting  the  nutritive  elements  of  the  blood  leads  to 
an  earlier  supervention  of  the  second  and  third  stages  of  the  pulmonary 
disease.  Another  symptom  which  rarely  occurs  in  the  early  stage,  but 
which  is  occasionally  met  with,  is  diarrhoea.  From  the  beginning  of  the 
patient's  failure  in  health  before  attention  has  been  directed  to  the  pul- 
monary disease  by  any  marked  symptoms,  a  chronic  persistent  form  of 
diarrhoea,  consisting  of  from  one  to  five  and  six  thin  serous  discharges 
from  the  bowels,  usually  accompanied  by  little  or  no  pain,  but  only  a 
sense  of  weakness  or  exhaustion,  will  come  on  insidiously  without  any 
apparent  cause  and  sometimes  without  either  impairment  of  the  appetite 
or  that  part  of  digestion  which  takes  place  in  the  stomach  itself.     In  many 


458  PHTHISIS. 

of  these  cases  the  diarrhoeal  discharges  are  confined  almost  entirely  to  the 
morning,  commencing  when  the  patient  first  rises  from  bed,  and  being  re- 
peated from  two  to  four  times  during  the  next  two  hours  and  then  ceasing 
for  the  remainder  of  the  day.  In  other  cases  the  discharge  will  take 
place  within  from  a  quarter  of  an  hour  to  an  hour  after  each  meal;  the  pres- 
ence of  food  in  the  stomach  not  occasioning  pain  or  symptoms  of  indiges- 
tion, but  simply  exciting  increased  peristaltic  motion  of  the  bowels,  until 
it  ends  in  a  discharge  of  thin  f^ces,  sometimes  a  second  discharge  follow- 
ing in  a  little  time,  and  then  the  alimentary  canal  becomes  quiet  until 
after  the  next  meal.  Such  patients  seldom  have  more  than  a  very  slight 
tendency  to  cough,  so  slight  and  so  little  of  associate  symptoms  referable 
to  the  chest,  that  the  condition  of  the  lungs  is  entirely  overlooked  and 
the  whole  difficulty  is  regarded  as  intestinal  catarrh,  in  modern  phraseol- 
ogy, or  slight  inflammation  of  the  mucous  membrane  of  the  ileum,  or  per- 
haps some  portion  of  the  colon,  but  chiefly  of  the  lower  portion  of  the 
small  intestine.  Remedies  that  are  given  to  overcome  this  condition  al- 
ways temporarily  relieve  the  patient,  but  the  relief  uniformly  proves  only 
temporary,  and  the  difficulty  speedily  returns. 

In  this  way  several  months  may  be  passed,  the  patient  on  the  whole 
gradually  losing  flesh  and  strength,  until  he  is  unfit  for  work  and  obliged 
to  keep  his  house.  If  at  any  time  during  the  progress  of  the  disease 
susjoicion  is  aroused  in  regard  to  the  lungs,  and  a  closer  examination  is 
made  by  auscultation  and  percussion,  the  evidences  of  diffuse  miliary 
tubercular  deposit  will  almost  always  be  recognizable  in  the  upper  part  of 
one  or  both  lungs.  The  true  explanation  of  these  cases  is  found  in  the 
deposit  of  the  gray  miliary  tubercle  in  the  follicles  and  a-laudular  struct- 
ures of  the  mucous  membrane  of  the  ileum,  simultaneously  with  their  de- 
posit in  the  lungs.  The  deposits  in  the  intestinal  follicles  soon  cause  a 
low  grade  of  inflammatory  action  around  them,  causi?)g  the  first  appear- 
ance of  the  diarrhoDal  discharges.  This  is  soon  followed  by  softening  and 
disintegration  of  the  tubercular  granules  and  their  disappearance  in  the 
evacuations,  while  numerous  small  but  irregular  ulcerations  are  left  in 
their  place.  The  progress  of  the  disease  in  the  intestines  apparently  di- 
verts more  or  less  of  the  nervous  sensibility  from  the  pulmonary  tissue, 
and  lessens  the  active  ordinary  symptoms  of  local  disease  of  the  lungs. 
Yet  in  some  cases  while  the  ordinary  symptoms  of  the  progress  of  local  dis- 
ease in  the  lungs  are  almost  entirely  absent,  the  deposit  in  the  lungs  un- 
dergoes its  ordinary  natural  changes  and  will  be  found  in  an  advanced 
stage  of  progress  when  the  patient  is  apparently  dying  from  the  exhaust- 
ing influence  of  protracted  diarrhoea  and  intestinal  ulceration,  as  may  be 
proved  by  the  careful  practice  of  auscultation  and  percussion.  These  in- 
testinal comjjlications  with  tuberculosis  need  careful  examination  on  ac- 
count of  their  liability  to  lead  the  practitioner  astray  in  his  early  diagno- 
sis, and  cause  him  to  give  assurances  to  his  patient  in  regard  to  recovery 
that  are  delusive;  and  although  it  may  not  alter  in  any  degree  the  prog- 
ress of  the  disease,  yet  such  false  assurances  in  regard  to  the  nature  of 
the  case  and  the  prospect  of  recovery,  ahvays  shake  the  confidence  of  the 
patient  and  his  friends  in  the  competency  of  the  physician,  and  not  in- 
frequently cause  his  dismissal  from  further  care  of  the  patient.  Conse- 
quently whenever  chronic  diarrhoea  shows  itself  without  an  apparent 
cause,  proves  persistent  and  recurs  after  temporary  relief  from  ordinary 
remedies,  you  should  suspect  some  latent,  unexplained  disease,  and  give 
the  patient  a  full  examination,  including  especially  physical  exploration 
of  the  chest.  This  condition  should  lead  you  not  only  to  make  a  direct 
physical  exploration,  but  also  a  careful  inquiry  into  the  family  history  and 


ANATOMICAL     CHANGES.  459 

tendencies  as  regards  any  hereditary  influence  in  the  direction  of  scrofula 
or  tuberculosis.  There  are  features  of  these  cases,  if  they  are  examined 
into  as  carefully  as  possible,  that  will  reveal  to  the  practitioner  such  a  his- 
tory and  tendencies  as  will  leave  no  doubt  concerning  the  true  nature  of  the 
case.  The  diarrhoea  I  have  already  mentioned  is  apt  to  supervene  in  the 
last  stage  of  exhaustion,  resulting  from  any  form  of  chronic  wasting  dis- 
ease. 

Anatomical  Changes. — The  anatomical  or  structural  changes  wliich  con- 
stitute the  commencement  of  the  early  stage  of  tuberculosis,  consist  in 
the  accumulation,  in  some  portion  of  the  pulmonary  structure,  of  small 
aggregations  or  masses  of  organic  matter  which,  when  examined  under 
the  microscope,  are  found  to  be  composed  of  imperfectly  formed  cells,  gran- 
ules, nuclei,  some  amorphous  hyaline  matter,  and  inorganic  material, 
chiefly  compounds  of  lime,  and  more  or  less  of  fat  granules.  These 
constituents  of  the  tubercle  appear  to  be  derived  either  from  imperfect 
cell  growth  in  processes  of  assimilation,  or  from  the  imperfect  disintegration 
of  cell  structure  in  the  natural  processes  of  waste.  Many  of  the  earlier 
investigators  regarded  the  tubercular  masses  as  a  result  of  previous  inflam- 
matory engorgement  and  exudations.  But  there  is  not  sufficient  evidence 
that  inflammatory  processes  have  any  necessary  connection  with  the  origin 
and  deposit  of  tubercles.  As  I  have  shown  when  speaking  of  the  consti- 
tutional conditions  constituting  the  scrofulous  and  tuberculous  diatiieses, 
there  is  in  almost,  if  not  all  cases,  a  stage  of  impairment  iu  the  properties 
or  forces  which  govern  the  iiolecular  movements  in  the  tissues,  constitut- 
ing nutrition  and  disintegration,  existing  prior  to  the  local  develop- 
ment of  the  tubercular  formations.  And  as  these  constitutional  condi- 
tions are  induced  by  causes  acting  with  feeble  intensity  through  consider- 
able periods  of  time,  and  the  local  development  of  tubercle  only  super- 
venes after  these  general  impairments  have  reached  a  considerable  de- 
gree of  development,  I  have  every  reason  to  suppose  that  they  are  sim- 
ply the  product,  as  before  stated,  of  imperfect  elaboration  of  material,  and 
by  its  failure  to  be  eliminated  through  the  excretory  organs,  it  assumes 
the  form  of  genuine  deposit  in  the  structure.  The  precise  location  of  the 
deposit  varies.  In  some  cases  it  appears  in  the  interstitial  spaces  of  the 
connective  tissue,  in  other  instances  in  the  alveoli  or  air  celis,  and  not  in- 
frequently in  both.  In  uncomplicated  tuberculization,  the  morbid  mate- 
rial commences  as  small  granular  masses,  most  frequently  of  a  grayish 
color.  These  masses  appear  to  increase  in  size  by  accretions  to  their 
growth,  until  when  examined  in  an  advanced  stage  of  the  disease,  they 
may  be  found  of  all  sizes,  from  a  millet  seed  to  that  of  a  hickory  nut. 

The  changes  which  these  masses  undergo  during  the  progress  of  the 
disease  appear  to  be  that  of  degeneration  of  the  more  elaborated  portion 
of  the  material  converting  the  imperfect  cells  and  nuclei  into  a  more 
yellow  caseous  substance,  and  still  later  into  pus.  These  changes  appear 
to  progress  faster  in  the  center  of  the  tubercular  masses  than  toward  their 
periphery;  giving  them,  when  laid  open  for  examination,  a  yellowish, 
friable  appearance,  softer  in  the  center  than  toward  the  circumference. 
As  tiie  lung  tissue  becomes  congested  and  a  low  grade  of  inflammatory 
action  is  set  up  around  the  larger  deposits,  this  apparent  degeneration  and 
softening  goes  on  through  the  whole  mass,  until  it  becomes  converted  into 
a  mixture  of  granular  or  cheesy  material  and  pus.  These  ingredients  of 
the  softened  tubercles  may  be  often  detected  in  the  sputa  of  patients 
during   the  second  stage  of  the  disease. 

Several  years  since  some  of  the  European  investigators,  through  experi- 
ments in  inoculating  tuberculous  matter  into  small  animals,  as  rabbits  and 


460  PHTHISIS. 

guinea  pigs,  claimed  to  have  demonstrated  that  the  disease  was  ca- 
pable of  transmission  by  inoculation.  And,  hence  the  conclusion 
was  reached  that  tuberculosis  was  an  infectious  if  not  a  directly 
contagious  disease.  More  recently,  however,  it  has  been  so  clearly 
shown  that  inoculation  of  these  animals  with  any  other  inflammatory 
product  or  even  with  organic  matter  derived  from  saliva,  would 
result  in  similar  deterioration  of  the  animals  and  apparent  tuber- 
cular deposit,  that  no  reliance  can.  be  placed  upon  the  deductions  from 
these  earlier  experiments.  Very  recently  Koch  has  discovered  in  the  tu- 
bercular mass  ill  the  lungs  and  more  readily  also  in  the  matter  of  expec- 
toration, an  organic  gerra  styled  "  bacillus  tuberculosis,"  which  he  claims 
to  be  peculiar  to  this  form  of  disease.  He  regards  it  as  the  essential 
cause  of  the  disease.  His  observations  have  been  confirmed  by  several 
other  eminent  microscopists,  and  have  been  either  denied  or  modified  by 
many  others.  That  the  bacilli  or  minute  organisms  may  be  found  in  the 
sputa  there  can  be  no  doubt.  The  conclusion,  however,  that  these  minute 
organisms  are  the  essential  cause  of  tuberculosis,  and  that  the  tubercular 
deposits,  with  all  the  subsequent  changes,  start  from  inoculation  of  these 
bodies  either  inhaled  through  the  lungs  or  in  any  other  manner  introduced 
into  the  sj'stem,  has  been  altogether  too  hastily  drawn.  Before  this  con- 
clusion can  be  considered  as  established  it  must  be  demonstrated  by  a 
sufficient  number  of  examinations,  that  these  identical  organic  germs  ex- 
ist in  all  tubercular  deposits;  not  only  in  those  that  are  undergoing  soft- 
ening disintegration  and  from  which  matter  of  expectoration  is  furnished, 
but  in  the  primary  tubercular  masses  in  the  lungs,  in  the  mesenteric 
glands,  and  in  other  lymphatic  or  adenoid  structures  in  different  parts  of 
the  body.  Some  examinations  of  the  tubercular  material  in  the  mesen- 
teric glands  have  been  very  recently  made  without  detecting  these  organ- 
isms. And  it  is  more  than  probable,  in  my  own  estimation,  that  mature 
investigation  in  the  early  stage  will  lead  to  the  final  conclusion  that  the 
bacillus  tuberculosis  is  only  an  accompaniment  of  the  degenerative 
changes  in  the  tubercular  masses  wherever  found,  thereby  destroying  the 
idea  of  their  causative  influence  or  of  their  playing  a:i  essential  part  in 
the    propagation  of  the  disease. 

.  Beside  the  formation  of  tubercular  deposits  and  their  transition 
from  the  imperfectly  elaborated  organic  material  of  which  they 
are  composed  into  purulent  material  in  the  advanced  stages  of 
the  disease,  the  pathological  changes  in  the  lung  tissue,  imme- 
diatelv  surrounding  the  tubercular  masses,  is  of  much  importance. 
These  changes  in  the  lung  structure  are  strictly  analogous  to  and  prob- 
ably identical  with  a  low  grade  of  pneumonic  inflammation.  There  is 
every  appearance  of  a  stage  of  engorgement  in  the  vessels  surrounding 
these  masses.  Engorgement  is  followed  by  exudation  into  the  interstitial 
spaces  of  the  tissue,  causing  increased  density  of  the  structure  to  such  a 
degree  as  to  incre  ise  the  fremitus  of  voice  and  diminish  the  resonance  on 
percussion,  and  to  cause  the  greater  part  of  the  febrile  phenomena 
accompanying  the  second  stage  of  the  disease.  It  is  the  accumulation 
of  true  inflammatory  exudative  products  in  different  stages  of  progress 
that  gives  to  the  tuberculated  portion  of  the  lung  its  varying  degrees  of 
density,  and  not  infrequently,  on  post  mortem  examinations,  a  close 
resemblance  to  the  gray  hepatization  of  the  suppurative  stage  of  un- 
complicated pneumonia.  As  the  separate  tubercular  masses  are  in  most 
cases  very  numerous,  and  as  the  changes  they  underoro  usually  take  place 
in  the  order  in  which  they  were  deposited,  the  earlier  deposits  generally 
mature   and    pass    into   the  second  stage  or  that  of  softening,  while  other 


DIAGNOSIS.  4P>1 

deposits  are  just  being  formed;  thus  presentincr  in  its  pronfress  a  suc- 
cession of  pathological  chang-es,  correspondino:  with  the  exacerbations  and 
remissions  that  characterize  the  general  symptoms  and  progress  of  most  of 
the  cases  of  tubercular  phthisis. 

The  same  circumstances  explain  why,  on  post  mortem  examination,  in 
laying  open  the  tuberculated  lung,  you  will  often  find  all  these  changes 
present  within  the  compass  of  a  single  lobe.  And  this  explains  why  so 
often  in  the  progress  of  this  form  of  disease,  the  patient  for  a  time  pro- 
gresses unfavorably  with  steadily  increasing  emaciation,  rapid  pulse,  co- 
pious expectoration,  night  sweats,  and  yet,  after  a  time  begins  to  im- 
prove; all  the  symptoms  and  the  quantity  of  the  expectoration  gradually 
diminishing  until  he  is  flattered  with  the  expectation  of  recovery,  wheti 
without  any  real  or  apparent  cause  he  begins  again  to  have  some  increase 
of  inflammatory  or  febrile  symptoms,  ending  in  a  similar  copious  expecto- 
ration and  a  little  further  progress  in  emaciation  and  loss  of  strength  than 
before.  They  thus  undergo  a  succession  of  exacerbations  lasting  two, 
three  or  four  weeks  with  intervals  of  moderate  improvement  perhaps  of 
a  similar  length  of  time,  which  improvement  raises  new  hopes  and  causes 
the  patient  and  his  friends  to  insist  that  they  are  recovering,  only,  however, 
to  be  disappointed  with  the  development  of  suppurative  action  in  the 
next  series  of  deposits. 


LECTURE    XLVII. 


Phthisis  Pulmonalis  Continued— Its  Diagnosis,  Prognosis  and  Treatment. 

GENTLEMEN:  In  regard  to  the  diagnosis  of  genuine  tubercular  phthis- 
is little  more  need  be  said  than  to  recall  your  attention  to  the  physical 
signs  I  have  already  mentioned  when  describing  the  progress  of  the  dis- 
ease, and  their  comparison  with  the  presence  or  absence  of  physical  signs 
in  the  diseases  with  which  tuberculosis  is  most  apt  to  be  confounded. 
Indeed,  there  is  but  one  form  of  disease  that  presents  any  apparent  diffi- 
culties in  its  differentiation  from  the  earlier  stage  of  the  tubercular  deposit 
and  that  is  bronchitis.  The  clinical  history  of  bronchitis  and  the  devel- 
opment of  tubercular  phthisis,  are  sufficiently  distinct  in  their  general 
features,  when  carefully  examined,  to  enable  the  practitioner  reliably  to 
separate  the  one  from  the  other,  but  from  many  patients  it  is  impossible 
to  get  an  accurate  history  of  their  case,  such  as  is  needed  to  form  reliable 
conclusions,  consequently  the  physical  signs  derived  from  auscultation 
and  percussion  become  not  only  important  but  necessary  to  enable  us  to 
distinguish  tubercular  deposits,  especially  when  of  very  limited  extent, 
from  any  form  of  bronchial  disease.  There  is  no  form  or  stage  of 
the  latter,  which  will  give  rise  to  diminished  resonance  on  percus- 
sion, increased  fremitus  of  voice,  and  simple  alterations  of  the  natural 
respiratory  murmur.  If  there  is  any  exception  to  this  rule,  it  is  in 
those  cases  of  chronic  capillary  bronchitis  which  have  resulted  in  the  oc- 
clusion or  closing  up  of  a  sufficient  number  of  the  bronchioles,  to  allow 
such  a  degree  of  collapse  of  the  alveoli  as  to  contract  the  chest  and  alter 


462  *  PHTHISIS. 

its  resonance  from  the  diminished  capacit}'  for  air  in  consequence  of  such 
contraction.  This  stage  of  bronchitis,  however,  is  preceded  by  a  his- 
tory so  characteristic  of  the  disease,  and  the  contractions  so  generally  af- 
fect the  middle  and  lower  parts  of  the  chest,  as  much  or  more  than  the 
upper,  and  are  therefore  so  different  from  the  flattening  of  the  infra-clavicu- 
lar region  of  the  chest  antero-posteriorly  at  its  apex  or  upper  part,  that  the 
one  can  hardly  be  confounded  with  the  other.  Consequently,  you  are 
safe  in  deciding  that  there  are  deposits  of  some  kind  in  the  lung  tissue 
and  probably  of  a  tuberculous  character  w^henever  accurate  percussion  in 
the  infra-clavicular  region  elicits  less  than  the  normal  resonance,  and  the 
voice  gives  increased  fremitus  or  vibration  through  the  walls  of  the  chest, 
and  the  respiratory  murmur  is  altered  either  by  irregularity  of  develop- 
ment, prolongation,  renewal  in  expiration  or  deficiency.  If  to  these  phj'S- 
ical  signs,  is  added  distinct  flattening  as  determined  either  by  measure- 
ment or  inspection,  you  have  all  the  evidences  that  are  neede  1  to  show, 
not  only  that  there  is  increased  densit}-  ot  the  lung  from  some  cause,  but 
that  such  density  is  the  product  of  tubercular  accumulations. 

For  wdiile  exudations  from  pneumonic  inflammation  may  give  rise  to 
increased  dullness  on  percussion  and  fremitus  of  voice,  they  are  necessa- 
rily accompanied  by  the  other  phenomena  of  pneumonic  disease,  such  as 
the  characteristic  expectoration,  the  phenomena  of  a  general  fever  and  are 
preceded  by  a  history  that  dates  comparatively  but  a  few  days  back, 
for  its  beginning.  Pulmonary  oedema  may  also  give  rise  to  diminished 
resonance  and  increased  fremitus  of  voice,  but  such  oedema  will  not  cause 
shrinking  of  the  chest,  and  can  result  only  from  some  prior  (Jisease,  such  as 
organic  or  structural  lesions  of  the  heart,  structural  diseases  of  the  kidrtey, 
or  other  conditions  tending  to  produce  general  dropsy.  An  exception 
may  be  met  with  in  some  instances  of  capillary  bronchitis  in  children  and 
in  old  persons  in  which  the  extreme  dyspnoea  causes  want  of  oxygenation 
and  decarbonization  of  the  blood,  and  by  thus  secondarily  impairing  the 
vaso-motor  influence  over  the  pulmonary  vessels,  a  degree  of  cedematous 
infiltration  may  take  place  in  the  pulmonary  tissue,  thereby  inducing  the 
physical  signs  I  have  named  without  the  existence  of  any  tubercular  de- 
posits. But  here  also  there  is  a  jDreceding  history  of  capillary  bronchitis, 
or  of  general  dropsy  from  either  renal  or  cardiac  disease,  which  differs 
very  much  from  that  of  any  stage  of  tuberculosis. 

Pleuritic  effusion  sufficient  to  compress  the  lung  may  cause  increased  dull- 
ness on  percussion  and  alter  the  fremitus  or  vibration  of  voice,  but  it  will 
neither  cause  flattening  of  the  infra-clavicular  spaces  nor  diminution  of 
the  chest  artero-posteriorly,  but  will  cause  greater  changes  in  the  middle, 
lower  and  lateral  parts  of  the  chest,  and  will  be  preceded  by  such  a 
clinical  history  as  points  distinctly  to  pleuritic  inflammation  and  its  con- 
sequences instead  of  tuberculosis.  Therefore,  if  you  are  careful  to  first 
ascertain  clearly  the  results  of  physical  exploration  by  inspection,  aus- 
cultation, and  percussion,  and  before  drawing  your  final  conclusion, 
compare  these  results  with  a  careful  study  of  the  preceding  history  of 
each  patient  with  the  present  general  symptoms,  you  can  hardly  fail  to 
distinguish  even  the  earliest  stage  of  tubercular  deposits  from  any  of  the 
other  pathological  conditions  with  which  it  is  liable  to  be  confounded.. 
I  call  your  attention  to  the  diagnosis  of  this  stage  more  particularly,  be- 
cause of  its  great  importance:  it  being  the  stage  in  which,  with  proper 
management,  there  is  a  reasonable  chance  for  the  patient's  recovery.  In 
the  subsequent  stages  of  tuberculosis,  the  diagnosis  is  still  more  easily 
made.  ^Yith  the  increased  accumulation  of  deposits,  increased  contrac- 
tion of  the  upper  part  of  the  chest,  mure  or  less  condensation  of  the  lung 


DIAGNOSIS.  463 

t'ssue  surrouiidin^^  the  tubercular  masses,  the  dullness  on  percussion  and 
increased  vil)ration  of  voice  become  still  more  plain  and  easily  recog- 
nized; and  with  the  beginning  of  softening,  come  always  more  or  less  of 
sul)-mucous  or  mucous  rales,  fixed  in  the  tissue  or  only  partially  removable 
temporarily  by  coughing.  The  expectoration  itself,  now,  if  properly  ex- 
amined, may  aid  in  confirming  the  diagnosis. 

In  many  cases,  when  softening  has  made  considerable  progress,  the 
microscope  will  reveal  more  or  less  of  the  broken  cells,  nuclei,  and  gran- 
ular material  that  constitute  the  tubercular  mass.  Not  infrequently  may 
be  detected,  also,  with  close  scrutiny,  the  fragments  of  the  connective 
tissue  of  the  lung.  These,  with  more  or  less  of  pus  globules,  may  be 
regarded  as  additional  evidence  that  the  expectorated  matter  is  derived 
from  softening  and  disintegration  of  tubercle,  and  not  from  any  suppu- 
rative condition  of  the  bronchial  membrane.  How  far  the  detection  of 
the  bacillus  in  such  expectoration  is  to  be  regarded  as  surely  and  posi- 
tivelv  distinctive  of  the  expectoration  from  the  tubercular  mass  remains 
yet  to  be  determined.  That  it  exists  in  a  great  number  of  the  cases  of 
this  kind  of  expectoration  there  is  no  doubt;  but  the  investigation  must 
be  carried  to  the  extent  of  making  similar  microscopic  examinations  with 
the  same  degree  of  minuteness  in  the  rauco-purulent  matter  derived  from 
the  second  and  third  stages  of  bronchial  inflammation,  and  also  the  ex- 
pectoration that  occurs  in  the  second  stage  of  pneumonia  when  diffuse 
suppuration  exists,  before  any  positive  conclusions  can  be  reached. 
There  is  nothing  yet  on  record  indicating  that  these  investigations  have 
been  made,  and  before  we  can  conclude  that  the  bacillus  of  Koch  is 
distinctive  of  expectoration  from  pulmonary  tubercle,  all  these  other 
forms  of  expectoration  must  be  examined  with  the  same  care  as  though 
each  came  from  a  well-marked  case  of  phthisis.  In  the  second  stage  of 
tuberculosis,  as  I  have  already  stated,  the  diagnostic  features  are,  the  in- 
creased dullness  on  percussion,  increased  vibration  of  voice,  more  or  less 
moist  rales,  varying  much  at  different  times  according  to  the  degree 
of  softening  and  condensation  of  lung  tissue,  and  the  character 
and  composition  of  the  sputa.  In  the  third  stage  of  the  disease, 
after  suppuration  in  some  portions  of  the  lung  has  been  completed 
and  cavities  have  been  formed,  auscultation  frequently  reveals,  not  merely 
fremitus  of  voice,  but  that  concentrated  transmission  of  the  voice  directly 
to  the  ear  or  funnel  of  the  stethoscope,  which  is  called  pectoriloquy;  while 
percussion  over  most  of  the  affected  lung  will  still  yield  only  marked 
dullness,  yet  whenever  there  is  a  cavity  of  considerable  size  near  the  sur- 
face of  the  lung,  percussion  may  elicit  a  degree  of  tympanitic  resonance 
.over  a  very  limited  area,  the  surrounding  parts  being  dull.  Or,  if  a  large 
cavity  has  a  free  communication  with  a  bronchial  tube,  percussion  over  it 
will  not  unfrequently  elicit  that  peculiar  sound  denominated  "bruit  du 
p6t  fele,"  or  cracked  metal  sound.  It  is  thus,  gentlemen,  that  by  means 
of  the  faithful  practice  of  auscultation,  percussion,  and  the  additional 
modes  of  physical  examination,  you  may  not  only  diagnosticate  accurately 
tubercular  disease  in  all  its  stages,  but  you  may  define  accurately  its  ex- 
tent or  degree  of  diffusion  through  the  lung  tissue,  and  very  nearly  the 
exact  stage  of  advancement  it  has  made  up  to  that  of  extreme  exhaustion 
of  your  patient  and  the  approach  of  death. 

Prognosis. — In  regard  to  prognosis  much  will  depend  upon  the  age  of 
the  patient  and  the  circumstances  which  have  led  to  the  development  of 
the  disease.  As  a  general  rule,  cases  of  a  strictly  hereditary  character 
are  less  likely  to  be  arrested  in  their  course  or  be  rendered  abortive  by 
any  process  of  treatment  than  those  which  have  originated  de  novo  with 
the  individual.     And  yet  if  the  diagnosis  lias  been  made  early,  while  the 


46  i  PHTHISIS. 

tubercular  deposits  are  small  and  comparatively  few  in  number,  and  the 
patient  under  thirty  years  of  age,  there  is  a  possibility  of  arresting  the 
further  progress  of  tubercle  formation  and  causing  that  which  already 
exists  to  remain  latent  or  slowly  diminish.  That  primary  crude  tu- 
bercular deposit  is  capable  of  undergoing  arrest  in  its  growth  or  in- 
crease, and  of  having  its  organic  materigl  slowly  undergo  disintegration 
and  disappearance  by  absorption,  leaving  only  a  small  speck  of  inorganic 
matter  in  the  lung,  we  have  abundant  evidence  furnished  by  postmortem 
examination  after  death  from  other  diseases,  in  subjects  who  had  at  a 
previous  period  been  known  to  be  tuberculous.  Not  only  may 
we  make  a  favorable  prognosis  in  many  of  the  cases  that  come  un-ler 
observation  in  the  early  stage,  but,  in  cases  that  are  further  advanced, 
even  in  the  stage  of  softening  or  suppuration,  if  on  careful  examination 
the  structural  chang^es  are  found  to  be  limited  to  the  apex  of  one  lung, 
and  the  patient  capable  of  availing  himself  of  the  most  favorable  circum- 
stances for  controlling  the  disease.  Under  such  circumstances  assur- 
ance may  be  given  that  there  is  a  reasonable  chance  of  recovery;  not  by 
arresting  the  progress  of  pathological  changes  in  the  affected  part  of  the 
lung,  but  by  sustaining  the  strength  and  nutrition  of  the  patient  until  the 
disintegrated  tubercular  mass  has  disappeared  by  expectoration  and  the 
resulting  cavity  filled  and  cicatrized  by  the  ordinary  process  of  repair. 
This  result  may  leave  the  upper  part  of  that  side  of  the  chest  more  or 
less  contracted  and  a  moderate  diminution  of  capacity  for  air  as  a  perma- 
nent change,  and  yet  the  general  health  will  be  restored  and  may  remain 
sufficiently  good  to  admit  of  an  active  life  during  an  indefinite  period  of 
time,  or  until  destroyed  by  other  forms  of  disease.  But  if  the  deposit  oc- 
cujDies  more  or  less  of  both  lungs,  or  if  one  lung  has  several  places  advanced 
to  the  second  or  softening  and  disintegrative  stage,  the  chances  of  any 
permanent  recovery  are  exceedingly  small.  Judicious  management  may 
greatly  retard  the  progress  of  the  disease  under  such  circumstances,  and 
render  the  patient  more  comfortable,  but  it  is  very  rare  that  it  will  do 
more  than  this.  As  a  large  proportion  of  all  the  tubercular  patients 
neglect  to  seek  thorough  examination  and  advice  till  the  second  stage  has 
actually  begun,  so  it  is  that  almost  all  those  that  thus  come  under  obser- 
vation force  us  to  an  unfavorable  prognosis,  which  is  only  too  surely 
vei'ified  by  their  ultimate  failure  and  death  from  the  subsequent  progress 
of  the  disease. 

Treatment. — The  management  of  the  diathesis  or  constitutional  condi- 
tion which  exists  prior  to  the  deposit  of  tubercle  in  the  lungs,  at  least  in 
the  large  majority  of  cases,  was  considered  suflSciently  in  detail,  both  in  re- 
gard to  hygienic  measure  and  the  administration  of  remedial  agents  in 
the  lectures  on  the  general  pathology  of  the  chronic  constitutional  dis- 
eases, and  in  that  in  reference  to  scrofula.*  Consequently  I  shall  here 
consider  the  treatment  only  as  it  relates  to  pulmonary  tuberculosis  after 
the  commencement  of  the  deposits.  In  the  first  stage  of  pulmonary  tuber- 
culosis, there  are  three  distinct  indications  to  be  fulfilled  or  objects  to  be  ac- 
complished in  its  management;  first,  to  so  change  the  functions  of  nutrition 
and  disintegration  as  to  prevent  the  further  development  of  the  tubercu- 
lar material  in  the  system;  second,  to  render  the  deposits  already  existing 
abortive  in  their  further  progress;  third,  to  correct  such  defects  in  the  con- 
formation of  the  chest,  or  in  the  constitutional  condition  of  the  patient  as 
may  have  supervened  during  this  first  stage.  Keeping  in  mind  the  fact 
that  tubercular    material  may  be  derived,  either   through  defects  in  the 

•  See  Lectures  XXVII  and  XXVIII. 


TREATMENT.  4G5 

processes  of  clisinteo;ration  and  elimination,  or  tlirough  imperfection  in  tlie 
processes  of  assimilation  and  the  appropriation  of  new  material  to  the 
tissues,  it  is  evident  that  the  management  of  cases  belonging  to  the  one 
class  may  require  measures  essentially  different  from  those  of  the  other. 
As  explained  when  speaking  of  the  etiology  of  the  disease,  those  cases 
which  originate  from  hereditary  influences  belong  to  the  class  in  which  the 
primary  fault  is  in  the  assimilation  of  new  rriaterial,  while  in  a  large  propor- 
tion of  the  cases  in  wliich  the  diathesis  has  been  acquired  without  hered- 
itary influence,  it  has  resulted  from  exposure  to  such  causes  as  interfere 
primarily  with  the  oxygenation  and  decarbonization  of  the  blood  and  sec- 
ondly with  disintegration  and  excretion. 

To  arrest  the  progress  of  further  development  of  tubercle  in  the  first 
stage,  such  measures  should  be  instituted  as  are  calculated  especially  to 
supply  the  patient  with  such  a  variety  of  food  as  will  furnish  all  the  mate- 
rial necessary  for  the  nutrition  of  the  various  structures  of  the  body;  such 
an  amount  of  pure,  fresh  air  as  will  secure  full  oxygenation  and  decarbon- 
ization of  the  blood;  and  that  degree  of  daily,  habitual,  muscular  exercise, 
including  especially  the  muscles  of  the  chest,  the  trunk  of  the  body  and 
upper  extremities,  as  is  calculated  to  promote  muscular  nutrition  and 
growth,  and  at  the  same  time  to  increase  the  efficiency  of  the  expansion  of 
the  chest.  In  many  of  these  cases,  if  the  circumstances  of  the  patient 
will  allow  them,  when  properly  directed,  to  secure  all  the  influences  neces- 
sary, including  food,  clothing,  air  and  exercise,  they  may  recover  without 
a  change  of  climate.  But  you  will  find  a  proportion  of  the  cases,  es- 
pecially patients  between  the  ages  of  puberty  and  twenty-five  vears, 
whose  growth  has  been  unequal  so  that  the  chest  is  narrow  in 
proportion  to  their  height,  lacking  capacity  for  air,  whose  nutrition  is 
defective  as  exhibited  by  a  delicate,  spare  condition  of  all  the  tissues. 
In  such,  a  judicious  change  of  climate  is  almost  an  absolute  necessity  to 
secure  success.  The  change  needed  for  this  particular  class,  is  to  an  ele- 
vation, ranging  between  twenty-five  hundred  and  five  thousand  feet,  with 
a  dry,  mild  condition  of  the  atmosphere,  if  possible  upon  a  dry  soil  with 
an  acclivity  to  the  south  or  east.  Such  an  elevation  of  itself  causes  un- 
consciously increased  frequency  and  force  of  respiration,  to  compensate  for 
the  increased  rarity  of  the  atmosphere.  If  the  patient  is  kept  much  in 
the  open  air  with  moderate  daily  exercise,  as  should  be  the  case,  this  un- 
conscious and  continuous  increase  of  the  I  espiratory  movements  leads  to 
a  steady  increase  in  the  expansion  and  capacity  of  the  chest.  And,  if  the 
patient  is  at  the  same  time  supplied  with  the  necessary  quantity  and  qual- 
ity of  food,  there  is  a  reasonable  certainty  that  a  continuous  residence  in 
such  a  locality  through  a  period  of  one,  two  or  three  years  will  secure  a  fair 
respiratory  capacity^  with  a  shrinking  of  the  tubercular  deposits  already  ex- 
isting or  their  conversion  into  small  calcareous  atoms  thus  rendering 
them  abortive,  and  thereby  accomplishing  the  second  object  of  treatment 
at  the  same  time  with  the  first. 

In  this  class  of  cases,  through  the  first  stage  of  the  disease,  compara- 
tively little  can  be  accomplished  by  the  administration  of  medicines.  I 
have  thought  in  some  instances  during  the  early  part  of  the  treatment 
and  especiably  when  patients  were  not  able  to  avail  themselves  of  the  ad- 
vantage of  a  change  of  climate,  that  the  long  continued  use  of  such  reme- 
dies as  the  lacto-phosphate  of  calcium  in  the  form  of  syrup,  or  the  syrup  of 
iodide  of  calcium  produced  decided  benefit.  The  addition  of  a  table- 
spoonful  of  cod-liver  oil  twice  a  day,  if  these  patients,  on  trial,  find  they 
can  digest  it  without  annoyance  to  the  stomach,  will  increase  the  benefit, 
and  add  materially  to  the  activity  of  nutrition  and  consequently  aid  in 
30 


466  -.'  PHTHISIS. 

larresting  the  further  accumulation  of  tubercular  material.  The  calcium 
compounds  I  regard  as  of  more  value  than  is  generally  supposed.  Evi- 
dently, one  of  the  defects  in  the  nutrition  favoring  tubercular  develop- 
tnents  is  imperfect  cell-growth.  Long  continued  clinical  observation  has 
led  me  to  the  conclusion  that  the  compounds  of  phosphorus  and  calcium 
in  such  forms  as  the  lacto-phosphate  of  calcium,  and  iodide  of  calcium  have. 
a  positive  influence  in  promoting  cell-growth  and  consequently  of  increas- 
ing the  perfection  of  the  nutritive  processes.  As  a  general  rule  almost 
any  remedial  agent  or  nutritive  material  that  will  increase  the  efficiency 
of  nutrition  will  he  beneficial  to  such  patients.  But  it  is  not  to  their  ad- 
vantage to  be  overdosed  with  medicines,  more  particularly  with  those 
that  are  calculated  either  to  diminish  the  appetite  for  wholesome  food, 
or  the  power  to  assimilate  it. 

The  class  of  tuberculous  patients  who  come  under  our  care  in  the  first 
stage  of  the  disease,  in  whom  the  tubercular  diathesis  has  been  created 
without  hereditary  influences,  by  living  in  damp,  ill  ventilated  rooms, 
confined  too  closely  to  indoor  occupations  and  all  those  modes  of  living 
by  which  the  functions  of  disintegration  and  elimination  are  more  or  less 
impaired,  are  as  much  benefited  by  the  same  rule  in  regard  to  well  regu- 
lated exercise  in  the  open  air,  the  selection  of  a  diet  containing  the  neces- 
sary variety  and  quality  of  material  for  healthy  nutrition,  and  change  of 
climate  in  the  same  direction,  as  the  class  of  patients  to  which  I  have 
already  referred.  But,  experience  has  shown  that  many  of  this  class  of 
cases,  when  they  first  coine  under  observation,  have  special  functional  de- 
rangements of  the  digestive  organs,  such  as  defective  secretion  of  gastric 
juice,  an  inactive  condition  of  the  bowels,  not  infrequently  defective  secre- 
tion of  urine,  a  dry  and  unhealthy  state  of  the  cutaneous  surface,  and 
they  will  be  greatly  benefited  by  giving  special  attention  to  the  removal 
of  these  various  functional  disturbances.  It  is  true  that  good  food,  warm 
•clothing  and  well  regulated  exercise  in  the  open  air  will  do  much  to  cor- 
rect these,  without  medication.  But  it  is  equally  true  that  the  judicious 
administration  of  such  remedies  as  will  promote  better  secretion  of  gastric 
juice,  secure  the  daily  evacuation  of  the  bowels,  and  the  taking  after  each 
meal  of  some  of  those  agents  that  exert  a  general  alterant  and  tonic  influ- 
ence upon  the  system,  will  render  the  efi"ects  of  good  air  and  outdoor  ex- 
ercise much  more  efficient  in  promoting  the  restoration  of  the  patient.  In 
this  class  of  cases  especially,  the  efi'ectas  a  general  alterant,  and  promoter 
of  nutrition,  of  the  syrup  of  the  iodide  of  calcium  in  doses  of  four  cubic 
centimeters  (fl.  3j)  after  each  meal  will  do  jnuch  good.  If  the  patient  al- 
ready has  some  cough  and  morbid  sensitiveness  to  atmospheric  changes, 
the  addition  to  each  dose  of  the  iodide  of  calcium  of  two  cubic  opntimeters 
(fl.  3ss)  of  the  fluid  extract  of  humulus  lupulus  will  render  it  more  quiet- 
ing and  increase  its  tonic  properties.  In  those  cases  where  the  digestive 
organs  are  impaired  causing  more  or  less  distress,  flatulency  and  gaseous 
or  acid  eructations  after  each  meal,  I  have  found  the  use  of  a  prescription 
containing  carboli  >  acid*  given  in  doses  of  four  cubic  centimeters  (fl.  3j) 
just  before  each  meal,  to  afford  much  relief  from  the  gastric  symptoms, 
while  the  intestinal  discharges  vaay  be  kept  regular  and  natural  by  taking 
at  bedtime  a  tonic  and  laxative  pill  composed  of  six  centigrams  (gr.  i) 
each,  of  the  extract  of  hyosciamus,  sulphate  of  iron  and  aloes,  and  two 
•centigrams  (gr.  -J)  each  of  blue  mass  and  extract  of  nux  vomica. 

For  restoring  the  skin  to  a  healthier  condition  and  securing  more  per- 
fect elimination  of  waste  material,  a  warm  bath  rendered  a  little  stimulat- 
ing by  the  addition  of  common  salt  may  be  taken  twice  per  week,  and  after 

•  See  formula  on  page  138  of  this  vol. ; 


TREATMENT.  467 

each  bath  as  soon  as  the  water  is  removed  from  the  skin  the  whole  cuta- 
neous surface  should  be  rapidly  and  freely  rubbed  with  dry,  soft  flannel  un- 
til a  comfortable  glow  of  warmth  is  felt  over  all  the  surface.  The  class  of 
patients  of  which  I  am  now  speaking  are  more  liable,  during  this  first 
stage  of  the  disease,  to  have  the  tubercular  deposits  accumulate  rapidly 
and  in  largor  masses  than  those  of  hereditary  origin,  and  correspondingly 
more  liable  to  hemorrhages.  Some  of  these  cases,  when  sent  to  the  moun- 
tain districts  for  better  climate,  and  especially  to  the  higher  altitudes,  be- 
come more  liable  to  hemorrhage,  experience  more  difficulty  of  breathing, 
and  are  soon  obliged  to  return.  The  same  parties  going  to  a  mild  cli- 
mate, at  a  lower  altitude,  such  as  is  found  in  the  interior  of  Florida,  some 
places  at  the  ends  of  the  Allegheny  and  Cumberland  mountains  in 
Georgia  and  Alabama,  or  still  better  in  the  Berinuda  Islands,  experience 
a  high  degree  of  relief,  and  make,  apparently,  rapid  progress  toward  re- 
covery. Observation  has  also  shown  that  some  rare  cases  of  tuber- 
culosis, in  the  early  stage,  are  much  more  inclined  to  increase  with 
frequent  exacerbations  of  cough  and  of  soreness  in  the  chest,  in  the  early 
part  of  autumn  and  in  the  spring  months,  and  are  better  during  the  steady 
cold  part  of  the  winter  season  than  during  the  heat  of  summer.  I  have 
seen  some  whose  attack  of  hemorrhage  occurred  invariably  during  the 
warmer  months  of  the  year. 

I  think  such  have  almost  always  been  most  benefited  by  going  to  an  el- 
evation of  three  or  four  thousand  feet,  and  within  the  boundaries  of  Col- 
orado, Dakota  or  the  northern  portions  of  California  and  Oregon.  Such 
of  them  as  have  resorted  to  the  south,  to  Florida  or  to  portions  of  the  Gulf 
States,  and  in  some  instances  to  the  Bermiida  or  the  West  India  Islands, 
have  been  attacked  with  more  frequent  hemorrhages,  and  an  increase  in 
all  the  symptoms  of  their  disease.  I  have  known  a  few  such  instances 
of  hemorrhagic  tendency  to  be  arrested  and  held  at  bay  for  years  by  re- 
sorting to  the  cold  dry  air  of  Minnesota  and  the  region  of  Lake  Superior. 
But  another  class  of  our  patients  manifest  directly  opposite  tendencies. 
During  the  warm  months  of  summer  up  to  the  commencement  of  the  cold 
wet  weather  of  autumn,  they  experience  little  inconvenience,  and  show 
but  little  outward  signs  of  the  existence  of  pulmonary  disease;  but  always 
manifest  indications  of  increased  sensitiveness  of  the  air  passages  and  lungs 
and  of  more  frequent  spitting  of  blood,  during  the  cold  season.  These,  so 
far  as  I  have  had  opportunity  for  observation  and  trial,  have  uniformly 
been  benefited  by  resorting  to  the  south,  either  to  the  hilly  districts  of 
Western  Texas,  as  represented  by  San  Antonio,  the  region  of  the  gulf  to 
which  I  have  already  alluded,  particularly  the  orange  grove  regions  of  the 
interior  of  Florida  or  the  Bermuda  Islands.  It  is  this  class  of  patients 
also,  that  are  found  to  be  greatly  benefited  by  sea  voyages;  more  partic- 
ularly long  sea  voyages,  taking  them  through  a  variety  of  climate  upon 
the  ocean,  but  usually  avoiding  the  higher  latitudes  and  colder  parts  of 
the  ocean  climate. 

In  speaking  of  the  benefits  of  change  of  climate  during  the 
first  stage  of  tuberculosis,  I  must  insist  especially  upon  the  bene- 
fits of  changes  which  are  either  permanent  or  of  protracted  duration. 
The  very  common  custom  of  making  visits  to  the  milder  climates  during 
two  or  three  of  the  worst  months  of  the  year,  and  returning  to  the  same 
influences  under  which  the  disease  was  originated  the  rest  of  the  year, 
while  productive  of  some  benefit  by  retarding  the  progress  of  the  disease 
and  prolonging  life,  very  rarely  is  efficient  in  actually  arresting  the  devel- 
opment of  tubercle  or  rendering  that  already  developed  abortive.  You 
will  perceive,  gentlemen,  by  these  remarks  in  relation  to  the  adaptation 
of  climates  to  particular  classes  of  tubercular  patients,  that  much  discrimi- 


468  PHTHISIS. 

nation  and  good  judgment  must  be  exercised  if  we  would  givo  to  this  largo 
class  of  patients  the  degree  of  benefit  to  which  they  are  entitled.  It  is  not 
enough  that  the  physician  should  by  careful  physical  exploration  ascertain 
the  existence  of  the  early  stage  of  tuberculosis  and  simply  tell  his  patient 
to  aro  to  a  mild  and  dry  climate,  but  it  is  equally  incumbent  upon  him  to 
inquire  carefully  into  his  patient's  previous  history,  training  and  habits, 
and  into  the  particular  circumstances  under  which  his  symptoms  became 
aggravated,  and  the  relative  influence  of  cold  and  warmth  at  different 
seasons  of  the  year,  that  he  may  select,  intelligently,  the  kind  of  climate 
as  to  altitude,  temperature,  dryness,  as  well  as  the  degree  of  exercise  and 
outdoor  exposure  which  is  best  adapted  for  benefiting  each  individual 
case.  I  am  satisfied,  from  long  observation,  that  the  lack  of  discrimina- 
tion in  these  respects,  together  with  the  neglect  to  enjoin  a  sufficient  de- 
crree  of  permanency  in  the  changes  made,  has  rendered  almost  nugatory 
a  laro^e  part  of  the  eiTorts  made  by  consumptive  invalids  for  the  recovery 
of  their  health. 

The  indications  for  treatment  in  the  second  stage  of  tubercu- 
losis, when  the  patient  begins  to  have  plain  indications  of  softening 
in  the  tubercular  masses  and  those  inflammatory  engorgements  or  low 
grades  of  circumscribed  pneumonic  attacks  in  the  lung  tissue  contiguous 
to  the  tubercular  mass,  which  usually  constitute  the  first  symptoms  that 
awaken  the  patient  and  his  friends  to  the  necessity  for  seeking  profes- 
sional advice,  are,  as  far  as  practicable,  the  continuance  of  all  those 
measures  calculated  to  sustain  and  improve  the  processes  of  assimilation 
and  nutrition,  and  in  addition  the  prompt  and  judicious  counteraction  of 
those  inflammatory  congestions  and  exudations  in  the  tubercuLited  por- 
tions of  the  lung  which  so  frequently  recur  during  this  stage  of  the  dis- 
ease. It  is  in  reference  to  the  warding  off  of  these  inflammatory  attacks, 
and  keeping  the  lung  tissue  as  long  as  possible  free  from  inflammatory 
exudation  and  suppuration  that  the  treatment  at  present  most  in  vogue 
for  consumptive  patients  is  defective. 

Reo-arding  the  disease  as  one  of  general  impairment  and  the  great  ob- 
ject to  be  accomplished,  that  of  improving  and  sustaining  nutrition,  the 
profession  has  recommended  too  indiscriminately  the  use  of  rich  food, 
alcoholic  drinks,  and  active  exercise,  without  due  regard  to  the  existence 
of  those  frequent  intercurrent  attacks  of  genuine  inflammation  in  the 
pulmonary  tissue  containing  the  tubercular  deposits.  The  physician  in 
this  second  stage  should  be  constantly  on  the  alert  for  these  attacks,  and 
promptly  direct  remedies  for  allaying  the  morbid  excitability  of  the  irri- 
tated pulmonary  tissue  and  lessening  the  vascular  congestion,  thereby 
mitigating  the  cough,  soreness,  feverishness,  and  postponing,  if  not 
preventing  the  establishment  of  the  suppurative  process,  and  all  its  de- 
structive consequences.  It  is  often  as  necessary',  on  a  fresh  exacerbation 
of  feverishness,  soreness  in  the  chest,  increased  cough,  and  quick  pulse, 
that  the  patients  be  placed  at  rest,  in  pure  air,  and  limited  to  a  well 
selected  diet,  and  given  mild  anodyne  expectorants  with  emollient  ap- 
plications to  the  sore  part  of  the  chest,  until  these  symptoms  disappear  or 
are  much  relieved,  as  it  would  be  in  similar  attacks  without  any  tuberculnr 
complications.  But  this  fact  is  often  overlooked,  and  patients  encouraged 
to  ride,  walk  and  exercise  every  day,  when  a  week  or  two  of  rest  with 
proper  treatment  would  effectually  remove  these  symptoms  and  place  the 
patients  in  a  condition,  where  the  cautious  resumption  of  daily  exercise, 
gradually  increased,  and  a  return  to  all  those  remedies  and  influences 
which  tend  to  strengthen  and  improve  the  nutritive  processes  and  the 
efficiency  of  the  respiratory  function  would  be  well  borne  and  highly 
beneficial. 


TREATMENT.  469 

I  have  seen  cases  not  infrequently  where  the  patients  were  suffering  with 
all  the  complex  indications  of  inflammatory  action  in  the  connective  tis- 
sue around  the  tubercular  masses,  who  had  been  ordered  directly  to 
change  climate,  take  free  outdoor  exercise  and  a  liberal  diet.  Some  of 
these  cases  resulted  in  a  general  pneumonic  attack,  diffuse  suppuration 
and  death  of  the  patients,  vi^hile  the  condition  of  others  was  simply  made 
worse.  The  remedies  which  1  have  found  most  efficient  in  warding  off 
these  inflammatory  attacks,  lessening  cough,  rendering  the  expectoration 
easy,  promoting  rest  at  night,  and  yet  producing  very  little  impairment  of 
appetite  or  digestion,  has  been  a  combination  of  muriate  of  ammonia,  tar- 
trate of  antimonium  and  potassium,  and  sulphate  of  morphia,  dissolved  in 
the  syrup  of  liquorice  in  such  proportions  that  four  cubic  centimeters  or  one 
teaspoonful  would  contain  four  decigrams  (gr.  vi)  of  the  first,  four  milli- 
grams (gr.  1-16)  of  the  second,  and  five  milligrams  (gr.  1-12)  of  the  third. 
This  quantity  may  be  given  every  four,  six  or  eight  hours  according  to 
the  severity  of  the  symptoms.  As  soon  as  the  more  active  inflammatory 
symptoms  have  abated  and  this  mixture  is  required  only  morning  and 
evening,  such  patients  may  profitably  commence  taking  almost  anv  ol 
those  agents  that  promote  nutrition,  such  as  the  compound  syrup  of  the 
hypophosphites  with  cod-liver  oil,  syrupof  the  iodide  of  calcium,  lactophos- 
phate  of  calcium,  and  in  some  instances  the  syrup  of  the  iodide  of  iron. 
Quinine  also  is  frequently  given  with  benefit  in  doses  of  thirteen  to  twenty 
centigrams  (gr.  ii  to  iii)  three  times  a  day. 

In  cases  liable  to  hemorrhages,  either  with  or  without  febrile  exacer- 
bations and  inflammatory  symptoms,  ergot  or  preferably  ergotin,  becomes 
one  of  our  best  remedies.  During  the  hemorrhage  the  ergotin  may  be 
given  in  doses  of  from  thirteen  to  twenty  centigrams  (gr.  ii  to  iii)  every 
two  or  three  hours,  according  to  the  activity  of  the  hemorrhage.  After 
the  blood  has  ceased,  the  patient  will  be  benefited,  and  a  recurrence 
of  hemorrhage  prevented  by  continuing  thirteen  centigram  doses  of  the 
erg(jtin  three  times  a  day,  for  one,  two  or  even  three  weeks.  And  if  night 
sweats  have  supervened,  as  occasionally  happens  in  the  last  half  of  the 
night,  two  decigrams  (gr.  iii)  of  the  ergotin,  taken  between  eight  and 
nine  o'clock  in  the  evening,  will  be  one  of  the  best  remedies  for  arresting 
these  sweats.  During  the  second  stage  of  tuberculosis,  the  question  of 
change  of  climate  and  the  degree  of  outdoor  exercise  that  the  patient  shall 
take  must  depend  much  upon  the  extent  of  the  tubercular  deposit  and 
the  degree  to  which  the  lung  tissue  has  become  involved  in  morbid 
changes. 

A  large  proportio  n  of  the  cases  in  this  stage  will  be  temporarily  bene- 
fited by  going,  during  the  cold  and  transition  periods  of  the  year,  to  a 
mild  and  dry  climate,  with  only  a  moderate  elevation.  The  higher  eleva- 
tions of  five,  six  or  even  four  thousand  five  hundred  feet  should  be 
avoided.  If  they  are  ever  reached  it  should  be  done  gradually  at  succes- 
sive stages  from  the  lower  to  the  higher  elevations  alluded  to.  But  if  the 
patient  finds  a  climate  in  which  the  progress  of  tubercular  changes  is  ar- 
rested, and  reparative  processes  are  so  far  established  as  to  indicate  re- 
covery for  the  time  being,  he  should  be  induced,  if  practicable,  to  make 
that  climate  his  permanent  home.  For  experience  has  abundantly  shown 
that  these  temporary  appearances  of  returning  health  are  often  delusive; 
and  if  the  patient  returns  to  the  same  climate  in  which  his  disease  origi- 
nated, characterized  b}-  cold,  damp,  and  frequent  changes,  as  in  the  north- 
ern belt  of  this  country,  he  will  rarely  pass  through  the  first  cold  season 
without  having  all  the  phenomena  of  his  disease  renewed  in  an  active 
form.     When  the  disease    has  passed  beyond  this  second  stage,  and  the 


470  PHTHISIS. 

suppurative  processes  have  completed  excavations  of  more  or  less  size  in 
the  structure  of  the  lungs,  with  many  additional  places  not  excavated  but 
in  a  softened  and  purulent  condition,  with  much  emaciation,  it  is  very 
rare  that  any  change  of  climate  proves  either  beneficial  or  desirable.  And, 
at  such  a  period  in  the  advancement  of  the  disease,  to  induce  the  patient 
to  tax  his  weary  limbs  and  emaciated  form  with  the  effort  to  find  a  better 
climate,  and  perhaps  die  among  strangers,  is  a  cruelty  instead  of  an  appro- 
priate remedy.  The  only  cases  in  the  third  stage  of  advancement  that  oifer 
a  hope  of  recovery  from  any  such  change  are  those  rare  instances  in  which 
the  deposits  have  been  limited  to  the  upper  portion  or  apex  of  a  single 
lung.  In  such,  although  the  part  affected  may  have  passed  through  the 
three  successive  changes  and  left  a  well  marked  excavation  furnishing 
purulent  sputa  and  moderate  hectic  symptoms,  yet  the  patient  still  has 
one  whole  lung  and  the  greater  part  of  the  other  left  intact,  which  should 
be  sufficient  for  carrying  on  the  respiratory  function  efficiently  until  the 
reparative  processes  have  restored  the  diseased  parts  by  granulation  and 
ultimate  cicatrization,  and  brought  the  patient  to  recovery.  I  have  seen 
some  instances  in  which  this  result  was  obtained  without  a  change  of  cli- 
mate. A  judicious  and  favorable  change,  however,  will  facilitate  it  and 
render  its  accomplishment  more  certain.  But  where,  as  in  the  great  mass 
of  cases,  the  suppurative  process  has  involved  a  considerable  portion  of 
one  or  of  both  lungs,  there  is  no  rational  hop©  of  the  patient's  living 
till  repair  can  take  place.  Consequently,  both  the  interests  of  the  patient 
and  his  friends,  as  well  as  the  common  principles  of  humanity,  require 
that  such  parties  be  candidly  informed  of  the  condition  and  prospects  of 
the  patient.  At  the  same  time  give  them  the  comfort  that  can  be  ob- 
tained by  quiet,  rest,  a  home  among  their  friends,  as  good  air  as  can  be  ob- 
tained, careful  selection  of  nourishment  and  repression  of  the  more  troub- 
lesome symptoms  by  appropriate  remedies  and  you  will  do  as  much  to 
alleviate  the  suffering  and  protract  the  life  of  your  patient  as  the  nat- 
ure  of  such  cases  will  permit. 

The  same  combination  of  anodynes  and  expectorants  as  were  men- 
tioned in  the  second  stage  may  still  be  taken  at  r.ight,  to  lessen  cough 
and  promote  rest.  The  use  of  such  tonics  as  syrup  of  the  iodide  of  iron, 
sometimes  combined  with  glycerine,  given  in  appropriate  doses,  largely 
diluted  with  water,  will  materially  lessen  the  suppurative  process,  and  the 
use  of  ergotin  in  sufficient  doses,  once  or  twice  in  twenty-four  hours,  will 
greatly  lessen  the  night  sweats.  The  particular  remedies  to  be  used, 
however,  must  be  selected  by  the  good  judgment  of  the  practitioner,  ac- 
cording to  the  indications  in  each  individual  case.  I  have  thus  described 
the  treatment  in  the  different  stages  of  tubercular  disease  in  the  lungs 
with  a  view  of  giving  you  the  principles  on  which  the  treatment  should 
be  based,  and  remedies  should  be  selected,  whether  hygienic,  climatic, 
or  medicinal  rather  than  to  multiply  suggestions  of  individual  remedies. 
I  am  fully  satisfied  that  there  are  large  numbers  of  cases  of  tubercular 
disease  of  the  lungs  which  if  diagnosticated  and  treated  on  the  principles 
that  I  have  indicated  in  the  early  stage  would  be  rendered  abortive,  the 
health  preserved,  and  a  few  would  be  snatched  from  the  further  progress 
in  the  second  stage  of  the  disease.  And  yet,  with  all  our  care,  and  the  most 
intelligently  directed  efforts  to  give  this  class  of  patients  all  the  chances 
that  the  present  status  of  medicine  and  hygiene  will  afford,  a  very  large 
majority  will  progress  to  a  fatal  result.  And  pulmonary  tuberculosis  will 
probably  continue  for  ages  to  come,  as  it  has  been  during  the  ages  past,  one 
of  the  most  direful  diseases  known  to  the  human  race;  destroying  more 
lives  by  far  annually  among  the  civilized  portions  of  the  human  race  than 
any  one  of  all   the  dreaded  epidemics  and  scourges  that  can  be   named. 


PEEICAKDITTS.  471 


LECTURE   XLVIII. 


Inflamrmtions  of  the  Central  Organs  of  Circulation  —  The     iflferent    structures    involved  — 
Pericarditis— Its  Causes,  Symptoms,  Anatomical  Changes,  Diagnosis,  Prognosis  and  Treatment. 

GENTLEMEN:  I  now  invite  your  attention  to  tlie  inflammations  affect- 
ing the  vascular  system  or  orcrans  of  circulation.  These  organs  include 
the  pericardium  and  the  heart  as  the  center  of  the  system,  and  the  arteries 
and  veins,  capillaries  and  lymphatics.  The  diseases  of  the  arteries,  veins 
and  lymphatics  are  so  largely  connected  with  injuries  and  affections  of  a 
surgical  character,  that  the  inflammations  affecting  them  are  fully  treated  of 
in  works  on  surgery,  and  instruction  concerning  them  is  usually  included 
•in  the  courses  on  surgery  in  all  the  medical  schools.  I  shall,  therefore, 
pass  them  by  with  the  exception  of  the  aorta.  This  leaves  for  our  consid- 
eration, chiefly,  the  central  organs  of  the  circulation  composed  of  the  peri- 
cardium, heart  and  the  aorta.  Inflammation  maybe  limited  to  the  serous 
membrane  called  the  pericardium,  which  surrounds  the  heart  in  the  form  of 
a  sac  and  is  reflected  over  its  exterior  surface.  It  is  then  called  pericarditis. 
It  may  be  limited  to  the  muscular  structure  of  the  heart  and  is  then  called 
either  carditis  or  myocarditis.  It  may  be  restricted  to  the  interior  cavi- 
ties of  the  heart,  including  the  valves  and  columnse  carnge,  and  is  then 
called  endocarditis.  The  two  latter,  myocarditis  and  endocarditis  are 
so  generally  associated  together  in  the  same  case,  that  for  practical  pur- 
poses they  may  be  considered  under  the  same  head.  You  may  have  in- 
flammation affecting  these  various  structures,  occurring  more  or  less  at  all 
periods  of  life,  and  in  both  sexes,  but  not  as  frequently  as  we  have  inflam- 
mation of  the  organs  of  respiration.  For  an  idiopathic,  primary  inflam- 
mation of  any  of  the  cardiac  structures  occurring  independently  of  other 
and  more  general  diseases,  is  comparatively  rare.  You  may  also  meet  with 
cases  of  inflammation  in  these  structures  presenting  all  grades  of  activity, 
from  the  most  acute  and  rapid  in  progress  to  the  most  chronic  and  pro- 
tracted in  duration. 

Pericarditis. — I  shall  first  direct  your  attention  to  inflammation  of 
the  serous  membrane  called  pericardium.  Acute  pericarditis  is  of  fre- 
quent occurrence  in  connection  with  acute  rheumatism  or  rheumatic  fe- 
ver, also  as  a  complication  of  renal  diseases,  more  particularly  the  different 
forms  of  albuminuria  and  structural  diseases  of  the  kidneys,  and  less  fre- 
quently as  a  complication  or  as  a  sequel  of  eruptive  fevers,  more  particularly 
scarlatina  and  diphtheria.  According  to  the  statistics  of  some  recent  writ- 
ers, one  ease  out  of  every  six  of  rheumatism  of  an  acute  character  be- 
comes complicated  with  pericarditis.  This,  however,  is  a  very  much 
higher  ratio  than  has  occurred  under  my  observation  during  a  period  of 
many  years  both  in  private  practice  and  in  the  hospitals.  In  referring  to 
some  of  the  records  I  am  quite  sure  that  taking  both  classes  of  cases, 
those  in  private  practice  and  in  the  hospitals,  I  have  not  met  with  pericarditis 
in  connection  with  any  grade  of  rheumatic  disease  in  a  larger  proportion  of 
cases  than  one  in  thirty.  When  it  occurs  in  connection  with  rheumatism 
it  is  not  in  the  form  of  metastasis  or  translation  of  the  rheumatic  inflam- 
mation from  the  fibrous  structures  or  articulations  to  the  pericardivtm,  but 
is  the  result  of  the  action  of  the  same  cause  pervading  the  blood,  that 
gives  rise  to  inflammation  in  any  other  portion  of  the  body,  and  its  occur- 
i-ence  in  the  pericardium  in  no  wise  lessens  its  coincident  progress  in  ei- 


472  PERICAEDITIS. 

ther  the  articulations  or  other  structures.  Its  occurrence  in  connection  with 
renal  disease  is  traceable  to  the  effects  of  retained  urea  or  an  excess  of  the 
constituents  of  urine  in  consequence  of  the  inability  of  the  kidneys  to  per- 
form their  office.  It  is  probable  that  it  originates  from  a  similar  cause 
when  it  occurs  coincidently  with,  or  is  a  sequel  of  the  eruptive  fevers;  it 
being  most  likely  to  occur  where  the  function  of  the  kidneys  has  been 
interfered  with  prior  to  the  occurrence  of  the  periodical  disease.  The  oc- 
currence of  acute  pericarditis  aside  from  its  connection  with  the  general 
diseases  and  pathological  conditions  already  alluded  to,  and  independent- 
ly of  traumatic  influences,  such  as  wounds  and  injuries,  is  very  rare.  Asa 
disease  arising  from  atmospheric  influences  such  as  exposure  to  cold,  sud- 
den changes,  dampness,  with  which  inflammations  of  the  respiratory  organs 
are  so  intimately  connected,  pericarditis  is  hardly  known.  I  have  met 
with  two  or  three  instances,  occurring  in  patients  who,  after  being  subject- 
ed to  severe  and  protracted  muscular  exercise,  causing  free  perspiration, 
were  suddenly  exposed  to  sufficient  cold,  damp  air  to  make  a  chilling  im- 
pression upon  the  system.  These  attacks  were  undoubtedly  the  result  of 
a  sudden  impression  of  cold  and  damp  on  a  state  of  the  system  rendered 
more  susceptible  by  the  immediately  preceding  exercise.  In  a  few  in- 
stances 1  have  met  with  pericarditis  as  a  complication  and  coincident  of 
pleuritis;  not  apparently  caused  by  extension  of  the  disease  from  the 
pleura  to   the  pericardium,  but  both  occurring  from  the  same  cause. 

Symptoms. — In  a  large  majority  of  cases  of  acute  pericarditis  the 
disease  manifests  itself  abruptly,  by  initial  chilliness,  coincident  with 
pain,  and  a  sense  of  oppression  in  the  region  of  the  heart.  The  chilliness 
is  of  very  brief  duration,  sometimes  hardly  noticeable,  and  is  followed  by 
acute  pain,  resembling  in  all  respects  the  pains  described  as  characterizing 
acute  pleurisy,  only  they  originate  more  directly  in  the  cardiac  region,  and 
often  radiate  backward  under  the  left  scapula,  and  sometimes  upward  to 
the  top  of  the  shoulder.  The  pain  is  not  continuous,  but  rather  paroxysmal, 
and  is  aggravated  much  by  full  inspirations  or  any  other  motions  of  the 
body  or  chest  which  may  cause  movements  of  the  pericardium,  in  its  re- 
lation to  the  parts  around  it.  The  acute  pains  in  the  pericardial  region 
are  accompanied  from  the  beginning  by  increased  frequency  of  pulse, 
short  and  hurried  breathing,  increase  of  temperature,  constituting  a  mod- 
erate grade  of  general  fever;  more  or  less  flushing  of  the  face,  a  decidedly 
anxious  expression  of  countenance,  and  a  frequent,  short,  voluntarily  sup- 
pressed cough  with  no  expectoration.  The  secretions  generally  are 
diminished,  the  urine  being  more  scanty  and  higher  colored  than  natural. 
A  thin  whitish  fur  forms  upon  the  tongue,  and  there  is  considerable  thirst. 
In  some    cases  there  is  severe  frontal  headache.     In  a  few  instances  the 

f)ain  in  the  head  is  accompanied  by  more  or  less  tendency  to  delirium,  the 
atter  being  sometimes  sufficiently  prominent  to  divert  attention  from  the 
real  seat  of  the  disease  in  the  pericardium.  In  its  acute  form,  the  course 
of  the  disease  is  usually  rapid,  the  pulse  becoming  more  frequent  and  less 
full,  until  it  ranges  from  one  hundred  and  twenty  to  one  hundred  and  forty 
per  minute,  and  is  easily  compressible. 

There  is  also  a  great  sense  of  oppression  or  fullness  in  the  cardiac 
region,  increased  by  attempting  to  assume  the  recumbent  position.  IjOSS 
of  flesh,  paleness,  and  still  more  anxiety  in  the  expression  of  the  counte- 
nance, more  frequent,  short,  dry  cough,  voluntarily  suppressed  as  much 
as  possible  to  avoid  the  pain  that  it  occasions  is  also  noticeable.  In  cases 
of  the  greatest  degree  of  intensity  these  symptoms  increase  rapidly,  not  in- 
frequently occasioning  feelings  of  syncope,  some  degree  of  mental  wander- 
ing, persistent  disposition  to  keep  the  upright  position  of  the  body  or  to 


SYMPTOMS.  473 

lean  a  lictle  forward.  The  heart's  action  is  irregular  and  feeble.  There  is 
coldness  of  the  extremities,  blueness  under  the  nailsand  of  the  lips,  short, 
panting-  respiration,  g-reat  desire  to  sleep  without  the  ability  to  do  so,  the 
patient  generally  starting  up  as  if  frightened,  almost  as  soon  as  conscious- 
ness was  lost  in  sleep.  The  patient  now  becomes  extremely  weary,  pale, 
haggard,  with  sometimes  a  little  puffiness  or  oedema  of  the  eyelids,  and  if 
not  relieved  by  treatment  before  the  middle  or  latter  part  of  the  second 
week,  the  heart  becomes  so  embarrassed  from  the  exterior  pressure  of  the 
pericardial  elfusion  that  it  is  no  longer  capable  of  maintaining  the  circu- 
lation, and  the  patient  dies. 

When  the  disease  occurs  as  an  idiopathic  affection  without  complication 
with  renal  or  other  prior  diseases,  it  rarely  presents  as  severe  a  course  as 
I  have  just  indicated.  The  symptoms,  however,  are  the  same,  only  less 
intense,  and  after  about  two  weeks  the  patient  begins  gradually  to  im- 
prove, the  fever  abates,  the  pulse  becomes  a  little  slower  and  more 
steady,  the  sense  of  oppression  in  the  chest  less,  and  the  improvement  in 
these  respects  increases  gradually  from  day  to  day  until,  during  the  fourth 
week,  the  patient  reaches  convalescence.  In  some  cases  there  will  be 
shortness  of  breath  and  inability  to  exercise  for  a  longer  period  than 
this;  often  as  long  as  from  six  to  seven  weeks  from  the  commencement 
of  the  attack.  This  protraction  of  the  case  arises  generally  from  the  con- 
tinuance of  irritative  action  and  the  slowness  of  absorption  of  the  effused 
fluid  in  the  pericardium.  A  great  majority  of  cases  run  their  course 
and  have  a  tendency  to  terminate  in  recovery  in  from  three  to  four  weeks. 
A  few  may  even  terminate  in  convalescence  in  two  weeks  from  the 
commencement  of  the  attack.  When  the  disease  occurs  as  a  complica- 
tion of  rheumatism  the  symptoms  are  essentially  the  same  as  I  have  de- 
tailed, throughout  its  entire  course,  with  the  exception  of  the  absence  of 
initial  chilliness  and  the  modifications  in  the  general  grade  of  fever  pro- 
duced by  the  accompanying  general  rheumatic  aifection.  In  the  cases 
associated  with  rheumatism  the  tendency  is  generally  to  recovery,  only  a 
small  proportion  of  the  whole  number  of  cases  terminating  fatally. 

When  the  disease  originates  from  retained  renal  excretions  or  from 
retention  of  similar  excretory  matter  in  connection  with  the  eruptive 
fevers,  it  is  very  much  more  likely  to  progress  unfavorably  and  terminate 
in  death.  The  latter  class  of  cases  usually  occur  in  conditions  of  the  sys- 
tem already  anremic  and  inclined  to  take  on  readily  copious  serous  effu- 
sions. And  in  the  cases  of  complication  with  renal  disease  the  patient  is 
not  infrequently  affected  with  general  anasarca  prior  to  the  superven- 
tion of  the  pericardial  inflammation.  In  consequence  of  this  the  latter 
affection  is  accompanied  by  early  and  unusually  copious  serous  effusion, 
and  is  very  liable  to  produce  fatal  compression  of  the  heart  before  it  can 
be  controlled  by  remedies.  Some  of  this  class  of  cases  may  reach  a  fatal 
result  within  twenty-four,  forty-eight  or  seventy-two  hours  from  the  time 
of  the  commencement  of  the  attack. 

Thus  far  I  have  spoken  only  of  the  general  symptoms  and  progress  of 
the  disease,  which,  though  sufficiently  characteristic  to  afford  a  pretty  safe 
diagnosis,  yet,  they  may  be  so  closely  simulated  by  pleuritic  inflammation 
Hnd  perhaps  some  other  affections  that  it  is  always  desirable  to  note  care- 
fully the  signs  to  be  obtained  by  auscultation  and  percussion.  If  these 
are  noted,  they  are  sufficiently  characteristic  to  render  the  diagnosis  easy 
and  reliably  certain.  During  the  first  stage  of  acute  or  subacute  inflam- 
mation the  pericardial  membrane  is  simply  intensely  injected,  tumefied 
and  dryer  than  natural.  The  membrane  covering  the  exterior  of  the 
heart  and  that  lining  the  pericardial  sac  have  their  surfaces  in  contact,  and 


474  PERICARDITIS. 

the  motions  of  the  heart  rub  these  surfaces  asjainst  each  other,  thereby 
producing  in  this  first  stage  of  the  inflammatory  process  a  rubbing  or  fric- 
tion sound  precisely'  of  the  same  nature  as  the  friction  sound  that  I  have 
described  when  speaking  of  the  first  stage  of  acute  pleuritis.  It  is  generally 
heard  as  a  double  sound  both  in  the  systolic  and  diastolic  movements  of  the 
heart,  and  while  of  the  same  character  as  the  friction  in  pleuritis  it  is  dis- 
tinguished from  the  latter  by  its  occurring  synchronous  with  the  move- 
ments of  the  heart  and  nob  with  those  of  respiration.  This  friction  sound 
is  usually  heard  most  distinct  and  earliest  over  the  central  part  of  the  car- 
diac region  near  the  base  of  the  heart.  And  in  some  cases  it  may  continue 
to.  be  heard  in  this  region  throughout  the  whole  course  of  the  disease. 
In  the  great  majority  of  acute  and  subacute  cases  it  ceases  to  be 
heard  somewhere  between  the  beginning  of  the  second  and  the  end  of 
the  fourth  day  of  the  disease.  When  this  disappears  the  cardiac  sounds 
appear  more  distant  and  the  imoulse  fails  to  be  felt  as  plainly  against  the 
walls  of  the  chest  as  in  the  natural  condition  or  as  existed  at  the  commence- 
ment of  the  disease. 

This  more  distant  beat  of  the  heart  and  lessening  of  the  impulse  occur- 
ring at  the  same  time  with  diminution  or  disappearance  of  the  friction 
sound  would  of  itself  suggest  the  occurrence  of  serous  effusion  sufficient 
t  >  separate  the  two  surfaces  of  the  pericardium  and  remove  the  heart  a 
little  farther  from  the  walls  of  the  chest.  If  we  now  practice  percussion 
carefully  we  shall  find  that  the  area  of  cardiac  dullness  is  decidedly  in- 
creased, more  particularly  transversely  on  a  line  with  the  lower  margin  of 
the  nipple,  and  to  a  very  appreciable  extent  also  vertically;  even  making 
the  area  or  extent  over  which  the  cardiac  dullness  is  well  marked,  from 
one  third  to  double  the  natural  size.  At  the  same  time  in  many  cases 
there  is  a  perceptibly  increased  fullness  or  bulging  of  the  cardiac  region 
particularly  noticeable  in  the  intercostal  spaces  in  the  center  of  the  car- 
diac region.  These  physical  signs  taken  in  connection  with  the  general 
symptoms  and  the  location  of  the  pains  the  patient  suffers  are  sufficient 
to  distinguish  the  disease  from  any  other  inflammatory  condition  within 
the  chest.  They  are  not  only  sufficient  to  distinguish  it  from  inflammations 
of  other  structures,  but  they  are  sufficient  also  to  indicate  the  stage  of  the 
disease,  and  the  pathological  changes  which  have  taken  place  during  its 
progress. 

Pathological  Changes. — You  will  have  noticed  from  the  description  I 
have  given  that  pericarditis  is  divisible  in  its  progress  into  the  same  num- 
ber of  stages  as  pleuritis.  The  pathological  changes  are  also  identically 
the  same:  that  is,  we  have  first,  intense  injection  or  accumulation  of  blood 
in  the  vessels  of  the  pericardium,  giving  it  an  intensely  red  and  tumefied 
appearance  during  which  we  have  friction  sound.  In  from  twenty-four 
to  forty-eight  hours,  usually,  this  engorgement  is  followed  by  exu- 
dation. In  the  large  majority  of  cases  the  exudation  is  of  a  mixed  char- 
acter, partly  plastic,  forming  a  layer  of  nrganizable  material  on  the  surface 
of  the  inflamed  membrane,  and  partly  serous,  which  gives  rise  to  a  more 
or  less  rapid  accumulation  of  a  serous  fluid  in  the  pericardial  sac.  The 
relative  proportion  of  these  two  kinds  of  exudation  varies  much  in  differ- 
ent eases.  In  a  very  few  occurring  in  individuals  whose  blood  is  highly 
plastic  the  exudation  is  entirely  of  a  plastic  organizable  character  and 
rapidly  solidifies  into  a  thick  layer  of  false  membranous  material  which 
closely  adheres  to  the  inflamed  surfaces,  and  soon  forms  a  bond  of  union 
between  them,  causing  adhesion  of  the  exterior  pericardial  membrane  to 
that  covering  the  body  of  the  heart.  The  motions  of  the  heart  frequently 
cause  this  layer  of  plastic  material  to  be  worked  into  little  masses  or  tufts, 


ANATOMICAL    CHANGES.  475 

that  give  to  the  surfaces  the  a])pearance  of  being  covered  with  a  ragged, 
fibrinous  layer  with  tuft-like  projections  which  had  been  united  with  the 
opposed  surfaces.  When  tlie  patient  survives  in  this  class  of  cases  this 
plastic  exudation  forms  a  bond  of  permanent  union  between  the  two  sur- 
faces of  the  pericardium. 

Occasionally  this  will  be  so  complete  that  the  pericardial  sac  is  entirely 
obliterated.  In  other  instances  the  adhesions  will  occupy  only  a  part  of 
the  surfaces,  leaving  other  portions  free.  At  first  the  adhesions  offer  some 
embarrassment  to  the  cardiac  action  and  give  rise  in  the  feelings  of  the 
patient  to  more  or  less  inconvenience  and  sense  of  oppression.  This 
gradually  disappears  with  time,  and  the  modified  friction  sound  that  con- 
tinues throughout  the  whole  course  of  the  disease,  and  that  may  be  pro- 
tracted even  into  the  period  of  convalescence,  eventualy  disappears.  The 
adventitious  tissue  becomes  smooth  and  attenuated  to  such  a  degree 
as  to  cause  no  longer  any  abnormal  sound.  In  a  larger  number  of  cases 
the  plastic  exudation  is  sufficient  only  to  form  a  layer  of  white  fibrinous 
material  unequally  distributed  over  the  inflamed  surface,  and  to 
cause  small  patches  of  adhesion  near  the  base  of  the  heart,  while  the 
serous  efi'usiou  accumulates  with  such  rapidity  as  to  separate  all  the  free 
surfaces  of  the  pericardium  from  each  other,  and  to  give  rise  sometimes  to 
a  degree  of  distension  of  the  sac  and  consequent  pressure  upon  the  body 
of  the  heart,  so  as  to  embarrass  its  action.  It  is  this  accumulation  of* 
serous  fluid  in  the  pericardial  sac  that  in  severe  cases  causes  the  extreme 
sense  of  fullness,  difficulty  in  lying  down,  and  irregularity  and  weakness 
of  the  heart,  to  so  great  a  degree  as  to  occasion  a  fatal  result.  More 
generally  the  pericardial  effusion  is  only  sufficiimt  to  produce  moderate 
distension. 

The  fluid  in  some  cases  is  clear,  and  in  others  slightly  turbid.  In  the 
latter  case  it  contains  some  white  corpuscles  and  pus  globules,  and  in 
rare  instances,  enough  of  the  red  corpuscles  of  the  blood  to  give  it  a 
tinge  of  redness.  Suppuration,  however,  in  the  pericardium  is  very  much 
more  rare  than  in  the  pleura.  Still  it  occasionally  occurs,  more  especially 
when  the  inflammation  has  supervened  upon  some  previous  impairment 
of  the  constitutional  condition  of  the  patient.  The  structural  changes 
in  the  inflamed  membrane  itself  are  simply  those  which  are  observed  in 
all  inflammations  of  structures  made  up  largely  of  connective  tissue. 
They  consist  in  an  increase  of  the  endothelial  cells  and  hypertrophy  of 
the  connective  tissue  itself.  If  you  follow  those  cases  of  pericarditis, 
that  result  in  extensive  adhesion  of  the  pericardial  sac  to  the  body  of; 
the  heart,  to  their  remote  consequences,  you  will  find  that  they  generally 
lead  very  slowly  but  surely  to  an  increased  growth  or  hypertrophy  of  the 
muscular  structure  of  the  heart;  so  gradually,  indeed,  that  it  requires 
many  years  in  some  cases,  before  this  hypertrophy  produces  sufficient 
inconvenience  to  attract  serious  attention.  In  a  few  instances,  however, 
the  progress  of  this  change  is  more  rapid,  and  in  addition  to  a  simple  in- 
creased muscular  growth,  you  find  more  or  less  dilatation  of  the  cavities 
of  the  heart,  making  the  increased  size  consist  partly  of  dilatation  and 
partly  of  muscular  hypertrophy. 

A  case  illustrating  the  slowness  of  these  changes  occurred  under  my 
observation  a  fevv  years  since,  in  which  I  had  the  opportunity  of  witnessing 
the  post  mortem  examination  of  the  patient  who  had  died  with  general 
dropsy,  which  was  preceded  one  or  two  years  by  constant  and  very  dis- 
tressing irregularity  and  inefficiency  of  cardiac  action,  rendering  him  wholly 
incapable  of  active  exercise;  yet  previous  to  these  last  two  years  he  had 
led  an  active  business  life,  being  very  rarely  confined  to  his  house  by  sick- 


470  PEKICAnDITIS. 

iiess,  making  no  complaint,  and  passing,  as  a  good  and  sound  subject  several 
times,  examinations  for  life  insurance.  As  his  family  physician  I  had  ex- 
amined him  several  times  in  the  course  of  the  twelve  years  prior  to  the  last 
two  without  detecting  any  other  fault  in  the  heart's  action  than  unusual 
slowness  of  beat  and  an  occasional  intermittence.  I  first  detected  the  slow- 
ness and  intermittence  of  his  pulse  on  his  recovery  from  an  attack  of  epi- 
demic cholera  in  1854.  And  yet  on  the  post  mortem  examination  the  peri- 
cardium was  found  so  closely  adherent  to  the  entire  surface  of  the  body  of 
the  heart  as  to  leave  not  one  square  inch  of  that  surface  free,  and  so  close  as 
to  require  actual  dissection  with  the  scalpel  to  sepaiate  one  layer  of  peri- 
cardium from  the  other.  Nearly  the  entire  circumference  of  the  pericar- 
dium, also,  contained  thin  laminjB  of  bone,  in  some  places  a  line  in 
thickness,  and  the  different  plates  so  closely  touching  each  other  a  to 
form  an  almost  continuous  bony  case  around  the  heart.  Plates  of  bone 
were  also  found  in  a  few  of  the  arteries;  quite  large  ones  in  the  aorta,  and 
in  various  places  where  examination  was  made  even  as  remote  as  the  femoral 
artery  in  the  middle  section  of  the  thigh.  The  muscular  structure  of  the 
left  ventricle  was  one  third  thicker  than  natural;  both  ventricles  were  di- 
lated to  a  larger  size  than  natural,  making  the  whole  heart  nearly  twice 
its  normal  size.  In  closely  examining  the  previous  history  of  the  patient 
it  was  found  that  these  pericardial  adhesions  had  resulted  from  an  attack 
of  acute  pericarditis  more  than  thirty  years  previously. 

Diagnosis. — In  describing  the  symptoms  and  physical  signs,  I  have  al- 
ready indicated  those  which  are  specially  diagnostic  of  this  form  of  dis- 
ease. Tiie  only  cases  in  which  they  are  liable  to  fail  in  constituting  a  safe 
guide,  are  those  rare  cases  of  pleuritis  in  which  the  latter  inflammation 
occurs  in  that  part  of  the  left  pleura  in  contact  with  the  pericardium. 
A  few  of  these  cases  have  been  found  to  yield  a  friction  sound  synchro- 
nous with  the  motions  of  the  heart,  although  the  pericardium  was  itself 
free  from  inflammation.  The  systolic  action  of  the  heart  produced  snfii- 
cient  motion  in  the  adjacent  pleura  to  occasion  a  friction.  These  cases  can 
usually,  however,  be  separated  from  the  friction  of  true  pericarditis  by 
noting  carefully  two  things:  first,  that  although  the  motions  of  the  heart 
produce  a  rubbing  or  friction,  the  respiratory  movements  also  produce  a 
friction.  After  carefully  watching  these  respective  movements  and  espe- 
cially having  the  patient  suspend  respiration  for  a  few  seconds  so  as  to  get 
the  movements  of  the  heart  separately,  then  resume  respiration,  usually  it 
can  be  ascertained  that  the  friction  sound  exists  with  the  respiratory 
movements  as  well  as  with  the  cardiac.  The  other  circumstances  which 
aid  in  the  diagnosis  are  that  this  friction,  when  dependent  upon  pleuritis, 
is  always  on  the  left  margin  of  the  cardiac  space,  and  is  also  audible  with 
tlie  respiratory  movement  alone  still  further  to  the  left,  showing  that  it  fol- 
lows the  position  of  the  pleura  and  not  of  the  pericardium. 

Prognosis. — You  will  infer  from  what  has  already  been  said  that  acute 
pericarditis,  when  not  associated  with  renal  disease  or  with  eruptive  fe- 
vers, has  a  general  tendency  to  recoverj-,  and  that  the  ratio  of  deaths  di- 
rectly from  the  disease  in  small.  This  remark  is  applicable  not  only  to 
strictly  idiopathic  pericarditis,  but  also  to  those  cases  of  the  disease 
which  arise  in  connection  with  acute  rheumatism.  On  the  other  hand  a 
very  large  proportion  of  the  cases  that  occur  as  complications  in  the  prog- 
ress of  acute  and  chronic  renal  diseases,  and  as  the  sequel  of  eruptive 
fevers,  prove  fatal. 

Treatment. — As  the  pericardmm  possesses  similar  anatomical  structure 
and  similar  functii  nal  relations  with  the  pleura,  and  as  the  inflammations 
affecting  it  pursue  the  same  general  course,  pass  through  the  same  stages, 


TREATMENT.  477 

and  produce  the  same  anatomical  changes  a3  in  inflammations  of  the 
pleura,  so  the  indications  for  treatment  are  in  all  respects  similar.  Hav- 
ing fully  discussed  the  subject  of  treatment  of  pleuritis,  only 
a  few  days  since,  I  do  not  deem  it  necessary  to  enter  into  the  same; 
detail  in  reference  to  the  disease  now  under  consideration.  The  princi- 
ples which  govern  us  in  the  management  of  acute  pericarditis  being 
identical  with  those  set  forth  for  pleuritis  in  the  several  stages, 
and  the  remedies  for  accomplishing  the  objects  being  also  the  same,  it  is 
sufficient  to  refer  vou  to  the  treatment  of  the  latter  disease  as  applicable 
to  the  former.  This  remark  applies  strictly  to  the  use  of  such  remedies  as 
bleeding,  general  and  local  and  cardiac  sedatives  in  the  first  stage  of  acute 
cases,  and  the  subsequent  use  of  remedies  to  promote  absor|ition  of  the 
effused  fluid,  and  diminish  the  plasticity  of  the  organizable  exudation  as 
alteratives,  diuretics,  and  counter-irritants. 

I  must  make  an  exception,  however,  in  reference  to  those  cases  which 
occur  in  the  progress  of  acute  articular  rheumatism.  In  these,  in  ad- 
dition to  such  treatment  as  I  have  recommended  in  the  diff"erent  stages 
of  pleuritis,  it  is  of  much  importance  that  the  patients  have  early  and 
efficient  treatment  with  alkaline  carbonates,  more  especially  the  carbonates 
a  d  bicarbonates  of  sodium  and  potassium,  sufficient  to  fully  neutralize  the 
supposed  acid  cause  of  the  rheumatic  inflammation.  And,  it  is  proper  to 
add,  that  as  the  exudations  in  the  earlier  stage  of  acute  rheumatic  inflam- 
mation are  pre-eminently  plastic  and  disposed  to  take  on  permanent 
organization,  the  use  of  mercurial  alteratives  as  an  item  in  the  treatment 
during  the  first  two  or  three  days  of  acute  pericardial  inflammation  may 
be  productive  of  decidedly  good  effects;  being  careful  always  not  to 
continue  their  use  until  the  establishment  of  salivation  or  anv  unpleasant 
symptoms  affect  the  mouth.  Those  cases  of  pericarditis  which  are  asso- 
ciated with  renal  disease,  or  occur  as  the  sequel  of  eruptive  fevers,  are  asso- 
ciated with  a  debilitated  and  generally  anajmic  condition  of  the  blood,  and 
consequently  they  will  not  bear  active  depletion,  either  by  loss  of 
blood  or  the  use  of  such  evacuants  as  are  calculated  to  further  deplete 
the  jjatient.  In  such  cases  the  chief  reliance  must  be  placed  upon  the 
use  of  such  anodynes  and  diuretics  as  will  lessen  the  pain,  keep  up  as 
efficient  action  of  the  kidneys  as  possible,  and  upon  the  cautious  use  of 
remedies  to  lessen  the  frequency  without  impairing  the  force  of  the  heart's 
action. 

Of  the- e,  the  fluid  extracts  of  the  cactus  grandiflora,  convallaria,  and 
digitalis  are  the  best.  To  these  may  be  added  blisters  or  some  form  of  effi- 
cient counter-irritation.  When  the  pericardial  inflammation  has  assumed 
a  chronic  form,  as  it  sometimes  does,  either  primarily  or  as  the  sequel  of 
an  acute  attack,  there  is  usually  a  tendency  to  continue  the  serous  exuda- 
tion causing  a  progressively  increased  distension  of  the  pericardial  sac 
and  pressure  upon  the  body  of  the  heart.  In  all  such  cases,  whether  they 
are  idiopathic,  or  whether  they  arise  as  complications  of  other  diseases,  the 
use  of  iodine  alteratives  internally,  aided  by  digitalis  and  persistent 
counter-irritation  by  a  succession  of  small  blisters,  will  constitute  the  best 
mode  of  treatment,  and  will  in  many  cases  check  the  further  progress  of 
the  disease  and  lead  to  the  ultimate  re-absorption  of  the  effused  fluid, 
and  the  recovery  of  the  patient.  But,  where  this  treatment  fails  and  the 
pressure  begins  to  assume  a  dangerous  degree  of  influence  over  the  heart's 
action,  threatening  the  life  of  the  patient,  no  further  time  should  be  lost 
without  resorting  to  the  puncture  of  the  pericardium  and  the  evacuation 
of  the  effused  fluid.  In  cases  requiring  such  puncture,  usually  the  disten- 
sion of  the  pericardium  is  such  as  to  have  increased  its  transverse  diame- 


478  ENDOCARDITIS. 

ter  more  than  one  half,  and  usually  the  most  favorable  place  for  the  punc- 
ture either  for  aspiration  or  any  other  method,  is  in  the  fifth  intercostal 
space,  perhaps  an  inch  or  an  inch  and  a  half  to  the  left  of  the  margin  of 
the  sternum.  This  may  be  varied  in  particular  cases,  and  the  practitioner 
should  judge  in  each  case  by  a  careful  examination  and  percussion  as  to 
the  exact  outline  of  the  pericardial  distension,  both  transversely  and  ver- 
tically, and  aim  to  make  his  puncture  over  the  most  prominent  and  fully 
distended  part  of  the  pericardial  sac.  In  the  large  majority  of 
cases  it  will  be  found  at  the  point  I  have  indicated.  The  op- 
eration of  tapping  the  pericardium  has  been  performed  a  suffi- 
cient number  of  times  to  show  that  it  is  not  only  justifiable,  but,  with 
a  sufficient  proportion  of  recoveries  from  cases  that  Avould  otherwise  have 
proved  fatal,  to  make  it  the  duty  of  the  practitioner  to  give  his  patient 
this  additional  chance  of  recovery.  Instead  of  using  the  aspirator  nee- 
dle and  removing  the  fluid  by  the  ordinary  process  of  aspiration,  it  is  bet- 
ter to  puncture  the  pericardium  with  a  trochar  to  which  is  fitted  a  David- 
son's syringe,  for  the  reason  that  the  stN'let  of  the  trochar  being  with- 
drawn leaves  no  sharp  point  to  wound  the  surface  of  the  heart  as  the  fluid 
is  drawn  off  and  the  distension  of  the  sac  diminishes.  In  those  cases  of 
pericarditis  which  occasionally  occur,  terminating  in  suppuration  and  pre- 
senting a  fluid  when  withdrawn,  either  wholly  or  partially  of  a  purulent 
cliaracter,  the  prognosis  is  very  much  more  unfavorable;  and  yet,  there 
are  on  record  several  cases  of  this  kind  that  ultimately  recovered.  There  is 
no  absolute  barrier  against  their  being  treated  in  the  same  manner  as 
cases  of  empyema  resulting  from  suj^purative  pleuritisj  that  is,  by  free 
opening  and  drainage. 


LECTURE     XLIX. 


Myo-  and  Endocarditis;  Their  Relations,  Causes,  Symptoms,  Anatomical  Changes,  Diagnosis,  Prog- 
nosis and  Treatment. 

GENTLEMEN:  As  we  stated  at  the  commencement  of  the  preceding 
lecture,  myocarditis  means  inflammation  limited  to  the  muscular  struct- 
ure of  the  heart.  In  a  large  proportion  of  the  cases,  more  especially  of 
rheumatic  inflammation  of  the  heart,  the  disease  has  commenced  in  the 
muscular  structure  alone.  I  have  been  able  to  detect  in  many  cases 
from  one  to  three  days  before  the  development  of  any  of  the  physical 
signs  of  inflammation  in  the  endocardium,  that  quick,  irritable  and  excit- 
able systolic  action  of  the  heart,  accompanied  by  a  lengthening  or  ex- 
aggeration of  the  first  or  systolic  sound,  and  a  dull  heavy  pain  in 
the  cardiac  region  which  indicated  positive  irritation  in  the  muscular 
structure.  And  in  a  very  few  instances  the  pain  accompanied  by  the 
physical  signs  I  has  described,  after  continuing  from  three  to  five  days, 
under  efficient  treatment  has  disappeared  without  the  supervention  of  any 
further  cardiac  symptoms.  I  have  regarded  these  as  cases  of  true  myocar- 
ditis of  a  mild  character,  progressing  no  further  than  to  involve  the  muscular 
structure,  while  the  former  cases  represented  the  commencement  of  the  dis- 


SYMPTOMS.  479 

easo  in  the  muscular  structure  first,  and  extending  directly  to  the  endocar- 
dial membrane,  and  finally  developing-  all  the  phenomena  of  endocarditis. 
Endocardial  inflammation  is  of  frequent  occurrence  as  an  accompaniment 
of  inflammatory  rheumatism,  but  as  a  separate  disease,  arising  from  the 
ordinary  causes  of  inflammation  in  other  structures  of  the  body,  it  is  com- 
paratively infrequent.  Neither  does  it  occur  as  often  as  pericarditis  in 
connection  with  either  renal  disease,  or  the  idiopatliic  or  eruptive  fevers. 

Si/mptoms. — The  symptoms  which  characterize  acute  endocarditis, 
whether  occurring  in  connection  with  rheumatism  or  idiopathically,  consist 
chiefly  of  a  dull  oppressive  pain  in  the  cardiac  region,  often  extending  up- 
wards to  the  shoulder,  sometimes  backward  under  the  scapula,  and  not 
infrequently  down  the  left  arm,  producing  a  peculiar  dull  aching  pain, 
more  particularly  between  the  shoulder  and  elbow. 

The  pulse  is  usually  full,  moderately  firm  under  the  finger,  accelerated 
in  frequency  to  from  eighty-five  to  one  hundred  beats  per  minute,  respira- 
tions accelerated  rather  more  in  proportion  than  the  acceleration  of  pulse; 
the  patient  frequently  feeling  a  sense  of  oppression  in  his  breathing;  and 
showing  a  disposition  to  have  the  shoulders  elevated  and  to  incline  the  body 
to  the  left  although  not  lying  over  upon  the  side.  There  is  usually  less  than 
the  ordinary  moisture  of  the  mouth,  whitish  fur  upon  the  tongue,  moderate 
degree  of  thirst,  less  than  the  natural  flow  of  urine  which  is  usually  deeper 
colored,  but  little  derangement  of  the  alimentary  canal,  although  in  most 
cases  of  an  acute  character,  the  appetite  is  lost  and  the  bowels  are  a  little 
inclined  to  constipation.  The  temperature  of  the  body  after  the  first  twen- 
ty-lour or  forty-eight  hours,  usually  ranges  from  three  to  five  de- 
grees above  the  natural  standard,  varying  but  little  between  morning  and 
evening. 

None  of  these  general  symptoms  are  sufficiently  distinctive  in 
their  character  to  enable  the  physician  to  render  a  positive  diagnosis  re- 
garding the  seat  of  the  disease.  But  by  resorting  to  the  physical  signs, 
auscultation  and  percussion,  such  alterations  from  the  natural  sounds  and 
movements  of  the  heart  may  be  detected  as  to  add  certainty  to  the  diag- 
nosis. First,  from  the  early  beginning  of  the  disease  in  the  interior  of 
the  heart,  the  impulse  against  the  walls  of  the  chest  is  increased  in  force 
and  frequency,  and  auscultation  readily  detects  the  exaggerated  and  more 
blowing  character  of  the  first  or  systolic  sound  of  the  heart.  This 
may  be  at  first  slight,  leaving  a  clearly  appreciable  interval  between 
the  first  and  the  second  sounds,  and  usually  in  from  twenty- four  to  forty- 
eight  hours  it  will  have  increased  sufficiently  to  be  easily  recognized  as 
■the  bellows  murmur,  and  sufficiently  prolonged  to  cover  nearly  or  quite  the 
interval  between  the  first  and  second  sounds,  apparently  obliterating  the 
latter.  This  sound  is  usually  heard  with  most  distinctness  a  little  to  the 
sternal  side  of  the  nipple  and  directly  over  the  base  of  the  heart,  and 
from  that  downward  to  the  leftside  over  the  apex.  If  there  be  no  per- 
icardial complication  and  efi"usion,  simple  inflammation  of  the  endocar- 
dium, does  not  alter  the  size  of  the  heart  sufficiently  to  give  any  in- 
creased area  of  dullness  on  percussion.  As  the  disease  advances,  the 
bellows  murmur  becomes  more  and  more  rough  or  harsh  in  its  quality, 
and  may  be  heard  more  distinctly  over  the  apex  or  immediately  below  the 
left  nipple,  but  when,  as  is  often  the  case,  the  inflammation  is  limited  to  the 
semi-lunar  valves  of  the  aorta  and  adjacent  parts,  an  equally  distinct  and 
rather  rough  bellows  murmur  may  be  traced  from  the  base  of  the  heart 
upward  along  the  course  of  the  aorta  nearly  or  quite  to  the  arch.  The 
sound  of  course  diminishes  in  proportion  as  we  recede  from  the  heart 
itself.  In  many  cases  of  endocarditis  the  inflammation  extends  beyond  the 
cavity  of  the  heart  along  the   lining  of  the   aorta,  causing   more  or   less 


480  EJTDOCAEDITIS. 

thickening  and  roughness  of  the  membrane  in  this  large  artery,  and  in 
such  cases  the  harsh  rough  sound,  synchronous  with  the  systole  of  the 
heart,  may  be  heard  as  distinctly  or  even  more  distinctly  than  the  ordinary 
bellows  murmur  over  the  heart  itself. 

It  is  rare  that  these  sounds  are  heard  as  distinctly  over  the  right  as  over 
the  left  side  of  the  heart.  In  cases  which  prove  protracted,  extending 
through  two,  three  or  four  weeks,  or  as  is  often  the  case  when 
associated  with  rheumatism,  the  alterations  of  the  mitral  valve,  or  the  semi- 
lunar of  the  aorta,  and  sometimes  of  both  in  the  same  case,  become  so 
great  that  the  valves  fail  to  close  their  respective  openings  during  the 
systolic  action  of  the  heart,  the  bellows  murmur  becomes  altered 
iu  such  a  direction  as  to  indicate  regurgitant  sounds.  If  the  alter- 
ations include  the  mitral  valve  only,  the  regurgitant  sound  will  accom- 
pany each  impulse  of  the  heart.  If  the  semi-lunar  valves  of  the  aorta  fail 
in  their  office  the  regurgitant  sound  will  be  heard  more  over  the  base  of 
the  heart  and  commencement  of  the  aorta,  and  will  immediately  fol- 
low the  impulse,  being  synchronous  with  the  diastole.  If  the  infl  imma- 
tion  subsides  early,  the  sounds  that  I  have  described  will  usually  diminish 
with  considerable  rapidity,  and  in  the  course  of  two  or  three  weeks  may 
entirely  disappear.  But  when  the  inflammation  runs  a  more  protracted 
course,  the  thickening  and  induration  of  the  valvular  structures  and  adja- 
cent parts  become  more  permanent,  and  either  perpetuate  the  sounds 
through  a  long  period  of  time,  or  as  is  not  unfrequently  the  case,  fail  ever 
to  subside  entirely,  leaving  the  patient  subject  to  permanent  cardiac  inef- 
ficiencv,  and  all  those  ulterior  consequences  which  will  be  hereafter  de- 
scribed. In  cases  of  very  acute  endocarditis,  after  the  first  few  days  the 
patient  usually  becomes  extremely  depressed,  or  affected  by  a  sense  of 
great  weakness,  oppression  in  the  chest,  a  feeling  of  insufficient  respiratory 
movements,  and  inclination  to  be  bolstered  up  more  in  the  bed,  and  to  be 
greatly  fatigued  by  any  slight  exertion.  Sometimes  getting  out  of  bed 
with  the  utmost  care  for  ordinary  evacuations  will  lead  to  panting,  hur- 
ried respiration,  irregularity  and  sometimes  intermission  of  the  pulse,  and 
such  a  sense  of  sinking  as  to  be  very  alarming  to  the  patient. 

Occasionally,  in  those  cases  that  are  severe  and  accompanied  by  much 
embarrassment  of  the  heart's  action,  and  probably  by  more  or  less  exud- 
ation upon  the  surface  of  the  inflamed  parts  of  plastic  material,  either  in 
minute  shreds  or  patches,  or  by  the  formation  of  fibrinous  clots  in  the 
cavities  of  the  heart,  some  of  these  materials  are  carried  from  the  cavity  of 
the  heart,  by  the  current  of  the  circulation,  into  remote  organs,  constitut- 
ing emboli  that  are  liable  to  suddenly  plug  the  vessels  and  thereby  in- 
terrupt important  functions.  Sometimes  larger  clots  form  in  the  cavity 
of  the  heart  and  greatly  add  to  the  embarrassment  of  its  action,  and  cause 
some  peculiarities  in  the  cardiac  sounds.  The  pulse  generally  becomes 
very  weak  nnd  irregular,  while  the  action  of  the  heart  is  tumultuous,  the 
breathing  hurried  and  greatly  oppressed,  and  the  countenance  expressive 
of  great  anxiety.  Occasionally  in  these  cases  larger  portions  of  a  fibrinous 
clot  in  the  heart  are  carried  into  the  vessels,  sufficient  thus  to  plug  one  or 
more  of  the  larger  arteries.  A  case  came  under  my  observation  within 
the  last  year,  the  history  of  which,  as  given  by  the  attending  physician, 
indicated  that  during  convalescence  from  a  moderate  grade  of  typhoid 
fever  the  patient  had  been  attacked  with  endocarditis,  followed  in  a  few 
days  by  the  formation  of  a  fibrinous  clot  in  the  left  ventricle,  giving  rise 
to  an  extraordinarily  tumultuous  action  of  the  heart,  and  great  anxiety  in 
the  mind  of  the  patient,  with  a  remarkable  degree  of  pulsation  throughout 
the  whole  arterial  system  of  vessels.     About  the  third  day  there  occurred 


SYMPTOMS.  481 

a  sudden  and  entire  suppression  of  the  pulse  in  the  right  arm.  There  was 
no  other  special  change  in  the  symptoms  but  a  complete  suppression  of  the 
radial  pulse.  On  tracing  the  artery  upward  to  its  connection  with  the  sub- 
clavian through  the  axilla,  it  was  found  that  the  obstruction  was  in  the  bra- 
chial artery  about  one  inch  below  the  border  of  the  axilla,  and  was  undoubt- 
edly from  a  clot  or  embolus  carried  from  the  cavity  of  the  heart.  About 
two  days  later,  symptoms  of  plugging  of  vessels  of  the  brain  followed, 
and  the  patient  died.     No  post-mortem,  however,  could  be  obtained. 

In  another  instance  that  came  under  my  observation  there  was  every 
evidence,  from  the  physical  signs  and  the  symptoms  of  the  case,  that  ex- 
tensive pulmonary  embolism  occurred  in  the  progress  of  endocardial  in- 
flammation, which  had  become  complicated  with  all  the  signs  of  a  heart- 
clot.  Similar  cases  have  not  been  of  frequent  occurrence  under  my 
observation,  and  yet,  that  they  are  liable  to  occur  now  and  then  should 
be  borne  in  mind  by  the  practitioner,  and  the  usual  liability  to  form 
fibrinous  exudations,  shreds,  and  larger  clots  or  emboli  in  the  progress  of 
endocardial  inflammation,  should  constitute  a  reason  for  the  practitioner, 
not  only  to  be  on  the  alert  for  their  detection,  but  it  should  also  lead  to 
such  treatment  of  all  these  cases  as  would  be  most  likely  to  lessen  the  tend- 
ency to  the  accumulation  of  the  fibrinous  elements  of  the  blood,  as  well 
as  to  limit  exudations  of  a  plastic  character.  In  the  great  majority  of  cases 
of  endocarditis  of  an  acute  or  sub-acute  grade,  whether  in  connection  with 
rheumatic  disease  or  not,  the  acute  stage  passes  by  in  from  two  to  three 
weeks;  often  leaving,  however,  such  changes  in  the  interior  lining  or  valv- 
ular structures  as  to  cause  more  or  less  morbid  sounds,  and  impairment 
in  the  circulation  for  a  much  longer  period  of  time. 

These  chang-es  to  which  I  allude  consist  of  the  usual  thickenino^  or 
tumefaction  and  induration  of  the  inflamed  structures.  The  principal 
structure  involved  is  the  delicate  membrane  lining  the  cavities  of  the 
heart,  and  which  also  constitutes  the  principal  structure  of  the  valves; 
the  latter  being,  in  fact,  but  little  else  than  the  lining  membrane  folded 
upon  itself.  But  while  the  effects  of  the  inflammation  in  the  membrane 
lining  the  walls  of  the  ventricles,  or  covering  the  columnas  carn^e,  may 
subside  to  such  a  degree  as  to  occasion  little  or  no  inconvenience,  or  even 
disappear  wholly,  yet  after  the  valvular  structures  have  been  in- 
volved, causing  them  to  be  thicker,  denser  and  less  flexible  than  natural, 
they  usually  remain  thus  mechanically  obstructing  the  free  passage  of  blood 
through  the  openings  of  the  heart,  thereby  inducing  secondary  changes 
which  take  place  slowly  at  first,  but  ultimately  reach  a  development  that 
seriously  impairs  the  patient's  usefulness,  and  shortens  life. 

What  was  but  a  slight  obstruction  to  the  circulation  during  the  first 
few  weeks  and  sometimes  months  after  the  subsidence  of  the  cardiac 
nflammatory  attack,  becomes  in  process  of  time  so  much  increased  as  to 
have  induced  increased  growth  in  the  muscular  structure,  constituting  hy- 
pertrophy of  the  walls  of  the  ventricles,  more  particularly  of  the  left,  cor- 
responding habitual  tendency  to  fullness  of  the  left  auricle  and  pulmona- 
ry veins,  thereby  producing  fullness  of  the  capillaries  in  the  lungs,  press- 
ure upon  the  air  cells,  difficult  or  asthmatic  breathing,  greatly  increased 
by  attempts  to  exercise,  or  whatever  tends  to  increase  the  frequency  of 
the  heart's  motion,  until  in  a  few  months  or  years  many  of  these  patients 
become  entirely  incapacitated  for  active  exercise.  When  they  have 
reached  this  stage  in  their  progress,  there  is  an  almost  uniform  tendency 
to  passive  congestion  of  the  kidneys  and  diminished  secretion  of  urine, 
which  added  to  the  irregular  and  inefficient  circulation  of  the  blood,  is 
31 


482  ENDOCAEDITIS. 

soon  followed  by  dropsical  effusions.  These  are  first  noticed  as  the  pa- 
tient rises  from  bed  in  the  morning,  in  the  form  of  fullness  or  oedematous 
swelling  of  the  loose  tissue  of  the  eyelids,  and  a  general  appearance  of 
fullness  of  the  face.  If  he  is  up,  with  his  feet  dependent  during  the  day, 
the  puffinessofthe  face  and  eyelids  disappears  in  a  great  measure,  but  as 
night  comes  on,  the  feet  along  tne  top  and  behind  the  malleoli  of  the  aniiles, 
present  a  swollen  appearance  which  pits  on  pressure,  showing  that  the  se- 
rous effusion  has  commenced  in  the  lower  extremities. 

These  slight  indications  of  dropsical  infiltration  continue  slowly  to  in- 
crease until  they  exist  universally  throughout  all  the  areolar  tissue  of  the 
exterior  of  the  body.  If  left  to  its  own  natural  tendency,  after  the  ex- 
terior areolar  tissue  becomes  thoroughly  oedematous,  the  serous  effusion 
will  begin  to  invade  the  interior  cavities  and  organs  of  the  body;  usually, 
first  filling  up  the  peritoneal  sac  to  such  an  extent  as  to  impede  the 
descent  of  the  diaphragm,  adding  greatly  to  the  oppressed  and  difficult 
breathinjT,  giving  to  the  patient  an  almost  constant  sense  of  impending 
suffocation,  and  terminating  finally  in  one  of  two  ways: — One  is  by  simple 
extension  of  the  oedematous  infiltration  into  the  pulmonary  tissue,  render- 
ing the  amount  of  air  capable  of  entering  the  lungs  so  small  that  the  lips  be- 
come blue,  the  extremities  cold  and  purplish,  the  cutaneous  surface  covered 
with  a  cold  clammy  sweat,  extreme  sense  of  suffocation  is  felt,  and  a  speedy 
death  from  apnoea  ensues.  The  other  is  by  failure  of  the  kidneys  to  secrete 
urine,  allowing  the  elements  of  the  urine  to  be  retained  in  the  blood  until 
their  toxemic  effect  upon  the  nervous  centers  induce  muscular  twitchings, 
drowsiness,  irregular  and  labored  breathing,  gradually  increased  to  stupor, 
and  finally  coma  and  death. 

In  some  of  these  cases,  during  the  progress  of  the  supervening  coma, 
■convulsions  occur,  sometimes  partial  but  more  frequently  general 
-clonic  spasms  repeated  once  or  twice,  and  ending  in  complete  coma, 
-relaxation  of  the  sphincters  and  death.  An  impression  is  very  general 
among  the  people  that  organic  disease  of  the  heart  renders  them  liable  to 
sudden  death  at  any  moment.  But  so  far  as  relates  to  death  from  disease 
of  the  valves  of  the  heart,  originating  from  attacks  of  endocardial  infiam- 
mation,  death  is  rarely  sudden.  In  much  the  greater  number  of  this 
class  of  patients  death  approaches  slowly,  leading  them  through  a  pro- 
tracted period  of  great  difficulty  of  breathing,  the  constant  sense  of  suffo- 
cation and  weariness  being  of  such  a  ch:iracter  that  many  of  them  long 
for  death  to  take  place  weeks  before  their  longing  is  gratified.  I  have 
spoken  of  the  symptoms  of  endocarditis  with  reference  to  the  separate 
cavities  of  the  heart  and  the  valvular  structures,  and,  as  you  will  have  ob- 
served, my  references  have  been  almost  entirely  to  the  left  cavities,  with 
the  mitral  and  semi-lunar  valves  of  the  aorta.  The  reason  for  this  is  the 
clinical  fact  that  endocardial  inflammation  very  rarely  invades  the  right 
cavities  of  the  heart,  whatever  may  be  the  physiological  reason,  whether 
it  is  from  the  sedative  effects  of  the  increased  amount  of  carbonic  acid  in 
the  venous  blood  with  which  the  right  cavities  are  filled,  or  some  other 
cause,  all  observations  show  that  we  have  at  least  fifty  cases  of  endo- 
cardial inflammation  in  the  left  to  one  in  the  right  cavities  of  the  heart. 
But  the  remote  consequences  of  these  inflammations,  especially  when 
they  leave  such  a  condition  of  the  mitral  valve  as  to  seriously  obstruct 
the  auriculo  ventricular  openings  of  that  side,  or  cause  mitral  stenosis  as 
it  is  called,  are  not  restricted  altogether  to  the  left  cavities  of  the  heart; 
but  in  many  cases  of  protracted  duration  the  long  continued  obstruction 
to  the  passage  of  blood  through  the  capillary  vessels  of  the  lungs  leads 
to  habitual  over-fullness  of  the  pulmonary  arteries,  and  ultimately  more 


DIAGNOSIS.  483 

or  less  of  the  same  increase.!  fullness  in  the  auricles  and  ventricles  of  the 
riwht  side  of  the  heart.  Most  of  the  post  mortem  examinations  of  this 
class  of  cardiac  diseases  reveal  decided  hypertrophy  or  increased  growth 
of  the.  muscular  walls  of  the  left  ventricle,  with  diminished  size  of  its 
cavity,  while  the  right  ventricle  and  auricle  are  both  dilated  with  thinning 
or  atrophy  of  the  muscular  walls.  And  usually  the  dilatation  of  the  right 
auricle  and  ventricle  also  includes  with  it  an  enlargement  of  the  auriculo- 
ventricular  opening,  rendering  the  tricuspid  valve  insufficient  for  its 
office,  and  consequently  allowing  the  regurgitation  of  blood  through  it 
with  each  systole,  giving  what  is  familiarly  known  as  the  venous  pulse  or 
regular  pulsation  in  the  veins  of  the  neck.  Such  are  the  more  common 
anatomical  changes  which  result  from  the  different  grades  of  endocardial 
inflammation,  involving  the  valvular  structures,  and  leaving  them  more  or 
less  permanently  incapacitated  for  fulfilling  their  natural  office. 

Diagnosis. —  The  symptoms  and  physical  signs  by  which  we  are  enabled 
to  detect  the  beginning,  and  the  progress  through  its  subsequent  stages, 
of  myo-  and  endocardial  inflammation,  have  been  so  fully  stated  in  giv- 
ing the  clinical  history  of  the  disease  and  its  ultimate  results  that  I  need 
not  re-enumerate  them  under  this  head.  The  principal  liability  to  mis- 
take is  in  reference  to  confounding  the  bellows  murmur  of  endocarditis, 
when  of  a  moderate  degree  of  intensity,  with  the  antemic  bellows  mur- 
mur that  is  met  with  frequently  as  the  accompaniment  of  the  more 
strongly  marked  anaemic  or  impoverished  conditions  of  the  blood,  uncon- 
nected with  any  inflammatory  action.  And,  it  is  a  matter  of  much  im- 
portance to  be  able  to  distinguish  between  these  two  conditions.  The 
principal  distinctions  are,  that  the  ansemic  murmur  is  always  synchronous 
with  the  systolic  action  of  the  heart,  and  is  never  sufficiently  prolonged 
to  obliterate  the  interval  between  the  first  and  second  sounds;  but  always 
leaves  an  appreciable  interval  between  them.  It  is  in  fact  a  mere  blow- 
ing or  exaggeration  of  the  first  sound  of  the  heart,  its  quality  neither  indi- 
cating roughness,  or  harshness,  nor  anything  of  a  regurgitant  character. 
Another  characteristic  of  the  anaemic  bellows  murmur,  is  its  being  heard 
as  loud  and  plain,  and  sometimes  even  more  prominently,  over  the  course 
of  the  aorta  as  high  up  as  the  arch  and  over  the  sub-clavian  arteries,  as 
over  the  body  of  the  heart  itself.  If  you  remember  these  qualities,  with 
the  rigid  restriction  of  the  morbid  sound  to  the  first  sound  of  the  heart, 
its  softness  rather  than  harsh  quality,  and  its  equal  development  over  the 
large  arteries,  and  the  further  fact,  that  these  anaemic  murmurs  are  in  sub- 
jects plainly,  either  chlorotic  or  deficient  in  the  red  matter  of  the  blood, 
you  will  hardly  be  liable  to  make  any  mistake  in  your  diagnosis.  I  may 
add,  however,  as  an  almost  constant  tact,  that  in  endocardial  inflammation 
and  its  consequences  the  pulse  has  a  pretty  uniformly  firm,  sustained  feel- 
ing of  tension:  whereas,  in  the  anaemic  conditions  of  sufficient  degree  to 
cause  a  bellows  murmur,  the  pulse  though  often  excited,  quick  and  having 
the  appearance  of  volume,  is  nevertheless  soft  and  easy  of  compression. 

Prognosis. — The  prognosis  in  endocardial  inflammation  so  far  as  direct 
danger  to  life  is  concerned  is  generally  favorable;  but  in  relation  to  the 
prospect  of  having  complete  recovery  without  embarrassing  sequelae,  the 
prognosis  is  not  so  favorable.  A  very  large  proportion  of  all  the  cases  of 
endocardial  inflammation  pass  through  the  active  stage  of  the  disease  with 
safety,  and  the  patient  convalesces.  In  many  of  them  the  recovery  is 
complete.  A  large  proportion  of  the  cases  are  nevertheless  left  with 
some  degree  of  permanent  thickening  of  the  valves,  which  constitutes  the 
beginning  of  that  slow  morbid  process  called  sclerosis,  or  increased  growth 
of  the  connective  tissue,  which  will  either  moderately   embarrass  them  on 


484  ENDOCAEDITIS. 

taking  active  exercise  through  life,  or  lead  to  some  of  those  more  seri- 
ous structural  changes  that  I  have  already  described  as  ultimately  term- 
inating the  life  of  the  patient.  Still  there  are  cases  of  endocarditis  of 
such  severity  as  to  cause  death  during  the  active  progress  of  the  disease. 

Treatment. — In  Lecture  XXXI  of  the  present  course,  when  speaking  of 
the  treatment  of  acute  articular  rheumatism  and  rheumatic  fever,  I  spoke 
freely  of  its  liability  to  become  complicated  with  both  pericardial  and  en- 
docardial inflammation.  When  discussing  the  treatment  of  that  grade  of 
rheumatism,  I  called  your  attention  to  the  additional  treatment  that 
might  be  required  for  the  acute  stage  of  these  cardiac  affections,  con- 
sequently it  is  not  necessary  to  repeat  the  directions  then  given  at  this 
time.  (See  Lecture  XXXI,  p.  299.)  But  the  remarks  then  made  were 
limited  to  the  treatment  during  the  acute  stage  of  the  progress,  both  of 
the  general  rheumatic  disease,  and  of  the  local  cardiac  complications. 
The  latter,  however,  are  very  liable  to  be  continued  in  what  may  be  styled 
the  chronic  form,  more  especially  when,  during  the  acute  stage,  the  valvulai 
structures  have  become  thickened  and  indurated  to  such  a  degree  as  to 
materially  interfere  with  the  circulation  of  the  blood.  It  is  then  difficult  to 
define  precisely  when  the  inflammatory  action  in  these  cases  has  ceased, 
and  we  have  only  to  deal  with  the  consequences,  in  the  form  of  structural 
changes  which  the  precedins:  inflammation  has  induced.  But  so  long  as 
there  are  obscure  dull  pains  in  the  cardiac  region,  and  slight  increase  of 
temperature  of  the  body,  with  some  degree  of  scantiness  in  the  urinary 
secretion,  it  may  be  safe  to  assume  that  some  degree  of  inflammatory  ac- 
tion still  exists  in  the  cardiac  structure.  This  inference  will  be  corrob- 
orated in  a  greater  or  less  degree  by  the  evidence  of  chronic  rheumatic 
inflam;nation  in  the  articulations,  or  other  fibrous  structures  in  any  part 
of  the  body.  So  long  as  evidence  of  inflammatory  action  remains,  how- 
ever moderate  in  its  degree,  there  is  a  tendency  to  increase  or  hyper- 
trophy of  the  connective  tissue  in  the  valvular  structures,  and  increase  in 
their  density,  thereby  rendering  it  almost  certain  that  the  structural  changes 
will  become  permanent  unless  counteracted  bv  persistent  treatment. 

It  is  better,  therefore,  to  err  sometimes  by  continuing  treatment  de- 
signed for  the  removal  of  these  low  grades  of  inflammatory  action  too  long, 
rather  than  omit  it  too  early.  The  most  efficient  treatment  during  the 
latter  stages  of  the  endocardial  inflammation,  or  what  might  be  called  its 
chronic  stage,  consists  in  the  administration  of  remedies  which  have  a 
two-fold  effect,  one  to  lessen  the  frequency  of  the  heart's  action  by  lessen- 
ing the  irritability  of  its  muscular  fibers,  and  the  other  to  overcome  the 
morbid  excitability  of  the  inflamed  structure  and  to  prevent  the  further 
atomic  or  cell  changes  which  take  place  in  all  persistent  low  grades  of  in- 
flammatory action  and  constantly  tend  to  increase  by  hypertrophy  the  con- 
nective tissue  and  endothelial  layer  of  the  membrane.  For  these  pur- 
poses in  the  stage  of  the  disease  now  under  consideration,  I  have  seen  much 
benefit  produced  by  the  administration  of  the  iodide  of  potassium  in  con- 
nection with  stramonium.  A  convenient  formula  would  consist  of  the 
following: 

^15.      Potassii  lodidi, 

Tinctures  Stramonii, 
Tincturae  Digitalis, 
Syrupus  Simplicis, 
Aquae  Distillatas, 

Of  this  formula  four  cubic  centimeters  or  one  teaspoonful  may  be  given 


10  grams. 
12    c.  c. 
30    c.  c. 

3iiss 
3iii 

|i 

15    c.  c. 
60    c.  c. 

§ss 

TREATMENT.  485 

to  the  patient  every  four  or  six  hours,  according  to  the  effects  of  the 
(li<ritalis  upon  tho  motions  of  the  heart.  At  the  same  time  it  is  desirable 
to  continue  trie  use  of  the  alkaline  carbonates,  either  of  potassium  or  so- 
dium, with  sufficient  degree  of  freedom  to  prevent  the  urine  from  again 
becominir  more  than  normally  acid.  These  remedies  will  usually  keep 
the  urinary  secretion  free  in  quantity,  lessen  the  cardiac  excitement,  favor 
the  disappaarance  of  what  rheumatic  pains  and  soreness  may  still  be  lin- 
gering in  any  part  of  the  system,  while  the  alterative  effects  of  the  iodide 
are  particularly  calculated,  not  only  to  prevent  further  inflammatory  exu- 
dation into  th )  valvular  textures,  but  to  aid  in  causing  the  disintegration 
and  removal  of  su  h  as  have  already  taken  place. 

In  sjme  of  these  cases,  the  bowels  remain  costive  unless  they  are 
prompted  by  some  laxative.  In  such  cases  a  pill  composed  of  blue  mass,  ex  • 
trj.ct  of  hyosciamus,  and  aloes  six  centigrams  (gr.  i)  each  given  at  night  will 
usually  produce  a  moderate  evacuation  in  the  morning,  which  is  all  that  is 
necessary.  I  have  seen  some  cases  of  endocardial  inflammation  arising 
in  the  progress  of  acute  rheumatic  disease  in  which  the  faithful  and  some- 
what persistent  use  of  the  remedies  here  indicated  was  followed  by  an  en- 
tire removal  of  the  physical  signs  of  valvular  thickening,  and  of  all  ob- 
struction to  the  free  circulatif)n  of  the  blood  through  the  various  cavities 
and  openings  of  the  heart.  On  the  other  hand  it  must  be  acknowledged 
that  there  are  many  of  the  cases  which  resist  all  efforts  to  remove  these 
inflammatory  changes.  The  consequence  is,  that  the  patient  recovers 
sufficiently  to  resume  more  or  less  attention  to  business,  or  ability  to  take 
moderate  exercise  indoors  and  out,  but  yet,  the  cardiac  murmurs  remain, 
the  pulse  retains  the  characteristic  qualities  that  belong  to  obstructions 
in  the  mitral  and  aortic  openings,  and  the  patient  sooner  or  later  again 
finds  himself  incapable  of  taking  active  exercise  or  of  ascending  stairs  with- 
out feeling  oppressed  in  breathing,  with  increased  frequency  and  irregu- 
larity of  the  heart's  beat.  The  question  how  best  to  manage  these  cases 
for  the  purpose  of  preventing  ulterior  changes  in  the  cavities  of  the  heart 
and  their  consequences,  is  one  of  much  practical  importance. 

My  own  experience  has  led  me  to  think  the  practitioner  should  give 
special  attention  to  the  accomplishment  of  three  objects  in  the.  manage- 
ment of  such  cases; — First  to  carefully  instruct  the  patient  in  regard  to 
the  importance  of  so  regulating  his  daily  habits  of  life  as  to  avoid,  as 
much  as  possible,  all  mental  excitement  or  anxiety  on  the  one  hand,  and 
hurried  or  exaggerated  physical  exercise  on  the  other;  such  occupations  as 
will  afford  his  mind  employment  without  intensity  of  application  or  much 
anxiety  in  regard  to  the  results  to  be  obtained,  and  the  regulation  of  exer- 
cise in  such  a  way  as  to  enjoy  the  open  air  passively  by  riding  and  moder- 
ate walking,  but  avoiding  the  ascent  of  hills  and  steep  places  out  of  doors, 
and,  as  much  as  possible,  the  stairs  within  doors.  Whenever  the  latter  is 
attempted  it  should  be  done  with  much  deliberation  and  slowness.  In 
other  words  the  patient  should  be  instructed  to  do  all  his  work,  both  men- 
tal and  physical,  in  quietude,  and  entire  freedom  from  hurry  or  violent 
exertion.  By  such  a  regulation  of  the  daily  habits  very  much  will  be 
gained  in  retarding  the  progress  of  the  cardiac  changes.  The  second 
important  object  to  be  accomplished  is  the  use  of  such  remedies  as  will  be 
most  efficient  in  keeping  the  frequency  of  the  heart's  beat  as  near  the 
natural  standard  as  possible.  When  the  mitral  valve  performs  its  office 
imperfectly  or  the  auriculo-ventricular  opening  is  contracted,  constituting 
mitral  stenosis,  the  more  frequent  the  systolic  action,  the  less  time  there 
is  for  the  blood  to  pass  from  the  auricle  through  the  narrow  opening  into 
the    ventricle.     Hence  it  is  that  every   excitement  or  exertion  that  quick- 


486  ENDOCARDITIS. 

ens  the  systolic  action  in  such  patients  brings  oppression  in  breathing,  and 
quickly  causes  them  to  demand  rest.  If  the  systolic  action  can  be  ren- 
dered slow,  leaving  the  full  length  of  interval  between  the  systole  and 
diastole,  the  blood  passes  in  larger  quantity  through  the  narrow  opening, 
the  ventricle  becomes  better  filled,  a  fuller  volume  of  blood  is  sent  to  the 
system  at  large,  and  the  pulmonary  circulation  is  relieved.  It  is  desirable 
however,  in  selecting  remedies  for  those  cases,  that  they  be  such  as  will 
render  the  action  of  the  heart  slower  without  impairing  its  force. 

It  is  also  desirable  that  they  should  be  exempt  from  liability  to 
disturbance  of  digestion  or  interference  with  the  functions  of  the  stomach. 
You  will  perceive  that  the  cardiac  sedatives,  such  as  veratrum  viride,  aco- 
nite, and  gelsemium,  are  not  well  adapted  to  these  cases.  For,  while  they 
are  efficient  in  rendering  the  heart's  action  slower,  they  tend  both  to  dimin- 
ish the  muscular  force,  and  to  disturb  the  functions  of  the  stomach,  unless 
they  are  administered  with  great  caution.  Digitalis,  cactus  grandiflora, 
and  convallaria,  are  almost  the  only  remedies  with  which  we  are  familiar 
that  possess  all  the  desired  qualities,  and  can  be  used  for  tlie  required 
length  of  time  in  such  a  way  as  to  regulate  the  heart's  action  and  greatly 
ameliorate  the  condition  of  the  patient,  and  at  the  same  time  retard  the 
ulterior  changes  to  which  such  cases  are  always  liable.  In  many  instances 
I  have  used  a  combination  of  one  part  of  the  tincture  of  digitalis  with  two 
parts  of  the  fluid  extract  of  Scutellaria,  giving  of  the  mixture  two  cubic 
centimeters  (min.  xxx)  every  four  or  six  hours  until  a  perceptible  slowing 
of  the  cardiac  action  was  obtained,  when  from  two  to  three  doses  in  the 
twenty-four  hours  would  usually  perpetuate  the  efi'ect  desired.  The  fluid 
extracts  of  the  cactus  and  of  the  convallaria  have  not  been  sufficiently 
tested  in  these  cases  to  justify  me  in  speaking  very  positively  of  their 
effects. 

I  think  they  are  less  reliable  than  digitalis,  but  maybe  used  for  a  longer 
period  of  time  without  danger  of  accumulating  and  suddenly  developing 
exaggerated  effects,  as  dig-italis  occasionally  does.  The  third  object  which 
the  practitioner  should  keep  in  view  in  all  these  cases,  is  the  regulation  of  the 
diet,  clothing,  and  other  hyg-ienic  conditions  of  his  patient,  with  a  view  of 
preventing  the  recurrence  of  rheumatic  attacks  during  the  transition  sea- 
sons of  the  year,  to  which  almost  all  such  cases  are  more  or  less  liable,  and 
which  seldom  fail  to  increase  the  local  cardiac  changes.  This  object  will 
be  accomplished  best  by  requiring  the  patient  to  wear  flannel  or  other  good 
non-condactors  of  heat  and  electricity  next  to  the  surface  during  all  the 
year,  unless  it  be  a  few  weeks  in  the  middle  of  the  summer  when  it  should 
be  exchanged  for  the  lighter  canton  flannel.  Another  item  of  a  hygienic 
character  of  much  value  to  such  patients  is  the  use  of  a  warm  alkaline  bath 
once  or  twice  a  week,  particularly  during  the  cold  season  of  the  year, 
from  the  iirst  beginning  of  the  cool  and  the  wet  weather  of  autumn,  until 
the  return  of  the  following  summer.  These  baths  may  consist  simply  of 
warm  water  holding  in  solution  sufficient  of  the  carbonate  of  sodium  or 
potassium  to  render  them  alkaline,  and  after  the  patient  has  been  im- 
mersed in  the  bath  as  long  as  is  conifortable,  on  removal,  the  water  should 
be  wiped  quickly  from  the  surface  with  ordinary  towels,  and  the  whole 
cutaneous  surface  briskly  and  rapidly  rubbed  with  dry  soft  flannel.  In 
this  way  the  skin  can  be  kept  healthy  and  active,  which  constitutes  the 
most  efficient  sal'eguard  against  the  accumulation  of  the  lactic  acid  or 
other  materials  in  the  blood  supposed  to  be  capable  of  causing  rheumatic 
inflammation.  I  have  seen  many  patients  who  by  systematic  careful  man- 
agement on  the  principles  I  have  indicated,  have  passed  from  ten  to  thirty 
years  of  life  with  a  reasonable  degree  of  comfort,  and  have  been  able  to 


TREATMENT.  487 

pursue  successfully  their  ordinary  occupations  after  the  establishment  of 
permanent  cardiac  murmurs. 

One  of  them,  a  lady,  has  during  the  time  reared  a  family  of  children, 
superintending  her  own  household,  always  preserving  calmness  and 
quietude  in  her  movements,  mental  and  physical;  and  though  many  times 
laid  up  temporarily  with  fresh  rheumatic  attacks  of  a  mild  character,  in- 
volving each  time  increased  cardiac  excitement  and  some  increased  bel- 
lows murmur,  yet  warding  them  off  by  such  means  as  I  have  indicated,  she 
continues  still  able  to  endure  a  moderate  degree  of  walking,  any  amount 
of  riding,  and  to  enjoy  life  to  a  reasonal^le  extent.  But  if  these  cases  are 
not  carefully  guided  by  accurate  instructions,  much  the  larger  proportion 
of  them  will  have  their  cardiac  troubles  increased  two  or  three  times  dur- 
ing every  cold  season  of  the  year,  and  they  speedily  reach  that  degree  of 
exaggeration  which  brings  general  dropsical  infiltration,  and  entire  failure 
of  the  patient. 

Inflainniation  of  the  Aorta. — Acute  or  sub-acute  inflammation  of  the 
lining  membrane  of  the  aorta  rarely  occurs  except  in  direct  connection 
with  endocarditis.  I  have  seen  a  few  cases,  however,  that  occurred  during 
the  progress  of  acute  rheumatic  attacks  in  which  all  the  physical  signs  of 
thickening  of  the  membrane  lining  the  aorta,  such  as  harsh  rough 
sounds  in  connection  with  the  systolic  action  of  the  heart,  decided  sense 
of  oppression,  distress  in  the  chest  behind  the  sternum,  and,  as  the  cases 
progressed,  more  or  less  difficulty  of  breathing,  decided  expression  of 
anxiet}^  in  the  countenance,  and  an  exaggeration  of  the  pulsations  in 
the  carotid  and  sub-clavian  arteries  indicative  of  actual  inflammatory  action 
in  the  larger  vessels,  and  yet  close  examination  by  auscultation  failed  to 
detect  the  cardiac  sounds  characteristic  of  endocardial  inflammation. 
The  rough  sounds  heard  over  the  aorta  at  different  points  from  the  semi- 
lunar valves  at  its  opening  to  its  arch,  were  not  detected  over  the  body  of 
the  heart,  or  at  the  apex.  In  one  of  these  cases  to  which  I  allude,  the 
patient  being  under  my  care  in  the  hospital,  there  occurred  indications  in 
connection  with  it,  of  a  moderate  degree  of  pneumonic  inflammation  in 
the  left  lung.  The  case  proved  fatal  about  the  end  of  the  second  week  of 
the  rheumatic  affection,  and  I  think  on  the  seventh  day  after  the  physical 
signs  indicated  involvement  of  the  aorta.  When  inflammation  takes  place 
in  the  lining  of  the  aorta,  it  produces  the  same  changes  anatomically,  that 
take  place  in  the  interior  of  the  cavities  of  the  heart.  The  membrane, 
or  parts  of  it,  become  thickened  and  often  studded  with  little  prominences 
made  up  of  the  proliferating  endothelial  cells,  and  sometimes  apparently 
springing  from  the  deeper  layers  of  the  connective  tissue. 

Very  few  of  these  cases  have  terminated  fatally  during  the  active  stage. 
[  am  quite  sure  that  I  have  traced  a  few  of  them,  however,  in  their  subse- 
quent course  to  the  establishment  of  permanent  rough  places  in  the  interior 
of  the  aorta,  causing  harsh  rough  sounds  synchronous  with  the  systolic 
action  of  the  heart,  keeping  up  more  or  less  feelings  of  oppression  and 
fullness  in  the  chest  which  were  much  increased  by  exercise.  It  is  highly 
probable  from  the  appearances  found  on  post-mortem  examinations  that 
these  rough  places  are  patches  of  increased  thickening  of  the  structure,  and 
which  in  time  present  more  of  an  atheromatous  character.  It  is  also 
probable  that  in  some  instances  these  atheromatous  changes  extend  deep 
enough  into  the  arterial  coats  to  impair  their  strength  and  thereby  prepare 
the  way  for  the  development  of  future  aneurismal  dilatations.  The 
treatment  in  these  cases  of  inflammation  in  the  aorta  is  similar  in  all  res- 
pects to  the  treatment  of  the  same  grades  of  endocardial  inflammation. 


488  ULCERATIVE    ENDOCARDITIS. 

Acute  Ulcerative  Endocarditis. — There  is  still  another  form  of  inflam- 
mation affecting  the  endocardium  requiring  a  brief  notice.  It  has  been 
recognized  as  a  distinct  form  of  endocarditis  only  the  last  few  years.  I 
allude  to  what  some  recent  writers  have  styled  '■'acute  ulcerative  endo- 
carditis." It  occurs  chiefly  as  a  complication  in  the  advanced  stages,  or 
during  the  early  part  of  convalesence,  of  the  general  acute  infectious  dis- 
eases: such  as  diptheria,  pyaemia,  typhoid  fever,  and  probably  never 
occurs  as  an  idiopathic  affection  unless  preceded  by  some  form  of  blood 
poisoning.  The  symptoms  of  the  disease  are  often  obscure  so  far  as  the 
inflammation  of  the  heart  is  concerned.  Generally  the  first  noticeable 
symptoms  are  the  chill,  followed  bv  an  unusually  high  fever,  the  tem- 
perature rising  rapidly  to  40=— mo"— 41  °  C.  (104-5— 6°  F.),  the  pulse 
becoming  exceedingly  rapid,  soft  or  easily  compressed,  feelings  of  great 
'prostration,  not  unfrequently  vomiting,  accompanied  by  extreme  distress 
in  the  epigastrium,  and  in  other  instances  diarrhoea,  and  occasionally  diar- 
rbceal  discharge  mixed  with  blood.  The  urinary  secretion  becomes  very 
scanty  and  in  most  cases  more  or  less  albuminous.  The  progress  of  these 
cases  is  usually  rapid;  the  patient,  more  generally  on  the  second  or  third 
day,  becomes  delirious,  pulse  small,  thread}',  extremities  cold  and  bluish; 
in  some  cases  purpuric  or  hemorrhagic  spots  appear  upon  the  surface,  par- 
ticularly over  the  abdomen  and  inner  surface  of  the  thighs;  the  heart's 
action  is  very  weak,  at  times  intermitting  and  sometimes  tumultuous,  but 
generally  growing  hourly  more  feeble  till  the  patient  sinks  into  a  drowsy, 
or  comatose  condition  and  dies.  There  are  some  cases,  however,  in  which 
the  symptoms  are  less  severe  and  the  progress  less  rapid,  presenting  some 
resemblance  in  their  clinical  phenomena  to  the  more  severe  grades  of 
typhoid  fever.  In  others,  they  have  been  so  similar  to  the  progress  o( 
cases  of  pyjemia  and  septiceemia  that  no  differential  diagnosis  has  been 
made  during  life.  Even  auscultation,  here,  does  not  always  furnish  the 
bellows  murmur,  or  the  altered  sounds  which  are  characteristic  of  inflam- 
mation in  the  interior  of  the  heart.  In  one  or  two  instances  that  have 
come  under  my  own  observation,  in  which  the  patients  were  not  seen  until 
the  disease  was  near  its  fatal  termination,  the  cardiac  action  was  so  weak 
and  rapid  as  to  render  it  impossible  to  analyze  the  sounds.  It  was  easy  to 
determine  that  they  were  abnormal,  that  there  was  an  unnatural  condition 
of  the  interior  of  the  heart,  but  I  could  not  distinguish  clearly  the  sounds 
belonging  to  different  parts  of  the  rhythm  of  the  heart. 

This  form  of  endocarditis  pretty  uniformly  terminates  fatally.  The 
anatomical  changes  that  accompany  it,  are  found  to  consist  of  little  reddish 
and  sometimes  gray  granules,  sometimes  arranged  in  rows  on  different 
parts  of  the  interior  surface  of  the  left  ventricle.  Generally  these  granules 
are  more  readily  seen  on  either  the  mitral  or  the  semi-lunar  valves  of 
the  left  side  of  the  heart.  The  granules  are  easily  rubbed  off,  leaving  the 
surface  on  which  they  rested  covered  with  minute  ulcerations.  Some- 
times these  ulcerations  enter  quite  deeply  into  the  valvular  structure.  A 
few  instances  have  been  observed  in  which  they  had  penetrated 
through  the  whole  depth  of  the  valve,  causing  jjerforations. 
In  more  cases  they  had  penetrated  only  deep  enough  to 
weaken  the  valves  and  cause  a  bulging,  and  sometimes  aneuris- 
inal  dilatation.  When  the  mitral  valves  have  been  thus  weakened  the 
bulging  is  toward  the  auricle  ;  the  same  change  taking  place  in  the  sem- 
ilunar valves,  the  bulging  is  toward  the  cavity  of  the  ventricle.  Micro- 
scopic examination  of  the  granulations  I  have  mentioned,  and  also  the 
surface  of  these  ulcers,  and  often  in  part  of  the  structure  constituting  the 
interior  of  the  heart,  shows  the  presence  of  great  numbers  of  the  spheri- 


TREATMENT.  489 

cal  bnctoria  or  microccoci.  They  seem  to  exist  in  clusters  ;  indeed  the 
appareTit  granules  are  larsrely  made  up  of  collections  of  these  micrococci,  at 
the  same  time  they  are  found  in  large  numbers  in  the  blood  taken  from 
any  part  of  the  body,  and  generally  may  be  found  also  in  the  other  tissues. 
How  far  they  have  any  causative  relation  to  the  end  ocardial  disease  is  not 
known.  This  form  of  endocarditis  has  not  been  definitely  diagnosticated 
except  in  those  instances  where  the  blood  of  the  patient  was  contaminated 
with  some  form  of  septic  or  poisonous  material. 

And  in  all  such  cases,  more  or  less  of  the  bacterial  forms  have  been 
found  present  wherever  microscopic  examinations  have  been  made  by 
those  competent  to  observe.  Yet  their  presence  in  these  cases  by  no 
means  justifies  the  conclusion  that  they  are  the  cause  of  the  disease,  either 
of  the  blood  generally,  or  of  the  local  affection  of  the  heart.  A  very  in- 
teresting and  marked  complication  which  occurs  with  many  of  these  cases 
of  acute  ulcerative  inflammation  of  the  endocardium,  is  the  formation  of 
multiple  abscesses  ;  not  in  the  heart  structure,  but  they  are  found  in  dis- 
tant organs.  The  organs  most  frequently  exhibiting  these  small  abscesses 
are  the  spleen,  kidneys  and  liver.  Whether  such  abscesses  are  produced 
by  the  invasion  of  some  of  these  detached  granules  containing  the  micro- 
cocci, or  by  minute  emboli  formed  in  the  heart,  or  whether  they  originate 
from  the  same  condition  of  the  blood  which  had  produced  the  endocar- 
dial disease,  investigation  has  not  determined.  Neither  is  it  a  point  of 
much  practical  importance.  As  I  have  stated  these  cases  of  ulcerative 
endocarditis  have  thus  far  uniformly  terminated  fatalh^  ;  no  treatment 
having  proved  successful,  and  from  the  very  nature  of  the  case  there  is  no 
reasonable  probability  that  treatment  will  ever  succeed  in  correcting  the 
morbid  condition  in  time  to  prevent  the  death  of  the  patient.  The  most 
important  direction  to  be  given  in  regard  to  the  management  of  these 
cases,  is  the  use  of  such  remedies  in  each  individual  case  as  the  more 
prominent  symptoms  may  indicate  ;  always  keeping  in  mind  that  the 
liberal  use  of  such  antiseptics  and  germicides  as  can  be  introduced  into 
the  blood  rapidly  and  with  safety,  and  in  addition  such  remedial  agents  as 
directly  tend  to  support  the  strength  of  the  patient,  and  as  far  as  possible 
maintain  the  nutritive  processes,  will  afford  the  best  chance,  both  of  palli- 
ating the  patient's  condition,  and  producing  recovery,  if  the  latter  were 
possible.  In  other  words  the  treatment  is  really  the  same  as  that  which 
is  required  in  the  more  severe  cases  of  pysemia  and  other  well  known 
forms  of  blood  poisoning.  I  have  now  completed  the  consideration  of  the 
inflammations  liable  to  affect  the  central  organs  of  the  ctrculatioa. 


LECTURE  L. 

Infiammntion  of  theOrgnns  of  Digestion;  the  several.parts  or  structures  inc^'urlcd— Iriflammatoiy 
aftectioiis  oithi.- mucous  membrane  of  the  mouth  and  lauces  and  its  appendages;  tlieir  clinical 
histury,  diagnosis  and  treatment. 

GENTLEMEN:  The  digestive  apparatus  includes  the  mucous  membrane 
of  the  mouth  and  fauces,  the  salivary  glands,  the  tonsils,  the  tongue, 
oesophagus,  stomach,  duodenum,  small  intestinos,  colon  and  rectum,  togeth-' 


490  STOMATITIS. 

er  with  the  2:landular  organs  connected  therewith,  the  more  important  of 
which  are  the  liver,  spleen,  pancreas  and  mesenteric  glands.  Inflammation 
in  its  various  grades  of  activity  may  occur  in  any  and  all  of  these  portions 
separately,  or  it  may  occur  in  several  of  them  simultaneously.  1  shall 
consider  them,  however,  as  they  relate  to  each  of  the  prominent  divisions  of 
the  apparatus  already  mentioned,  commencing  with  the  mouth. 

Stumatitis. — Many  writers  use  the  word  stomatitis  to  designate  all  the 
various  grades  of  inflammation  in  the  mucous  membrane  of  the  mouth. 
For  practicable  purposes,  we  may  include  these  several  inflammatory  con- 
ditions under  the  following  heads:  Diffuse  or  superficial  inflimmation, 
apthous  and  follicular,  mercurial,  nursing,  scorbutic,  ulcerative,  and  gan- 
grenous. The  first  grade  of  inflammation  mentioned,  that  of  diffuse  su- 
perficial inflammation  of  the  membrane  lining  the  mouth,  occurs  in  two 
essentially  distinct  conditions  of  the  system.  The  first  is  the  result  usu- 
ally of  the  action  of  some  local  irritant  applied  directly  to  the  membrane 
itself,  and  may  occur  in  any  or  all  classes  of  subjects.  The  taking  into 
the  mouth  of  substances  at  too  high  a  temperature,  producing  slight 
scalds  or  burns  ;  the  use  of  irritating  liquids,  or  anything  in  contact  with 
the  membrane  of  the  mouth  which  is  capable  of  producing  irritation,  may 
cause  this  form  of  disease.  It  is  much  more  frequently  caused  by  the 
simple  taking  of  liquids  too  hot,  and  the  incautious  use  of  certain  acid 
substances  not  sufficiently  diluted.  The  symptoms  which  accompany 
this  form  of  inflammation  are  a  sense  of  heat,  at  first  dryness,  followed 
by  increased  flow  of  saliva,  and  soreness  of  the  inflamed  membrane,  while 
to  the  eye  it  looks  red,  and  slightly  tumefied.  There  are  some  substances 
capable  of  exciting  superficial  inflammation  of  the  membrane  when  ap- 
plied to  it,  that  instead  of  being  followed  by  redness,  seem  to  contract  the 
vessels  of  the  surface  and  so  alter  it  as  to  cause  increased  paleness  or  a 
white  instead  of  a  red  and  congested  appearance.  Sucii  is  the  case 
wMth  the  application  of  carbolic  acid  of  sufficient  strength,  and  of  creasote. 
When  the  inflammation  is  simply  of  a  superficial  character,  arising  from 
any  of  the  various  causes  to  which  I  have  alluded,  it  usually  runs  its 
course  and  subsides  with  little  or  no  treatment  in  a  few  days.  When  it 
is  more  severe,  however,  and  the  services  of  the  physician  are  required,  on 
account  of  the  intensity  of  the  hot,  burning,  smarting  pain,  and  the  incon- 
venience that  the  patient  suffers,  one  of  the  best  remedies  will  consist  in 
use  of  a  cold  mucilaginous  infusion  to  be  held  in  the  mouth  as  much  of 
the  time  as  the  patient  can  make  convenient.  The  mucilage  of  the  gum 
arabic,  ulmus  fulva,  or  of  Symphytum  officinale  (comfrey)  rendered  cold  by 
small  pieces  of  ice,  are  among  the  best  applications  that  can  be  used  lo- 
cally. After  the  first  stage  of  the  inflammatory  action  is  passed  and  the 
heat  and  smarting  pain  are  less  severe  or  have  passed  away,  if  there  is 
left  some  blush  of  redness,  with  tenderness,  or  the  contact  of  food  is 
painful,  with  a  disposition  to  excessive  flow  of  saliva  as  sometimes  hap- 
pens, from  the  orifices  of  the  salivary  ducts  being  involved  in  the  inflam- 
mation, an  infusion  prepared  by  putting  the  coptis  or  gold  thread  root 
and  sage  leaves  each  four  grams  (3!)  and  borate  of  sodium  six  decigrams 
(gr.  X.),  into  an  ordinary  tea-cup,  two  thirds  full  of  boiling  water,  to  which 
may  be  added  a  little  white  sugar  or  honey,  and  the  mouth  freely  rinsed 
or  gargled  with  it  every  three  or  four  hours  during  the  day  will  give 
additional  relief.  If  at  any  time  during  the  progress  of  the  case  the 
patient's  bowels  are  found  to  be  inactive,  or  if  any  feverishness  is  mani- 
fested, it  will  be  well  to  give  a  dose  of  some  saline  laxative,  sufficient  to 
procure  from  one  to  three  intestinal  evacuations.  In  the  great  majority  of 
cases  any  one  of  the  local  remedies  I  have  named,  together  with  the  use  of 


THRUSH    OR    MIGUET.  491 

as  bland,  anirritatiiig  nourishment  as  possible,  will  constitute  all  tlie  treat- 
ment that  will  be  needed.  The  other  vaiiety  of  diffuse  superficial  inflam- 
mation is  liTnited  in  its  occurrence  almost  entirely  to  patients  sufferin2;from 
imperfect  nutrition.  The  great  majority  of  cases  are  in  young  children, 
commencing  i^efore  the  end  of  the  first  week  after  birth;  and  are  caused  by 
afailureof  nutrition,  either  from  the  reception  of  an  insufficient  supply  of 
milk,  or  an  inability  to  assimilate  what  it  does  receive.  Under  such  cir- 
cumstances, somewhere  from  the  second  to  the  fifth  day,  the  child's  mouth 
begins  to  show  a  general  increase  of  redness  of  the  mucous  membrane,  and 
during  the  next  twenty-four  hours  this  meml)rane  will  become  dotted 
over  with  small  specks  of  a  white  curdy  exudation  upon  the  surface;  or 
it  may  be  so  completely  covered  with  the  exudation  as  to  render  the  whole 
surface  of  the  mouth,  gums,  edges  of  the  tongue  back  to  the  fauces, 
completely  white.  But  if  there  are  any  places  where  this  white  covering 
is  either  detached  or  scraped  ofl',  the  membrane  itself  will  be  seen  red  and 
slightly  tumefied.  This  condition  of  the  mouth  in  nursing  children  is 
familiarly  called  thrushy  and  by  the  French,  miguet. 

In  many  of  them,  soon  after  this  condition  of  the  mouth  appears,  the 
the  skin  shows  a  peculiar  sallow  hue  somewhat  resembling  jaundice,  and 
dark  purplish  red  spots  make  their  appearance  upon  the  skin,  more  partic- 
ularly over  the  face  and  upper  part  of  the  chest.  When  this  alteration  of 
color  in  the  cutaneous  surface  and  the  red  spots  appear,  the  nurses  call  it 
red  gum.  Most  of  the  children  suffering  from  the  disease  to  the  extent 
I  have  indicated,  are  drowsy  or  inclined  to  sleep,  sometimes  to  such  an 
extent  as  to  make  it  difficult  to  arouse  them  sufficiently  to  take  nourish- 
ment either  by  nursing  or  from  the  spoon  when  fed.  Very  generally,  the 
bowels  are  at  first  inactive,  the  urinary  secretion  scanty,  and  in  some  in- 
stances suppressed. 

My  attention  was  called  to  a  child  only  three  days  old,  a  few  weeks 
since,  in  which  the  bowels  had  not  moved  for  forty-eight  hours,  and  there 
had  been  no  secretion  of  urine  whatever  during  the  whole  period  of  time. 
The  child  was  exceedingly  drowsy,  had  all  the  symptoms  of  thrush  and 
the  red  spots  upon  the  skin  which  I  have  mentioned,  but  gave  no  signs  of 
urremic  disturbance  except  an  occasional  sudden  starting  from  the  drowsy 
condition,  and  immediately  lapsing  into  it  again.  In  most  of  these  cases, 
about  the  third  day  after  the  appearance  of  the  curdy  exudations  upon  the 
surface  of  the  membrane  lining  the  mouth,  it  begins  to  disintegrate,  and  dur- 
ing the  next  two  or  three  days  it  usually  disappears.  If  the  patient  has 
been  improving  as  these  exudations  disappear,  the  membrane  of  the 
mouth  then  shows  more  nearly  a  natural  color;  the  breath  is  free  from  of- 
fensiveness,  and  all  the  symptoms  of  disease  speedily  disappear.  But  in 
cases  in  which  the  cause  of  the  difficulty  has  not  been  removed,  the  disap- 
pearance of  the  curdy  exudation  is  accompanied  by  a  slight  offensive 
odor,  with  superficial  abrasions  of  the  mucous  membrane,  particularly 
along  the  edges  of  the  tongue,  the  gums,  and  sometimes  on  the  inside  of 
the  lips  and  the  central  part  of  the  cheek,  constituting  the  slightest  form 
of  the  ulcerative  abrasions  of  the  membrane  of  the  mouth.  The  other 
circumstances  in  which  this  same  form  of  inflammation  of  the  mouth  oc- 
curs in  adult  life,  are  extreme  emaciation  from  the  influence  of  some  pre- 
existing disease,  such  as  tubercular  phthisis,  chronic  diarrhoeas,  dysentery, 
or  any  other  form  of  disease  that  is  capable  of  producing  extreme  im- 
poverishment of  blood  and  wasting. 

When  this  stage  of  extreme  impoverishment  supervenes,  in  the  progress 
of  wasting  diseases  the  patient  generally  complains  first  of  simple  tender- 
ness and  heat  in  the  mouth,  as  if  it  had  been  slightly  burned.     On  inspac-. 


402  STOMATITIS.       ' 

tioii,  tha  membrrine  covering  the  fauces  and  usually  the  edges  of  the 
tongue,  will  be  seen  unnaturally  red,  with  small  patches  of  a  white  curdy 
exudation  on  its  surface.  In  some  cases  these  patches  increase  in  size 
until,  as  in  the  very  young  children,  a  large  part  of  the  membrane  be- 
comes white  with  it.  In  this  class  of  cases  the  disappearance  of  the 
exudation  is  almost  always  followed  by  more  or  less  destruction  of  the 
membrane,  leaving  irregular  superficial  ulcerations,  which  cause  the  pa- 
tient much  inconvenience  and  suffering  in  attempting  to  take  food  and 
drink.  The  disease  in  these  cases  has  no  natural  tendency  to  recovery  or  is 
not  self-limit  in  duration  unless  the  associated  general  disease  which  has  led 
to  the  impoverishment  is  capable  of  removal;  when  this  is  the  case,  the 
disease  in  the  mouth  ceases  spontaneously,  simply  from  the  removal  of  its 
cause.  As  both  the  thrush  or  curdy  sore  mouth  of  infancy,  and  that  wliich 
occurs  in  adult  life,  originate  from  defective  nutrition,  the  primary  object 
of  the  treatment  must  be  to  restore  this  process  to  the  healthy  natural 
standard  of  activity.  All  local  applications  will  be  merely  palliative  in 
their  effects.  In  young  children  the  most  important  item  in  their  man- 
agement is  to  secure  for  them  a  good  supply  of  healthy  mother's  milk.  If 
the  natural  mother,  from  defects  in  the  nipples,  or  from  inflammation  affect- 
ing the  mammar}'- glands,  or  any  other  cause,  is  rendered  incapable  of  fur- 
nishing the  necessary  nourishment  to  the  child,  it  will  be  of  great  advan- 
tage if  a  healthy  wet  nurse  can  be  found  to  take  her  place.  When  this 
is  inconvenient  or  impracticable,  the  next  best  resort  is  the  use  of  fresh, 
pure  cow's  milk,  to  which  may  be  added  a  tablespoonful  of  lime  water, 
to  each  teacupful  of  milk,  and  just  enough  of  either  sugar  of  milk,  or  ordi- 
nary white  sugar,  to  give  it  a  slightly  sweetish  taste.  By  this  degree  of 
dilution,  and  the  addition  of  a  small  proportion  of  sugar,  the  composition 
of  the  cow's  milk  is  brought  as  near  to  that  of  the  mother's  or  human  milk 
as  can  be  conveniently  done;  while  the  use  of  the  lime  water  as  a  diiutent, 
instead  of  pure  water,  gives  the  additional  advantage  of  rendering  the 
coagulation  of  the  casein  in  the  child's  stomach  slower,  and  therefore  less 
likely  to  occur  before  absorption  can  take  place. 

In  the  absence  of  the  ability  to  nurse,  the  rule  for  feeding  the  child 
should  be  to  give  it  just  such  quantities,  and  with  such  frequency  as  will 
appear  to  satisfy  its  appetite.  I  know  of  no  arbitrary  rule  that  can  be 
given  for  the  frequency  of  feeding  infants.  They  differ  much,  one  from 
another,  in  the  frequency  of  their  demands  for  food.  Usually,  when  they 
are  well  supplied,  they  will  be  quiet,  good-natured,  and  rest  well.  But  if 
not  fed  enough,  or  fed  on  material  so  diluted  that  the  tissues  are  starved 
when  the  stomach  is  full,  they  will  persistently  cry  or  worry  until  they 
have  a  better  supply.  And  yet  both  mothers  and  nurses  sometimes  mis- 
take the  crying  as  indicative  of  colic,  and  dilute  the  food  still  more,  only 
to  be  annoyed  by  the  increased  restlessness  and  worrying  of  the  child. 
After  providing  the  child  with  an  adequate  amount  of  some  proper  form  of 
nourishment,  the  only  other  remedies  required,  usually,  are  such  as  will 
secure  a  moderate  movement  of  the  bowels  about  once  in  twenty-four 
hours,  and  promi:,te  the  renal  secretion  where  this  is  defect- 
ive, internally,  and  the  application  of  some  very  mild,  slightly  astringent 
solution  to  the  mouth.  The  best  laxative  in  most  cases  where  this  is  re- 
quired consists  of  an  infusion  of  manna,  anise  seed,  and  soda.  Four 
grams  (3i)  of  manna,  half  that  quantity  of  anise  seed,  bruised,  and  five  deci- 
grams (gr.  viii)  of  bicarbonate  of  sodium  may  be  put  into  one  hundred  cubic 
centimeters  (riii)  of  water  boiling  hot;  stir  it  up  frequently  till  it  is  cool;  add 
a  little  white  sugar,  and  feed  the  baby  a  teaspoonful  of  this  infusion  every 
two  hours  till  the  bowels  are  moved.     If  the  kidneys  need  prompting,  the 


FOLLICULAR   STOMATITIS.  493 

addition  of  from  one  to  two  minims  of  nitrous  ethar  (s'.veet  spirits  of 
nitre)  to  each  dose  of  the  laxative  will  have  the  desired  effect.  After  the 
bowels  have- been  moved  once  or  twice,  and  the  urinary  secretion  rendered 
sufficient,  if  the  child  appears  debilitated,  with  coldness  of  the  extremities, 
from  two  to  five  minims  of  the  compound  tincture  of  cinchona  may  be 
jriven  in  half  a  teaspoonlul  of  sweetened  water  every  four  or  six  hours. 
For  local  application  to  the  membrane  of  the  mouth  I  have  found  nothing 
more  beneficial  or  more  easily  applied  than  a  powder  composed  of 
alum  six  decigrams,  saccharum  alba  (white  sugar)  eight  grams,  a  small 
portion  of  which  on  the  point  of  a  penknife  may  be  passed  into  the 
mouth  of  the  child,  or  be  placed  upon  the  child's  tongue,  three  or  four 
times  a  day.  The  powder  quickly  dissolves  and  diffuses  itself  into  the 
mouth  more  perfectly,  and  consequently  becomes  applied  to  the  inflamed 
surface  more  efficiently  than  can  be  done  by  any  process  of  swabbing 
which  is  so  frequently  resorted  to  by  nurses  in  these  cases.  Indeed,  the 
frequent  introduction  of  the  ordinary  swab  for  applications  in  this  class 
of  cases  is  usually  productive  of  much  more  harm  than  good,  from  the 
mechanical  irritation  induced. 

No  apprehension  need  be  felt  concerning  the  child's  swallowing  the 
dissolved  powder,  for  the  small  portion  of  alum  that  would  be  con- 
tained in  any  one  of  the  applications  would  have  no  perceptible 
effect  upon  the  child's  stomach.  Usually  the  exudations  rapidly  dis- 
appear under  this  treatment,  no  ulceration  follows,  and  no  additional 
local  applications  are  necessary.  If,  however,  as  occasionally  happens, 
the  disappearance  of  the  exudation  is  accompanied  by  more  or  less  offen- 
siveness  of  the  breath  and  saliva,  and  the  membrane  remains  tender,  or 
slightly  abraded,  it  will  be  well  to  have  the  affected  surface  wet  three  or 
four  times  a  day  with  the  infusion  of  coptis  or  gold-thread,  sage,  and  borax, 
to  which  I  alluded  a  few  moments  since.  In  those  cases  of  this  va-"iety 
of  sore  mouth  occurring  in  the  advanced  stage  of  wasting  diseases,  the 
same  local  applications  will  be  found  as  beneficial  as  any  that  can  be 
used.  The  internal  treatment  must  be  guided  entirely  by  the  more  prom- 
inent disease  which  has  occasioned  the  emaciation  and  suspension  of 
nutrition. 

Follicxdar  StomafAtis. — By  follicxdar  inflammatioyi  of  the  mouth  is 
meant  those  cases  in  which  the  inflammation  is  limited  to  the  follicles  in- 
stead of  its  diUusion  over  the  membrane  generally.  This  form  of  inflam- 
mation is  indicated  by  the  appearance  on  some  portions  of  the  fauces,  in- 
side of  the  cheeks,  inside  of  the  lips,  and  on  the  tongue,  of  little  red  prom- 
inences accompanied  by  a  sense  of  heat,  tenderness  on  taking  food  and 
drinks  into  the  ir>outh,  and  generally,  after  the  first  day,  an  increased  flow 
of  saliva,  if  the  lollicular  disease  has  resulted,  as  is  often  the  case,  from 
derangemeiiLS  ot  the  functions  of  the  stomach  and  the  processes  of  diges- 
tion, it  will  speedily  disappear  whenever  these  derangements  are  corrected. 
In  most  instances  its  natural  tendency  is  to  continue  no  more  than  from 
throe  to  five  days  and  disappear,  leaving  no  ulcerations  or  abrasions  of 
the  membrane.  Another  variety  of  inflammation  more  troublesome,  from 
its  tendency  to  be  .more  protracted  in  its  duration  than  the  follicular,  has 
been  termed  apihous  inflammation  of  the  mouth.  This  appears,  first,  in 
the  form  of  distinct  vesicles,  generally  strictly  oval,  varying  in  size  from 
a  millet  seed  to  the  circumference  of  a  small  pea,  filled  at  first  with  a 
transparent  rather  viscid  fluid.  If  examined  during  this  follicular  stage 
there  will  usually  appear  a  slight  areola  of  redness,  directly  around  the 
base  of  the  visicle. 

In  the  slightest  forms  of  the  disease,  not  more  than  one  or  two  of  these 


494  STOMATITIS. 

vesicles  will  appear  at  a  time  in  the  mouth.  In  other  cases  there  may  be 
three,  four  or  five  vesicles  closely  aggregated  together,  constituting  a 
group,  or  there  raav  be  several  of  these  groups  in  different  parts  of  the 
mouth.  Perhaps  they  more  frequently  appear  on  the  inside  of  the  lips 
and  cheeks  than  elsewhere.  When  they  occur  in  clusters,  the  inflamma- 
tion is  more  severe;  not  only  causing  redness  in  a  narrow  areola  around 
their  base,  but  causing  some  actual  tumefaction  and  slight  hardening  of 
the  parts  on  which  the  vesicles  rest.  The  walls  of  the  vesicles  are  usually 
broken  by  the  motions  of  the  mouth,  in  taking  food,  within  the  first 
twenty -four  or  thirty-six  hours  after  their  appearance.  When  the  walls 
of  the  vesicles  have  broken  and  disappeared  there  is  left  n  slightly  ex- 
cavated ulcer,  with  usually  irregular  edges,  its  surface  being  covered  with 
a  very  thin  white  exudation;  giving  it  the  appearance  of  an  excavated 
irritable  ulcer,  surrounded  by  a  narrow  line  of  redness.  These  are  ex- 
tremely irritable,  causing  a  feeling  of  burning,  smarting,  stinging,  great- 
ly aggravated  whenever  the  patient  makes  those  movements  necessary 
in  talking  or  taking  food  and  drink.  In  most  cases  they  soon  manifest  a 
tendency  to  undergo  repair  and  cicitrization,  and  make  sufficient  progress 
to  render  the  process  of  recovery  complete  in  from  five  to  nine  days. 
Where  they  occur,  however,  in  patients  affected  by  an  unhealthy  consti- 
tutional condition,  whether  scrofulous,  or  simply  impaired  by  bad  sanitary 
surroundings,  such  as  residence  in  impure  air,  damp,  and  cold  rooms, 
and  the  us3  of  indigestible,  or  insufficient  nourishment,  the  ulcers  left 
by  the  disappearance  of  a  group  of  vesicles  under  such  circumstances,  in- 
stead of  putting  on  a  granulating  aspect  and  progressing  toward  recov- 
ery, slowly  spread  until  sometimes  they  occupy  tfie  whole  diameter  of 
the  inside  of  the  cheek,  or  a  large  portion  of  the  inner  surface  of  the  lip; 
keeping  up  a  constant  flow  of  saliva,  accompanied  by  some  degree  of  offen- 
siveneirs  of  the  breath  and  of  the  salivary  secretion.  Nearly  all  the  cases 
of  apthous  inflamniauon  of  the  mouth  have  for  their  cause  derangements 
of  the  digestive  organs  of  such  a  character  as  to  produce  an  undue  amount 
of  acidity  of  the  stomach,  generally  associated  with  constipation,  though 
occasionally  the  reverse  condition  of  the  bowels  will  exist. 

The  treatment  required  both  for  the  follicular  and  apthous  forms  of  in- 
flammation in  the  mouth,  should  have  for  its  object,  first,  the  correction 
of  whatever  derangements  in  the  function  of  the  stomach  and  digest- 
ive apparatus  may  exist,  the  removal  of  the  patient  from  whatever 
bad  sanitary  conditions  he  may  be  placed  in,  the  supply  of  a  sufficient 
quantity  of  good,  easily  digested  food,  and  such  local  applications  as  will 
directly  diminish  the  morbid  sensitiveness  of  the  inflamed  follicular  or 
apthous  ulcers,  and  establish  a  new  or  healthier  molecular  movement 
in  them.  In  the  simple  follicular  grade  of  inflammation  mucilaginous  or 
slightly  astringent  v/ashes  will  constitute  all  the  local  app'ications  re- 
quired. But  the  apthous  ulcers,  a'.ter  the  vesicles  are  broken,  will  be 
most  speedily  changed  to  a  condition  of  repair  and  freedom  from  sensitive- 
ness or  pain  by  touching  them  once  or  twice  in  the  twenty-four  hours  with 
a  smooth  pencil  or  crystal  of  the  sulphate  of  copper.  Placing  the  smooth 
surface  of  the  solid  sulphate  of  copper  for  one  or  two  seconds  directly  upon 
the  surface  of  the  apthous  ulcer,  while  it  produces  momentary  smarting, 
is  almost  invariably  followed  in  the  course  of  an  hour  by  a  great  mitiga- 
tion of  the  burning,  and  all  other  painful  sensations.  Repeating  this  ap- 
plication once  or  at  most  twice  a  day  for  the  first  three  days  is  usually 
sufficient  to  cause  a  rapid  disappearance  of  the  ulcer.  Many  recommend 
an  application  of  a  pencil  of  nitrate  of  silver  to  the  surface  of  these  ulcers 
instead  of  the  sulphate  of  copper.     And  many  use,  instead  of  either  mildly 


MERCUKIAL    STOMATITIS.  495 

asti-ingent  and  antiseptic  washes,  such  as  solutions  of  the  sulphate  of  zinc, 
sulphate  of  iron,  permanganate  of  potassium,  or  some  one  of  the  vegetable 
astringents.  -Of  these,  the  nitrate  of  silver  is  by  far  the  most  efficacious. 
But,  so  far  as  ray  observation  goes,  this  is  not  as  uniformly  and  promptly 
beneficial  as  the  application  of  the  sulphate  of  copper  in  the  manner  I 
have  already  mentioned.  It  generally  blackens  whatever  it  touches,  mak- 
ing it  very  unpleasant  to  use,  and  as  it  possesses  no  adv^antage  in  a  cura- 
tive aspect,  over  the  sulphate  of  copper,  the  latter  should  be  preferred. 
Many  of  these  apthous  ulcers  may  be  relieved,  though  a  little  less  speed- 
ily, by  touching  them  with  a  crystal  or  pencil  of  the  sulphate  of  aluminium 
(alum).  If  this  is  used  it  should  be  held  in  contact  with  the  ulcerated 
surfaces  a  longer  time  than  the  sulphate  of  copper;  but  it  will  not  be  found 
as  promptly  beneficial. 

Mercurial  Stomatitis. — In  former  years,  when  the  mercurial  prepara- 
tions were  much  more  freely  used  in  the  treatment  of  disease  than  at  the 
present  time,  a  severe  inflammation  of  the  mucous  membrane  of  the  mouth, 
gums  and  fauces,  was  not  un frequently  induced,  and  was  known  by  the 
familiar  name  of  salivation.  There  are  a  few  persons  possessed  of  such 
idiosyncrasy,  that  even  the  smallest  quantity  of  mercurials  taken  internally 
will  speedily  result  in  the  establishment  of  an  inflammation  in  the  mucous 
membrane  of  the  mouth,  together  with  more  or  less  irritation  of  the  sali- 
vary glands.  But,  without  any  such  idiosyncrasy,  it  is  well  known  that 
the  continued  administration  of  small  doses  of  mercurials,  more  particu- 
larly of  the  mild  chloride,  blue  mass,  and  the  iodides,  is  liable  to  develop 
this  inflammation  to  a  greater  or  less  extent.  The  first  symptoms  of  the 
presence  of  this  form  of  inflammation  are  tenderness  in  the  sockets  of  the 
teeth,  a  peculiar  fetid  odor  of  the  breath,  and  a  slightly  swollen  and  bluish 
line  along  the  edges  of  the  gums  around  the  teeth.  The  observant  prac- 
titioner may  frequently  detect  this  odor  of  the  breath,  and  note  the  change 
in  the  appearance  of  the  edge  of  the  gums  before  the  patient  has  suffered 
sufficient  inconvenience  to  attract  his  attention.  But,  from  this  slight 
beginning,  if  the  remedy  has  been  administered  in  sufficient  quantity 
and  suffered  to  accumulate  in  the  system,  the  inflammation  will  extend 
over  the  entire  mucous  membrane  of  the  mouth,  causing  it  to  become  red- 
dened and  swollen,  with  tumefaction  of  the  tonsils  and  fauces,  and  an  in- 
creased flow  of  saliva. 

In  bad  cases,  four  or  five  days  after  the  commencement  of  the  inflam- 
mation, a  large  portion  of  the  teeth  will  be  fijund  loose,  the  gums  swollen 
and  commencing  to  ulcerate,  with  superficial  ulcerations  along  the  inside 
of  the  cheeks  and  lips  and  over  the  fauces,  which  together  with  the  swell- 
ing of  the  salivary  glands,  will  often  impede  the  opening  of  the  mouth 
l)eyond  a  very  limited  extent,  and  occasion  a  constant  flow  of  saliva. 
There  is  a  sense  of  heat,  burning,  and  often  decided  pain,  particularly  in 
the  fauces,  along  the  roots  of  the  teeth,  sometimes  radiating  through  the 
branches  of  the  nerves  supplying  not  only  the  teeth,  but  the  sides  of  the 
face,  even  up  through  the  temples  and  backward  over  the  mastoid  region. 
In  the  more  severe  cases  the  tongue  partakes  of  the  inflammation  and  be- 
comes much  swollen;  adding  to  the  difficulty  of  swallowing  or  taking 
either  nourishment  or  medicine;  sometimes  preventing  the  patient  from 
closing  his  mouth,  and  keeping  the  swollen  tongue  constantly  protruding 
beyond  the  teeth  and  suspending  the  ability  to  perform  deglutition,  as 
well  as  occasioning  considerable  difficulty  in  breathing.  In  all  these  cases 
the  breath  and  saliva  have  a  very  ofi'ensive  odor,  so  peculiar  as  to  be  at 
once  recognized  by  the  practitioner  as  diagnostic  of  this  form  of  disease. 
When  the  mercurial,  which  has  been  the  cause  of  the  disease,  has  not  been 


496  STOMATITIS. 

administered  aftor  the  supervention  of  the  symptoms  of  salivation,  the 
usual  tendency  of  the  infiaramation  is  to  reach  its  climax  of  severity  in 
from  three  to  five  days  after  its  commencement.  In  the  milder  class  of 
cases  soon  after  this,  it  spontaneously  begins  to  decline,  all  the  unpleasant 
symptoms  diminish  from  day  to  day,  and  at  the  end  of  the  second  w^eek 
the  mouth  will  generally  have  returned  to  its  natural  condition.  In  the 
more  severe  cases,  however,  the  climax  of  the  tumefaction  of  the  tongue, 
and  parts  inflamed  throughout  the  mouth,  will  not  be  reached  until  from 
seven  to  nine  days.  And  in  some  cases,  when  this  climax  is  reached,  the 
symptoms  continue  with  but  little  abatement  for  almost  as  much  longer, 
and  then  slowly  decline,  until  at  the  end  of  from  four  to  six  weeks  all  the 
more  important  consequences  of  the  inflammation  have  disappeared.  I 
have  not  known  any  cases  of  mercurial  salivation  to  terminate  fatally.  But 
when  the  inflammation  has  been  very  severe  and  protracted,  the  gums 
have  been  so  far  destroyed,  and  the  teeth  loosened  from  their  sockets,  that 
it  became  necessary  for  their  removal;  in  some  instances  the  inflammation 
has  extended  to  the  periosteum  of  one  or  both  jaw-bones,  ending  in  more 
or  less  necroses. 

Such  is  the  general  course  of  the  different  degrees  of  salivation,  or  in- 
flammation induced  by  the  incautious  use  of  mercurials.  Forty  years 
since,  during  the  earlier  years  of  my  professional  life,  I  saw  many  cases  il- 
lustrating all  the  various  grades  of  inflammation  produced  by  mercurials. 
But  the  change  which  has  taken  place  in  the  administration  of  this  class 
of  remedies  has  been  such  that  I  have  met  with  very  few  instances,  and 
these  of  the  milder  character,  during  the  last  twenty-five  years. 

Treatment. — In  the  treatment  of  mercurial  inflammation  of  the  mouth, 
of  course  the  further  use  of  mercurial  preparations  must  be  dispensed 
with  ;  the  patient  placed  at  rest  on  the  use  of  the  most  bland  and  simple 
nourishment,  such  as  milk,  thin  wheat  flour  and  milk  gruel,  oat  meal 
gruel,  beef  tea  or  other  animal  broths,  in  sufficient  quantities  to  sustain 
nutrition,  and  all  attempts  to  use  solid  food  or  articles  requiring  mastica- 
tion should  be  avoided.  It  is  better  that  the  bowels  be  kept  in  a  regular 
condition,  either  by  the  mildest  laxatives  or  enemas,  while  all  drastic  ar- 
ticles of  physic  are  worse  than  useless. 

For  ameliorating  the  condition  of  the  mouth,  I  have  found  nothing  more 
valuable  than  a  solution  of  the  chlorate  of  potassium  in  mucilage  of  gum 
arable,  with  tincture  of  belladonna  added  in  such  proportions  that  with 
each  dessert  spoonful  of  the  solution  the  patient  would  get  from  three  to 
five  decigrams  (gr.  v-iii)  of  the  chlorate  and  from  one  third  to  one  fifth  of  a 
centimeter (min.  iii-v)  of  the  tincture,which  quantity  may  be  given  profit- 
ably as  often  in  the  milder  cases  as  once  in  six  hours,  and  in  those  more 
severe  every  two  or  three  hours,  until  the  symptoms  have  materially  im- 
proved. In  those  cases  in  which  there  is  acute  glossitis.,  or  inflammation 
and  much  tumefaction  of  the  tongue,  I  have  thought  the  iodide  of 
potassium  given  in  the  same  manner  and  in  the  same  doses  as  the  chlorate 
exerted  a  more  beneficial  influence. 

In  the  later  stages  of  the  disease,  when  patients  have  become  consider- 
ably debilitated,  and  the  ulcerations  in  the  mouth  seem  disposed  to  heal 
slowly,  an  increased  amount  of  nourishment  should  be  given  and  the  use 
of  compound  tincture  of  cinchona,  or  tincture  of  the  chloride  of  iron,  may 
be  substituted  for  the  chlorate  of  potassium  or  the  iodide.  For  local 
remedies  directly  to  the  mouth,  weak  solutions  of  carbolic  acid  or  perman- 
ganate of  potassium  are  perhaps  the  best,  particularly  in  all  the  earlier 
stages  in  the  progress  of  the  inflammation.  When  the  flow  of  saliva  is 
very  profuse  I   have  thought  the  addition  of  belladonna  to  the  solutions 


STOMATITIS    MATERI?!.  497 

either  of  the  permanganate  or  carbolic  acid  had  some  effect  in  lessening  this 
flow,  and  consequently  aided  in  relieving  the  patient.  But  it  is  with 
the  same  motive,  namely,  to  aid  in  checking  the  flow  of  saliva  by  its  in- 
fluence upon  the  vaso-motor  nerves  that  I  add  belladonna  to  the  solutions 
of  chlorate  of  potassium  and  iodide  of  potassium,  as  I  have  already  rec- 
ommended for  internal  use.  When  the  disease  has  passed  its  climax  and 
the  ulcerations  in  the  mouth  are  inclined  to  heal  but  slowly,  or  re- 
main stationary,  you  sometimes  derive  much  advantage  from  the  use  of 
local  applications  of  a  more  stimulating  or  astringent  quality.  The  infu- 
sion of  coptis  root  and  sage  leaves,  as  already  mentioned;  infusions  of  the 
geranium  maculatum  root,  or  of  calamus  (sweet  flag)  root  will  be  found 
among  the  best,  as  washes  to  be  applied  freely  to  the  whole  surface 
of  the  mouth  and  fauces  three  or  four  times  a  day.  In  some  rare  instances, 
individual  ulcers  assuming  a  more  indolent  form,  may  be  benefited  by 
touching  them  directly  with  the  solid  sulphate  of  copper  in  the  same  man- 
ner as  mentioned  in  the  treatment  of  apthous  ulcers. 

Sloynatitis  Materni. — The  disease  commencing  in  the  mouth  designated 
as  nursing  sore  moicth^  is  peculiar  to  women  during  the  period  of  nursing, 
and  in  some  cases  during  the  advanced  stage  of  pregnancy.  It  appears 
to  originate  from  a  deficiency  in  the  relative  proportion  of  some  of  the 
constituents  of  the  blood  needed  for  maintaining  healthy  nutrition, 
caused  by  the  separation  of  too  large  a  proportion  of  those  ingredients  for 
the  nutrition  of  the  foetus  in  the  latter  months  of  utero-gestation,  and  still 
more  in  the  milk  secreted  during  the  period  of  nursing.  Precisely  which 
of  the  elements  of  the  blood  necessary  for  maintaining  nutritive  processes 
are  deficient,  has  not  been  ascertained.  Examination  with  the  microscope, 
together  with  some  chemical  analyses  made  by  myself  several  years  since, 
led  me  to  the  conclusion  that  there  was  deficiency  both  in  the  chlorine 
and  the  phosphatic  salts  in  the  serum  of  the  blood,  avid  some  degree  of 
deficiency  in  the  hasmatin,  or  the  particular  form  of  iron  necessary  for  the 
formation  of  the  red  corpuscles.  But,  without  attempting  to  define  posi- 
tively the  particular  change  in  the  condition  of  the  blood  which  precedes 
and  accompanies  this  form  of  sore  mouth,  it  is  sufiicient  for  our  present 
purpose  to  recognize  the  well  established  clinical  fact  that  the  disease 
originates  and  progresses  only  during  the  period  when  there  is  a  drain 
upon  the  nutritive  elements  of  the  mother's  blood,  of  such  materials  as 
are  required  to  nourish  her  infant,  either  in  the  advanced  period  of  its 
growth  before,  or  durino;  the  most  rapid  period  of  its  development  after, 
birth.  The  great  majority  of  cases  of  this  kind  commence  in  from  two  to 
eight  weeks  after  the  confinement  of  the  mother,  and  the  commencement 
of  her  nursing.  It  is  not  very  uncommon,  however,  for  it  to  commence  at 
a  later  period,  and  a  smaller  number  not  only  begin  but  make  con- 
siderable progress  during  the  last  two  months  of  pregnancy. 

Symptoms. — The  initial  symptoms  of  the  disease  are  usually  a  feeling  of 
heat  and  tenderness  along  the  edges  of  the  tongue,  the  inside  of  the  cheeks, 
and  a  little  later,  the  inside  of  the  lips  and  the  edges  of  the  gums.  On  ex- 
amining the  mouth  at  a  very  early  period,  the  parts  aflPected  will  present 
only  a  slightly  reddened  and  granular  appearance  as  though  the  epithelial 
layer  of  the  membrane  had  been  disturbed.  A  few  days  later  there  will 
be  very  distinct  red  spots  upon  the  edges  of  the  tongue,  sometimes  upon 
the  interior  face  of  the  fauces,  inside  of  the  cheeks,  varying  in  size  from 
the  head  of  a  pin  to  elevated  patches  the  size  of  a  silver  half  dime.  Usu- 
ally the  inflammation  thus  begun  in  the  membrane  of  the  mouth  extends 
pretty  rapidly  until  in  a  few  weeks'  time  it  will  occupy  the  greater  part 
oi  the  membrane  lining  the  inside  of  the  cheeks,  the  lips,  edges  of 
32 


498  STOMATITIS   MATERNI. 

the  tongiie,  and  along  the  gums  and  fauces.  In  many,  the  tonsils  become 
slightly  swollen  as  well  as  the  sub-maxillary  and  sub-lingual  glands,  caus- 
ing a  considerably  increased  flow  of  saliva  and  a  constant  sense  of  heat 
or  smarting  greatly  aggravated  whenever  the  patient  attempts  to  take 
either  food  or  drink.  In  the  meantime  the  general  condition  of  the  pa- 
tient shows  progressive  impoverishment,  by  a  paler  countenance,  some  loss 
of  flesh,  decided  feelings  of  weakness  or  weariness  on  slight  exertion,  a 
little  quickening  of  the  pulse,  sometimes  headache,  and  in  the  earlier 
stages  moderate  constipation  of  the  bowels.  In  some  instances  the  pa- 
tients often  complain  of  much  dull  aching  pain  and  a  sense  of  weariness, 
especially  in  the  lower  extremities  during  the  latter  part  of  the  afternoon 
and  evening,  with  slight  elevation  of  the  temperature  above  the  natural 
standard.  The  more  inflamed  patches  of  the  membrane  lining  the  mouth 
gradually  soften  and  disintegrate,  presenting  appearances  of  irregular  su- 
perficial ulcerations.  The  saliva  and  breatla  become  more  or  less  offen- 
sive. 

In  many  cases  the  disease  extends  slowly  but  steadily  backward  over 
the  pharynx,  adding  difficulty  and  pain  in  deglutition,  and  sooner  or 
later  attacking  the  membrane  lining  the  stomach.  Its  invasion  of  the 
gastric  mucous  membrane  is  marked  by  feelings  of  heat,  or  burnmg  in  the 
stomach,  greatly  aggravated  whenever  the  patient  takes  food,  and  after 
making  progress  for  one  or  two  weeks,  destroys  the  appetite  and  prompts 
the  patient  to  frequently  reject  by  vomiting  even  the  i^landest  articles  of 
nourishment.  The  patient,  now  being  able  to  take  and  retain  but  a 
very  small  amount  of  nourishment,  becomes  much  more  rapidly  impover- 
ished than  while  the  disease  was  confined  to  the  mouth  and  fauces.  If  no 
measures  are  taken  to  counteract  the  progress  of  the  disease,  evidences  of 
inflamed  patches  of  the  mucous  membrane  of  the  ilium  are  added  to  those 
of  the  stomach.  Sensations  of  more  or  less  heat  or  burning,  and  occasion- 
ally griping  pains,  are  felt  in  the  abdomen,  with  increased  peristaltic 
motion,  and  now,  instead  of  a  tendency  to  constipation  the  bowels  become 
loose,  often  giving  rise  to  from  four  to  six  or  eight  thin  reddish  brown  pas- 
sages every  twenty- four  hours.  The  disease,  having  thus  invaded  a 
large  portion  of  the  mucous  membrane  of  the  mouth,  stomach,  duodenum, 
and  lower  half  of  the  small  intestine,  deprives  the  patient  of  the  ability  to 
eithe]-  receive  or  digest  noxirlsliment  on  the  one  hand,  and  to  undergo 
sufficiently  active  wasting  from  the  diarrhoea  on  the  other,  to  cause  so  much 
emaciation  and  loss  of  strength  as  to  compel  her  to  take  her  bed.  And  if 
the  nursing  pi-ocess  is  continued,  the  disease  and  exhaustion  progress 
with  steadily  increasing  rapidity  until  the  destruction  of  a  large  portion 
of  the  mucous  membrane  of  the  alimentary  canal  has  taken  place,  when 
the  discharges  become  involuntary,  the  urinary  secretion  nearly  sup- 
pressed, and  the  patient  dies  from  asthenia,  or  exhaustion.  Such  is  the 
clinical  history  of  severe  cases  of  this  form  of  disease,  when  it  is  allowed 
to  take  its  own  course  uncontrolled  by  appropriate  treatment,  or  by  the  re- 
moval of  its  cause.  But  there  are  very  many  milder  cases  in  which  the 
inflammation  is  limited  dui-ing  the  whole  period  of  its  progress  to  the 
membrane  of  the  mouth  and  fauces  causing  the  mother  much  inconven- 
ience and  suffering,  and  yet  not  destroying  her  ability  to  maintain 
sufficient  nutrition  to  go  through  the  ordinary  period  of  nursing,  at  least 
nine  or  twelve  months,  and  on  the  cessation  of  this  process  by  weaiiing 
of  the  child,  the    mouth  speedily  heals  and  her  usual  health  is  restored. 

There  are  many  other  cases  of  considerable  severity,  in  which  the 
mother,  by  the  use  of  appropriate  remedies  and  diet,  and  the  addition  of 
good  hygienic  surroundings,  may  so  far  control  the  progress  of  the  disease 


TREATMENT.  499 

as  to  secure  entire  relief  and  continue  her  nursing.  In  many  cases, 
however,  the  best  treatment  will  only  hold  the  disease  so  far  in  abeyance 
that  the  suffering  amounts  to  no  more  than  an  uncomfortable  tenderness 
and  feeling  of  heat  in  the  mouth,  increased  while  taking  food,  but  not 
interfering  with  the  process  of  nutrition  sufficient  to  prevent  her  from 
continuing  the  duties  of  her  household  throughout  the  whole  period  usu- 
ally allotted  to  nursing.  My  attention  was  first  strongly  directed  to 
this  form  of  disease  nearly  forty  years  since.  I  then  studied  a  few  cases 
with  much  care,  watching  closely  the  influence  of  different  remedial 
agents,  and  also  chemically  and  microscopically  examining  the  composi- 
tion of  the  blood,  until  I  became  satisfied  that  the  elements  chiefly  ex- 
hausted, or  reduced  to  too  small  a  proportion  for  the  proper  nutrition  of 
the  mother,  were  the  phosphatic  compounds,  and  perhaps  in  a  less  degree 
the  chlorine  salts.  Becoming  satisfied  of  the  general  correctness  of  this 
conclusion  I  have  since  treated  all  the  cases  that  have  come  directly  un- 
der my  own  care,  mainly,  with  the  view  of  increasing  the  amount  of  these 
agents  in  the  blood,  and  the  result  has  been  entirely  satisfactory. 

Treatryient. — At  the  period  of  time  to  which  I  allude,  a  case  of  the  dis- 
ease occurred  in  my  own  family.  As  it  was  very  desirable  to 
avoid  taking  the  child  from  the  mother's  breast,  I  procured  as  emi- 
nent counsel  as  could  be  obtained  then  in  the  city  of  New  York, 
and  the  patient  was  treated  for  four  months  with  the  best  diet  and  what 
was  deemed  the  most  efficient  tonics,  including  the  various  preparations 
of  iron,  quinine,  the  different  preparations  of  cinchona  and  other  bitter 
tonics,  aided  by  the  liberal  use  of  milk-punch,  egg-nog,  and  all  the  class 
of  agents  supposed  to  be  capable  of  sustaining  strength  and  promoting 
nutrition.  But  the  disease  steadily  increased,  apparently  being  in  no 
sense  controlled  or  modified  by  the  treatment  adopted,  until  at  the  end 
of  the  four  months  the  mother  had  become  so  much  reduced,  that  it 
was  deemed  no  longer  safe  to  allow  nursing  to  proceed;  and  consequently 
the  child  was  removed  from  her  breasts.  The  further  secretion  of  milk 
soon  ceased  and  was  followed  directly  by  indications  of  improvement  in 
the  condition  of  the  mouth  and  stomach,  and  in  a  few  weeks  without  any 
other  remedial  influences  the  mother  had  recovered.  It  was  the  unsatis- 
factory result  of  the  treatment  in  this  case  that  led  to  the  further  study 
of  the  pathological  condition  of  the  blood  to  which  I  have  already  al- 
luded. Acting  upon  the  hints  gained  in  that  study,  I  commenced  in 
all  the  subsequent  cases  that  came  under  my  observation  in  their  early 
stage,  while  the  mouth  was  simply  tender  and  burning  with  only  slight 
patches  of  redness  in  it,  to  give  internally  four  cubic  centimeters  of  the 
compound  syrup  of  the  hypophosphites,  or  the  same  quantity  of  the 
syrup  of  the  lacto-phosphate  of  calcium,  immediately  after  each  meal. 

The  patients  have  been  allowed  to  take  no  stimulants,  no  preparation  of 
iron,  but  the  simpler  and  more  easily  digestible  articles  of  food,  being 
careful  that  they  had,  as  far  as  practicable,  access  each  day  to  some  out- 
side air  by  riding,  or  at  least  sitting  in  the  sunshine  outside  the  door. 
When  the  use  of  these  remedies  was  begun  thus  early  they  invariably 
checked  the  progress  of  the  disease.  And  although  I  have  seen  many  of 
these  cases  within  the  last  thirty-five  years,  in  no  instance  where  the  rem- 
edies have  continued  to  be  used  steadily  with  proper  attention  to  diet 
and  good  air,  have  the  patients  failed  to  so  far  keep  the  disease  in  check 
as  to  be  able,  with  only  a  very  moderate  degree  of  inconvenience,  to  go 
through  the  ordinary  period  of  nursing.  The  same  mother  whose  case 
proved  so  obstinate  that  the  child  had  to  be  weaned  after  the  fourth 
month,  in    two    subsequent   pregnancies  began   to  exhibit  the   incipient 


OUU  STOMATITIS    MATEENI. 

stage  of  sore  mouth  about  the  end  of  the  eighth  montli  of  each,  and  it 
slowly  increased  through  the  remaining  month  to  the  time  of  confine- 
ment. The  commencement  of  the  process  of  nursing  was  almost  immedi- 
ately attended  by  an  increase  of  these  manifestations  of  soreness  in  the 
mouth,  bringing  the  disease  to  a  degree  of  development  that  was  unmis- 
takable, when  a  resort  to  the  use  of  the  remedies  I  have  just  named  soon 
arrested  its  further  progress,  and  so  long  as  they  were  faithfully  used  at 
each  meal-time,  the  disease  was  held  so  far  in  abeyance  as  to  leave  at 
times  no  feelings  of  inconvenience  in  the  mouth.  But  if,  as  happened 
several  times  during  the  progress  of  the  period  of  nursing,  the  mother 
feeling  but  little  inconvenience  and  weary  with  the  daily  taking  of  medi- 
cine, neglected  it  for  one  week,  the  symptoms  of  inflammation  were 
again  plainly  manifested.  The  resumption  of  their  use  was  followed 
again  by  the  usual  degree  of  relief.  It  appears  to  me  that  these  cases, 
together  with  others  that  I  had  the  most  favorable  opportunity  to  watch, 
furnish  as  perfect  a  demonstration  of  the  efficacy  of  these  remedial  agents, 
in  supplying  the  needed  materials  to  the  blood,  and  in  consequence  either 
entirely  arresting  or  ameliorating  the  disease,  as  we  could  get  by  any 
process  of  experimentation  on  the  use  of  remedies.  But,  it  is  only  when 
the  treatment  has  been  commenced,  in  the  early  stages  of  the  disease, 
more  particularly  before  it  has  invaded  the  membrane  lining  the  stom- 
ach, or  produced  very  extensive  ulceration  in  the  fauces,  that  it  is  certain 
to  arrest  its  progress.  If  the  use  of  the  remedies  is  delayed  until  the  dis- 
ease has  made  considerable  advancement,  and  especially  after  it  has  in- 
vaded the  membrane  of  the  stomach,  producing  a  tendency  to  reject  food 
and  sometimes  the  medicine  itself,  the  patient  will  continue  to  lose  flesh 
and  strength  and  the  disease  will  continue  to  extend  until  it  occupies  the 
whole  of  the  mucous  membfane. 

There  are  other  remedies,  however,  besides  those  I  have  named,  that 
are  regarded  as  producing  some  beneficial  effect,  and  I  am  quite  sure, 
when  the  patients  are  living  in  a  highly  malarious  district,  the  use  of 
quinine  in  moderate  doses  will  aid  materially  in  retarding  or  arresting 
the  disease.  Chlorate  of  potassium  is  also  a  remedy  which  has  been  used 
with  a  considerable  degree  of  success.  Some  writers  speak  confidently  of 
the  efficacy  of  large  doses  of  the  chlorate  of  potassium,  ten  to  fifteen  deci- 
grams (gr.  XV  to  xxv)  three  times  a  day.  I  have  not  used  this  remedy 
in  such  large  doses,  but  I  have  given  many  patients  a  solution  of  the 
chlorate  of  potassium  in  mucilage  of  gum  arabic  in  doses  of  from  two  to 
three  decigrams  (gr.  iii  to  v)  three  times  a  day  with  decided  advan- 
tage. A  weak  solution  of  chlorate  of  potassium  and  belladonna  may  be 
used  as  a  wash  for  the  mouth  and  gargle  for  the  throat  three  or  four  times 
a  day  also  with  benefit.  Another  excellent  wash  and  gargle,  especially 
after  the  disease  has  progressed  to  superficial  ulceration,  is  the  infusion 
of  coptis  or  gold-thread  root,  sage  leaves  and  a  little  borate  of  sodium, 
prepared  as  I  have  previously  mentioned  in  the  treatment  of  another  form 
of  sore  mouth.  The  burning  in  the  mouth  will  be  much  alleviated  in 
most  cases  by  allowing  the  patient  to  take  frequently  and  plentifully 
of  cold  mucilaginous  fluid,  such  as  solutions  of  gum  arabic,  slippery  elm 
or  comfrey  root. 

They  may  be  made  more  cold  by  placing  in  them  lumps  of  ice.  When- 
ever the  disease  has  progressed  so  far,  before  coming  under  treatment,  as 
to  invade  the  mucous  membrane  of  the  stomach,  or  any  part  of  the  ali- 
mentary canal,  making  it  difficult  for  the  patient  to  retain  food,  or  causing 
more  or  less  wasting  diarrhoea,  it  is  not  proper  to  subject  the  patient  to 
the  further  risk  of  losing   her   health  and,  perhaps,  ultimately  her  life,  by 


SCORBUTIC    STOMATITIS.  501 

continuing  the  process  of  nursing'.  But  the  child  should  be  taken  from 
the  breast  and  provided  for  in  some  other  proper  way,  a  good  healthy  wet 
nurse  being  altogether  the  best  when  it  is  practicable,  and  the  mother  re- 
lieved from  further  drain  occasioned  by  the  secretion  of  milk.  If  this  is 
done,  and  at  the  same  time  the  remedies  I  have  recommended,  together 
with  a  simple  diet  consisting  largely  of  wheat  flour  and  milk  gruel,  or  oat- 
meal gruel,  are  perseveringly  used,  it  rarely  happens  that  improvement 
does  not  commence  within  a  week  and  progress  rapidly  until  the  patient's 
recovery  is  complete.  Only  one  exception  to  this  remark  has  come  under 
my  notice  during  the  whole  period  of  m.y  practice.  It  was  that  of  a  young 
mother  who  had  the  symptoms  of  the  disease  developed  before  the  end  of 
the  first  month  after  she  commenced  nursing.  She  obtained  but  little 
treatment  of  any  kind  during  the  next  three  or  four  months,  until  the  dis- 
ease had  rendered  the  whole  mouth  and  fauces  excessively  sore,  and  the 
mucous  membrane  of  the  stomach  so  far  involved  that  very  little  food  or 
drink  would  be  retained  long  enough  for  absorption,  but  would  occasion 
severe  distress  during  the  little  period  of  tin:e  it  was  retained.  Still  neg- 
lecting to  remove  the  child  from  the  breast  r.fter  another  month,  diarrhoea 
commenced,  and  the  symptoms  of  inflammation  and  ulceration  of  the  mu- 
cous membrane  of  the  ilium  and  parts  of  the  colon  supervened,  with  very 
rapid  exhaustion  of  flesh  and  strength.  Although  at  this  late  period  of 
time  the  nursing  was  stopped,  yet  the  patient  continued  to  have  a  wasting 
diarrhoea,  and  in  the  next  six  months  reached  the  stage  of  fatal  exhaus- 
tion.    I  saw  her  only  in  consultation,  perhaps  six  weeks  before  her  death. 

Scorbictic  /Si07natitis. — Another  afi"ection  of  the  mouth  which  will  re- 
quire a  few  words  of  comment  is  that  form  of  inflammation  which  exists 
in  connection  with  a  scorbutic  condition  of  the  system.  Scurvy,  as  you 
are  aware,  originates  from  a  defect  in  the  supply  of  food;  such  defect 
usually  consisting  in  the  absence  of  a  proper  proportion  of  vegetables 
containing  the  ordinary  fresh  vegetable  juices  and  saline  matters,  until 
these  elements  become  deficient  in  the  whole  mass  of  the  blood.  Among 
the  evidences  of  general  impairment  of  nutrition  in  such  cases,  we  have 
early  the  appearance  of  a  swollen,  reddened  and  sensitive  condition  of  the 
gums  around  the  teeth,  and  to  some  extent  also  of  the  lining  membrane 
of  the  inside  of  the  cheeks,  and  over  the  anterior  face  of  the  fauces.  The 
gums,  particularly,  are  swollen,  tender,  and  bleed  on  the  slightest  touch. 
And  as  the  disease  advances  the  inflammation  follows  the  periosteal  mem- 
brane into  the  sockets  of  the  teeth,  causing  them  to  become  loose,  some- 
times to  the  extent  of  falling  out  spontaneously,  the  gums  become  ulcer- 
ated, with  patches  of  ulceration  all  along  the  inside  of  the  cheeks,  portions 
of  the  fauces  about  the  junction  of  the  jaws,  and  sometimes  the  inner 
surface  of  the  lips.  There  is  much  general  debility,  dullness  of  the  pa- 
tient's sensibilities;  in  many  cases  petechial  spots  on  the  cutaneous  surface, 
slight  hemorrhages  in  the  areolar  tissues,  and  very  frequent  oozing  of 
blood  both  from  the  gums  and  the  nostrils. 

If  the  disease  is  allowed  to  progress,  the  patient  is  apt  to  exhibit  an 
oedematous  condition  of  the  feet,  ankles  and  sometimes  backs  of  the  hands. 
Often  the  face  about  the  eyes  looks  pufi"y  and  bloated,  the  urinary  se- 
cretion becomes  scanty,  general  dropsical  infiltration  of  the  tissues  super- 
venes and  not  infrecjuently  diarrhoea,  hemorrhages  from  the  bowels,  some- 
times vomiting  of  blood,  ultimately  complete  exhaustion,  collapse  and 
death  of  the  patient  takes  place.  This  is  not  the  place,  however,  to  discuss 
the  general  subject  of  scorbutic  disease,  but  only  so  far  as  it  tends  to  in- 
duce inflammation  in  the  mouth.  You  will  sometimes  meet  with  these 
cases  of  scorbutic  inflammation  in  the  mouth  where  you  would  not  suspect 
them. 


502  SCOEBUTIC   STOMATITIS. 

It  has  been  my  fortune  several  times  during  my  residence  here  in 
Chicago  to  meet  with  well  marked  cases  of  this  disease  in  the  poorer  class 
of  families  living  in  bad  sanitary  surroundings,  during  the  middle  and  lat- 
ter part  of  winter  when  fresh  vegetables  were  too  expensive  for  their  use, 
causing  them  to  live  almost  entirely  upon  salted  meat,  bread  and  tea.  In 
two  or  three  different  seasons  when  there  has  been  special  scarcity  of 
fresh  vegetables  in  the  market,  the  children  in  one  of  the  orphan  asylums 
were  almost  all  found  to  be  affected  with  well-marked  scorbutic  inflamma- 
tion of  the  mouth  and  gums;  and  some  of  them  with  characteristic  pete- 
chial spots  on  the  surface,  swelling  of  the  feet,  ankles,  wrist?,  backs  of  the 
hands  and  rheumatic  pains  to  such  an  extent  as  to  be  rendered  entirely 
helpless.  I  recollect,  many  years  ago,  one  of  the  most  active  and  eminent 
members  of  the  State  Medical  Society  (Illinois)  called  the  attention  of 
the  society,  at  one  of  its  meetings,  to  the  fact  that  in  the  open  prairie 
country  in  the  central  part  of  the  State,  he  had  found  well-marked  devel- 
opments of  scorbutic  disease  in  the  families  of  well-to-do  farmers  living 
without  the  use  of  fresh  vegetables  during  almost  the  entire  winter  and 
early  spring.  For  as  he  very  correctly  remarked,  at  that  period  of  time 
many  farmers  in  Illinois  who  possessed  hundreds  of  acres  of  rich  prairie 
lands,  and  sold  thousands  of  dollars'  worth  of  cattle  and  grain  in  the  mar- 
ket would  not  take  the  trouble  to  raise  an  ordinary  supply  of  garden  vege- 
tables for  their  own  use. 

The  essential  treatment  for  this  variety  of  sore  mouth  consists  in  sup- 
plying the  patient  with  bland  nutritious  food,  embracing  a  sufficient 
amount  of  fresh  vegetable  ingredients.  The  use  of  good  potatoes  is  often 
efficient  when  present  in  sufficient  quantities  in  the  market.  Almost 
any  of  those  vegetables  that  contain  plenty  of  the  vegetable  acids  may 
be  used,  if  they  are  palatable  to  the  patient.  In  one  of  the  orphan  asy- 
lums to  which  I  alluded,  in  a  season  when  not  less  than  twenty  or  thirty 
had  become  severely  affected  before  any  medical  aid  had  been  called  for, 
fresh,  tender  rhubarb  stems  or  pie  plant,  stewed,  with  the  addition  of  a 
little  sugar,  making  a  pleasant  tart  sauce,  was  given  to  all  of  them,  very 
much  to  the  gratification  of  their  tastes,  and  certainly  affording  much 
aid  in  their  recovery.  In  addition  to  the  supply  of  proper  nourishment, 
good  air,  and  cleanliness,  the  three  things  most  essential  in  the  treatment, 
some  good  can  be  obtained  by  the  use  of  antiseptic  and  slightly  astrin- 
gent washes;  perhaps  among  the  best  is  a  solution  of  permanganate  of 
potassium,  of  the  strength  of  two  or  three  decigrams  (gr.  iii  or  v)  to 
sixty  cubic  centimeters  (?ii)  of  water,  with  which  the  mouth  may  be 
rinsed  from  three  to  four  times  a  day. 

Another  excellent  wash  for  local  effect  upon  the  mouth  consists  of  car- 
bolic acid  and  sulphate  of  zinc,  each  three  decigrams  (gr.  v),  pure 
glycerine,  ten  cubic  centimeters  (fl.  3'iss)  with  a  hundred  and  seventy- 
five  cubic  centimeters  (fl.  jvss)  of  water.  Some  advantage  may  also  be  ob- 
tained by  the  administration  internally  of  the  compound  syrup  of  the 
hypophosphites  acidulated  with  phosphoric  acid  sufficient  to  give  it  a 
slightly  tart  taste;  and  perhaps  still  better  the  syrup  of  the  lacto-phos- 
phate  of  calcium,  and  a  small  amount  of  the  sulphate  of  quinine  or  some  of 
the  more  palatable  preparations  of  peruvian  bark.  If  diarrhoea  exists  it 
should  be  controlled  by  the  very  cautious  use  of  anodynes,  of  which,  if 
the  stomach  will  retain  it,  small  doses  of  the  compound  powder  of  opium 
and  ipecacuanha  will  be  preferable.  If  this  is  not  well  borne  bj'  the 
stomach,  small  doses  of  carbolic  acid  in  solution  with  camphorated  tinc- 
ture of  opium  may  be  given  as  a  substitute,  the  dose  of  the  two  ingredi- 
ents being  duly  proportioned  to  the  age  of  the  patient. 


GANGRENOUS   SOEE   MOUTH.  503 

Gongrenoxis  Sore  Mouth. — Another  inflammatory  affection  of  the 
mouth  sometimes  though  rarely  met  with,  is  what  I  shall  denominate 
gangrenous  inflammation.  This  appears  in  two  forms.  One,  of  which  I 
have  seen  only  a  few  cases,  is  limited  almost  entirely  to  the  gums.  It  at- 
tacks the  thin  edge  of  the  gums,  causing  that  edge  to  the  depth  of  a  sin- 
gle line  to  turn  an  ash  gray  color,  become  shriveled,  and  in  three  or  four 
days  to  separate  from  the  living  part,  leaving  the  latter  raw,  and  trun- 
cated ill  appearance.  But  in  a  case  that  came  under  my  observation,  in 
three  or  four  days  after  the  separation  of  the  first  slough,  another  layer 
appeared  to  sufl"er  death  in  the  same  way,  and  go  through  the  same  proc- 
ess of  withering,  separating  and  leaving  a  still  deeper  degree  of  ulceration 
and  truncation  of  the  remaining  gums.  Another  of  these  cases  of  disease 
seemed  to  attack,  first,  only  the  gums  around  two  or  three  of  the  front  teeth 
and  extending  directly  from  them  backward,  attacked  the  gums  successive- 
ly until  all  or  nearly  all  of  the  gums  in  the  mouth  had  undergone  the  same 
change.  Cases  of  this  variety  have  been  known  to  extend  from  the  gums 
to  the  alveolar  process,  until  the  teeth  have  been  loosened  and  removed 
from  their  sockets,  the  jaw  denuded  of  its  flesh  and  the  bone  itself  affected 
with  caries.  The  disease  extends  finally  to  the  cheeks,  inducing  a  degree 
of  phagedeenic  ulceration,  which  soon  destroys  all  the  soft  parts,  leaving  an 
open  door  to  the  mouth  through  which  the  saliva  is  constantly  drooh'ng. 
This  causes  rapid  wasting  of  the  patient  like  one  suffering  from  some 
malignant  form  of  disease.  ISuch  instances  generally  end  fatally. 
When  disease  thus  assumes  a  phagedenic  ulcerative  character,  and  des- 
troys the  cheeks  and  soft  parts  of  the  mouth,  it  has  been  denominated  by 
most  writers,  cancrum  orts.  But  this  latter  disease  by  no  means  always 
commences  with  gangrene  of  the  gums.  It  not  infrequently  has  its  be- 
ginning in  small  irritable  ulcers  upon  the  inside  of  the  cheeks  which 
extend  rapidly  in  all  directions  until  they  produce  the  extent  of  de- 
struction I  have  already  alluded  to.  In  most  of  the  cases  that  have  come 
under  my  observation  the  disease  has  been  limited  to  the  gums.  Two 
of  them  recovered  under  constitutional  treatment,  combining  tonics  with 
mild  alteratives,  and  the  use  of  local  astringents  and  slightly  stimulating 
washes. 

One  of  them,  however,  persisted  until  the  safety  of  the  teeth  and  gums 
was  threatened.  The  patient  being  an  inveterate  user  of  tobacco,  he 
was  persuaded  to  discontinue  its  use.  Within  a  week  after  the  discon- 
tinuance of  the  tobacco  the  gums  began  to  improve,  and  continued  to  do 
so  until  recovery  was  complete.  After  getting  entirely  well  and  remaining 
so  for  three  or  four  months,  the  patient  began  again  his  old  habit  of  using 
tobacco,  gradually  increasing  it  until  he  had  returned  nearly  to  his  former 
excessive  use,  when  to  his  surprise  the  disease  again  attacked  his  gums. 
On  omitting  his  tobacco  recovery  soon  took  place;  and  after  going  without 
it  for  a  year  he  resumed  his  old  habit,  which  was  again  followed  by  a  re- 
turn of  the  disease  in  his  gums  and  mouth. 

I  think  all  the  patients  I  have  seen  with  this  form  of  gangrene  have 
been  users  of  tobacco;  and  yet  it  would  be  unfair  to  assume  that  it  was 
the  chief  cause  of  this  disease.  That  the  use  of  this  agent  is  the  chief 
cause  of  many  chronic  affections  of  the  mucous  membrane  of  the  mouth 
and  fauces,  and  that  it  tends  to  perpetuate  or  prevent  the  cure  of  many 
more  having  their  origin  in  some  other  cause,  I  have  no  doubt.  The 
treatment  of  this  form  of  gangrenous  and  ulcerative  sore  mouth  consists 
in  the  use  of  tonics  internally,  and  the  discontinuance  of  all  habits  that 
may  have  an  injurious  influence  upon  the  patient;  mild  and  nutritious  diet, 
and  the  local  application,  first,  of  slightly  stimulating  washes.     If  no  fa- 


504  GAXGREXOUS    SORE    MOUTH. 

vorable  impression  is  made,  one  or  two  applications  of  a  strong  solution 
of  the  chloride  of  zinc,  or  of  the  concentrated  carbolic  acid  will  usually 
60  far  change  the  morbid  action  that  the  subsequent  use  of  milder  astrin- 
gent washes  will  be  sufficient  to  arrest  the  disease.  Some  of  the  cases, 
called  cancrum  oris^  or  eating  ulceration,  occurring  chiefly  in  children, 
are  more  malignant,  and  persist  in  their  destructive  progress  in  opposition 
to  all  remedies.  The  other  form  of  gangrenous  inflammation  of  the  mouth 
to  which  1  alladed,  occurs  usually  in  connection  with  some  one  of  the 
acute  general  diseases,  either  during  the  last  part  of  their  progress  or  in 
the  early  stage  of  convalescence.  The  only  cases  I  have  seen  occurred 
in  connection  with  typhoid  fever  and  small-pox.  The  first  sj-mptom  of 
the  disease  is  usually  the  appearance  of  a  pade,  ash-gray  colored  spot  on 
the  inside  of  the  lip,  or  of  the  cheek,  accompanied  by  considerable  tu- 
mefaction from  exudation  into  the  subjacent  connective  tissue. 

Before  opening  the  mouth  you  will  observe  the  lip  or  the  cheek,  as 
the  case  may  be,  to  be  swollen  exteriorly,  the  skin  a  little  paler  than  nat- 
ural, smooth  or  shining  in  appearance.  Placing  your  finger  upon  the 
surface  you  find  it  more  dense  or  harder  than  natural.  Examining  the  in- 
terior surface,  you  will  find  a  prominent  spot  of  the  size  usually  of  a  half 
dime,  the  central  portion  of  which  presents  a  pale  ash-gray  color  with  a 
dark  areola  around  its  margin.  The  patient  complains  very  little  of  pain 
or  any  kind  of  unpleasant  sensation,  except  the  feelings  of  stiffness  or  in- 
convenience in  the  motions  of  the  mouth. 

The  swelling  as  I  have  described  usually  appears  suddenly.  In  from 
twenty-four  to  forty-eight  hours  after  its  commencement,  this  central  pale 
spot  on  the  interior  of  the  swollen  part  will  have  turned  brown  and  more 
corrugated,  presenting  distinctly  the  appearance  of  a  gangrenous  slough. 
Sometimes  the  gangrene  extends  only  through  the  mucous  membrane, 
or  a  little  way  into  the  subjacent  areolar  tissue.  The  separation  takes 
place  at  the  line  of  the  areola  of  redness,  and  in  four  or  five  days  the 
dead  tissue  becomes  loose,  and  is  removed,  leaving  an  open  ulcer  with  a 
non-granulating  surface  resting  upon  a  rather  hard  base.  In  other  cases 
it  extends  through  the  whole  depth  of  the  tissues  to  the  exterior.  In  the 
more  superficial  cases  due  attention  to  the  patient's  general  condition, 
with  mild  soothing  applications  to  the  ulcer,  will  cause  granulations  to 
spring  up,  and  in  a  brief  time  cicatrization  is  completed  without  resulting 
deformity.  When  the  separation  of  the  slough  leaves  an  opening  direct- 
ly through  the  cheek  or  a  portion  of  the  lip,  leaving  a  gap  through  which 
saliva  drools  from  the  mouth,  and  renders  it  difiicult  for  the  patient  to 
take  his  food,  much  care  is  required  in  the  local  management,  both  for 
the  purpose  of  aiding  the  retention  of  the  saliva  and  in  so  directing  the 
progress  of  repair  as  to  make  the  resulting  deformity  as  little  as  possible. 

One  of  the  most  marked  cases  that  have  come  under  my  observation 
occurred  in  connection  with  a  case  of  confluent  small-pox  many  years 
since.  The  patient,  a  woman  at  the  head  of  a  family,  was  attacked  with 
the  initial  symptoms  of  small-pox  simultaneously  with  her  confinement; 
the  pustules  of  the  small-pox  began  to  show  upon  her  face  in  twenty-four  ' 
hours  after  her  delivery;  and  its  development  proved  severely  confluent. 
She  became  much  enfeebled,  and  just  at  the  completion  of  the  suppura- 
tive stage  of  the  eruption,  gangrene  attacked  the  inner  side  of  one 
cheek,  resulting  in  destruction  of  the  whole  of  the  tissues  and 
leaving  an  opening  exteriorly  at  least  six  lines  in  diameter.  The  pa- 
tient, however,  survived,  and  during  convalescence,  by  keeping  the  open- 
ing exteriorly  so  covered  as  to  prevent  the  contents  of  the  mouth  from 
coming  through,  it  gradually  filled  up  by  granulations  on  the  edges  and 


GLOSSITIS.  505 

by  an  occasional  application  of  nitrate  of  silver,  the  process  was  continued 
until  it  ultimately  closed  the  whole  opening,  leaving  only  a  depressed  and 
unseemly  scar  in  the  center  of  the  cheek.  Another  case  occurred  in  a 
boy  who  suffered  a  long  time  from  angular  curvature  of  the  spine,  and 
in  addition  a  severe  attack  of  typhoid  fever.  Just  as  convalescence  had 
fairly  begun  from  the  fever,  this  form  of  gangrene  attacked  the  inside 
of  the  lower  lip  about  midway  between  the  center  of  the  lip  and  the  an- 
gle of  the  mouth.  It  resulted  in  the  death  of  the  entire  thickness  of  the 
lip,  and  separation  as  a  gangrenous  slough,  from  the  median  line  of  the 
incisor  teeth  to  a  little  beyond  the  angle  of  the  mouth  and  down  to  the 
junction  of  the  lip  with  the  jaw,  taking  out  the  entire  left  half  of  the 
lower  lip. 

Convalescence,  however,  was  not  interrupted  and  after  the  recovery  was 
complete  and  as  good  a  condition  of  general  health  restored  as  he  was 
capable  of  having  with  his  old  angular  curvature  of  the  spine,  there  was 
left  a  large  gap  through  which  the  saliva  and  the  liquids  taken  into  the 
mouth  freely  escaped.  My  colleague  in  the  chair  of  clinical  surgery,  Dr. 
Edmund  Andrews,  at  my  request  then  performed  an  operation  somewhat 
similar  to  that  for  hare- lip,  which  resulted  in  restoring  the  continuity  of 
the  parts,  and  remedying  all  the  inconveniences  the  patient  had  suf- 
fered except  a  straight  seam  where  the  edges  of  the  lip  were  united. 
The  lower  lip  appeared  shorter  than  the  upper.  I  know  of  no  treat- 
ment that  is  required  for  this  form  of  gangrene  in  the  mouth  except 
that  which  is  needed  by  the  general  condition  of  the  patient,  and  the  use 
of  such  antiseptic  applications  as  will  destroy  the  formation  of  septic  ma- 
terial, and  the  ofFensiveness  of  the  odor  during  the  separation  of  the 
gangrenous  parts  from  the  living.  And  after  such  separation  to  so  treat 
the  gaps  that  may  be  left  as  to  leave  the  least  deforiwity  on  the  completion 
of  the  patient's  recovery. 


LECTURE  LI. 


Inflammations  of  the  Organs  of  Digestion,  continued— Glossitis,  Tonsilitis,  etc.;  their  Symptoms, 
Diagnosis,  Prognosis  and  Treatment. 

GENTLEMEN  :  By  glossitis  is  meant  inflammation  of  the  muscular 
structure  and  connective  tissue  of  the  tongue  ;  and  except  in  con- 
nection with  mercurial  salivation,  of  which  I  have  already  spoken, 
it  is  of  rare  occurrence.  The  action  of  some  of  the  corrosive  poisons 
when  taken  into  the  mouth,  and  attempted  to  be  swallowed,  extends 
to  the  substance  of  the  tongue  and  causes  severe  glossitis.  Occasion- 
ally a  case  of  inflammation  involving  the  tonsils,  fauces  and  tongue 
will  be  met  with  in  the  same  patient,  occurring  idiopathically  or 
without  any  known  cause.  Within  the  last  three  days  I  have 
seen  two  cases  of  this  kind  in  which  inflammation  of  an  acute  grade 
attacked  the  tonsils  and  extended  rapidly  over  the  whole  fauces  and  to 
the  root  and  back  part  of  the  tongue.  The  inflammation  steadily  ir.creased 
for  about  three  or  four  days  from  the  commencement  of  the  attack,  when, 


506  GLOSSITIS. 

in  both  instances,  the  tongue  was  sufficiently  swollen  to  make  it  difficult 
for  the  patient  to  retain  it  inside  the  mouth  ;  causing  the  jaws  to  be  kept 
open  and  the  tongue  to  protrude  between  the  teeth.  At  the  same  time 
three  or  four  other  children  in  the  same  family  had  different  degrees  of 
inflammation  of  the  fauces  and  tonsils,  when  one  of  them  presented  a 
diffuse  red  exanthematous  rash  of  moderate  extent,  much  resembling  the 
rash  of  scarlatina.  But  in  neither  those  having  glossitis,  nor  those  having 
simple  sore  throat,  did  their  symptoms  correspond  with  scarlet  fever, 
nor  did  they  show  any  appearance  of  diphtheritic  exudation  upon 
the  surface  of  the  tonsils.  Tlae  disease  ran  a  brief  course  reaching  its 
climax  in  about  four  or  five  days,  then  declined  until  convalescence  was 
reached  at  the  end  of  the  seventh  day.  Such  cases  as  involve  the  fauces 
are  of  frequent  occurrence  during  the  transition  seasons — fall  and  spring, 
but  extension  of  the  inflammation  to  the  tongue  is  quite  uncommon.  The 
symptoms  of  glossitis  are  pain,  usually  of  a  dull  character,  referred  to  the 
region  of  the  larynx  and  roots  of  the  tongue,  much  swelling  or  enlarge- 
ment usually  of  the  whole  body  of  the  tongue,  though  sometimes  it  is 
limited  more  to  the  back  part,  at  others  to  one  half  of  the  tongue  longi- 
tudinally. The  degree  of  swelling  varies  much  in  different  cases,  from  a 
moderate  degree  of  enlargement,  the  tongue  may  swell  so  as  to  fill  up  the 
whole  mouth,  protrude  beyond  the  teeth  and  render  it  almost  impossible 
for  the  patients  to  perform  the  act  of  deglutition.  After  the  first  twenty- 
four  hours  there  is  usually  an  increased  flow  of  saliva,  either  dribbling 
from  the  mouth  when  the  tongue  protrudes  or  accumulating  in  the  fauces 
giving  the  patient  more  or  less  difficulty  and  pain  in  dislodging  it. 

The  pulse  is  usually  moderately  accelerated  in  frequency  and  increased 
in  force,  with  slight  general  increase  of  temperature.  In  most  cases  there 
is  some  degree  of  headache,  especially  in  the  frontal  region,  and  a  very 
unpleasant  feeling  of  fullness  and  obstruction  in  the  fauces.  Sometimes 
the  disease  has  been  known  to  be  protracted  a  week,  and  finally  termi- 
nated in  suppuration,  forming  circumscribed  abcesses  in  the  tongue  itself. 
Far  more  frequently,  however,  the  inflammation  reaches  its  climax  in  from 
three  to  five  days,  and  then  gradually  declines  and  disappears  by  resolu- 
tion, without  suppuration.  I  have  noticed  it  much  more  frequently  in 
young  persons  between  the  ages  of  five  and  fifteen  years,  than  either  at 
an   earlier  or  later  period  of  liie. 

When  the  disease  is  of  a  moderate  degree  of  intensity,  it  is  sufficient  to 
keep  the  patients  at  rest,  giving  them  bland,  simple  nourishment,  opening 
the  bowels  moderately  by  a  saline  laxative,  after  which  from  two  to  three 
decigrams  (gr.  iii  to  v)  of  iodide  of  poiassium  in  solution  with  the 
same  number  of  minims  of  tincture  of  belladonna  may  be  given  every 
three  or  four  hours  until  the  inflammation  abates  and  the  tongue  returns 
more  nearly  to  its  natural  condition.  When  the  saliva  is  very  viscid  and 
difficult  to  dislodge  from  the  back  part  of  the  mouth,  rinsing  out  the  mouth 
freely  with  slightly  acidulated  gargles,  such  as  a  weak  solution  of  chlorate, 
of  potassium,  rendered  very  slightly  acid  by  a  few  drops  of  hydrochloric 
acid,  will  often  much  relieve  the  patient.  In  cases  more  acute  and  severe 
in  their  character,  leading  to  rapid  swelling  of  the  tongue,  sufficient  to 
threaten  much  obstruction  to  deglutition,  and  greater  or  less  obstruc- 
tion to  breathing,  an  application  of  leeches  directly  along  the  side  of  the 
pharynx  under  the  angle  of  the  jaw,  the  number  being  adapted  to  the  age 
of  the  patient,  thereby  producing  free  local  bleeding,  will  be  of  much 
advantage.  In  the  two  recent  cases  to  which  I  alluded  the  particu- 
lar remedies  used  were  a  solution  of  the  chlorate  of  potassium  with 
tiucture  of  belladonna  in   the  proportion  just  named,  given  every  four 


TONSILITIS.  507 

hours,  and  three  decigrams  (gr.  v)  of  the  salicylate  of  sodium,  in  solu- 
tion, between. 

Tonsilitis. — --Tuflammation  of  the  tonsils  to  which  I  next  call  your  atten- 
tion, is  very  much  more  frequent  in  its  occurrence  than  any  form  of  prlos- 
sitis.  It  occurs  chiefly  during  the  cold  seasons  of  the  year,  especially 
during  cold,  wet  and  changeable  weather,  and  occurs  much  more  fre- 
quently during  the  period  of  early  adult  life  than  later.  Some  patients 
acquire  such  a  degree  of  susceptibility  to  inflammation  of  the  tonsils,  that 
they  sufi'er  an  attack  from  one  to  three  times  almost  every  year;  more 
frequently  in  the  early  spring  months,  but  sometimes  both  in  the  latter 
part  of  the  fall  and  the  spring.  Inflammation  attacking  these  glands  may 
be  met  with  of  almost  every  degree  of  intensity,  from  a  purely  chronic 
giade,  to  that  of  the  most  acute  and  severe.  The  symptoms  whicli  char- 
acterize the  beginning  of  the  acute  and  subacute  attacks  are  usually  a 
brief  period  of  chilliness,  with  more  or  less  aching  in  the  back  and  limbs, 
sometimes  in  the  head,  followed  by  a  moderate  degree  of  general  fever. 
It  causes  acceleration  of  pulse,  ranging  from  ninety  to  ninety-five  per  min- 
ute, dryness  and  heat  of  the  skin,  slight  degree  of  thirst  and  frequently  a 
thin  white  coat  upon  the  tongue.  In  most  instances  the  urinary  secretion 
is  redder  than  natural  and  scanty.  Among  these  early  symptoms,  coinci- 
dent with  moderate  feelings  of  chilliness,  is  a  sense  of  soreness  and  full- 
ness in  the  fauces,  causing  sharp  pain  in  deglutition,  and  often  sending 
sharp  pains  in  the  direction  of  the  middle  ear.  On  looking  into  the  fau- 
ces the  tonsils  are  seen  to  be  swollen,  one  or  both  of  them,  forming  rounded 
projections  on  each  side  of  the  arch  of  the  fauces  between  the  folds  of  the 
palate,  having  an  intensely  red  appearance,  at  first  rather  dryer  than  nat- 
ural, but  before  the  end  of  the  first  twenty- four  hours,  accompanied  by  an 
increased  secretion  of  viscid  saliva.  In  acute  cases  the  swelling  and  red- 
ness increase  with  considerable  rapidity  for  about  three  days;  at  the  end 
of  which  time  the  patient  finds  it  extremely  difficult  to  perform  the  act  of 
deglutition,  the  eft'ort  causing  very  acute  pain  both  in  the  fauces  and  in 
the  direction  of  the  ears;  the  respiration  is  moderately  obstructed  more  by 
the  collection  of  viscid  mucus  than  by  the  actual  narrowing  of  the  passage 
of  the  larynx;  a  great  sense  of  fullness  and  obstruction,  sometimes  creating 
a  feeling  of  suffocation  is  experienced.  There  is  much  frontal  headache, 
marked  acceleration  of  pulse,  and  in  many  cases  a  feeling  that  the  patient 
can  not  take  the  recumbent  position,  but  must  lean  forward  to  let  the 
saliva  "  drool "  from  the  mouth,  or  be  turned  to  one  side  so  that  it  will 
not  gravitate  back  into  the  fauces.  In  the  most  acute  class  of  cases,  such 
as  are  met  with  only  occasionally,  with  both  tonsils  involved  at  the  same 
time,  the  swelling  becomes  so  great  that  the  glands  touch  each  other  in 
the  center,  crowding  the  uvula  in  front  of  them,  and  so  narrowing  the 
passage  over  the  root  of  the  tongue  as  to  produce  really  much  obstruction 
to  respiration,  preventing  the  patient  from  assuming  the  recumbent  posi- 
tion altogether,  so  far  interfering  with  the  oxygenation  and  decarboniza- 
tion  of  the  blood  as  to  give  a  leaden  hue  to  the  countenance,  purplish 
appearance  under  the  nails  and  lips,  coldness  of  the  extremities,  small, 
thready,  weak  pulse,  with  disposition  to  drowsiness;  and  yet  inability  to 
continue  sleep  more  than  a  few  seconds  on  account  of  feelings  of  suffoca- 
tion, making  an  assemblage  of  symptoms  decidedly  alarming,  and  if  not 
speedily  relieved  they  might  result  in  the  actual  death  of  the  patient. 

But  in  nearly  all  the  cases  that  have  come  under  my  own  observation, 
the  arrival  of  this  stage,  with  the  symptoms  just  named,  has  been  accom- 
panied by  suppuration,  or  the  maturing  of  an  abscess  in  the  tonsil,  which  if 
not  opened   by  a  free  incision  has  broken  spontaneously   during  some 


508  TOXSILITTS. 

severe  effort  of  the  patient  to  clear  his  throat,  and  on  the  discharge  of  the 
pus  by  either  process,  the  relief  to  the  more  distressing  symptoms  has 
been  so  speedy  and  complete,  that  in  less  than  an  hour  the  patient  has 
been  resting  in  a  horizontal  position  in  a  quiet  comfortable  sleep.  The 
rapidity  of  improvement  after  acute  tonsilitis  has  terminated  in  suppura- 
tion and  discharge  of  pus  is  remarkable.  I  have  seen  many  patients  that 
thought  they  were  in  danger  of  suffocation,  Avho  by  having  the  abscess 
opened  freely,  were  up  and  dressed  the  next  day,  declaring  that  thev  were 
cjuite  well.  In  the  more  acute  form  of  tonsilitis  there  is  a  decided  ten- 
dency to  suppuration  ;  so  much  so  that  if  the  disease  is  not  promptly  met 
by  means  strongly  calculated  to  check  the  inflammatory  process  in  its 
incipiency,  the  majority  of  cases  will  proceed  to  suppuration  in  spite  of 
any  subsequent  treatment.  The  cases  of  a  subacute  character  will  often 
proceed  very  slowly,  accompanied  by  symptoms  of  a  milder  character, 
reaching  their  climax  at  the  end  of  five  or  six  days,  and  then  very 
gradually  declining  by  resolution  or  return  to  their  normal  condition. 
Where  patients  are  attacked  with  subacute  tonsilitis  once  or  twice  a 
year,  there  is  usually  a  tendency  to  hypertrophy  or  permanent  enlargement 
of  the  glands.  In  children  especially  who  have  been  a  few  times  attacked 
with  mild  subacute  inflammation  of  the  tonsils  from  ordinary  colds,  the 
exudation  appears  to  be  suflBciently  plastic  to  become  incorporated  with 
the  natural  structure  of  the  gland,  and  to  remain,  giving  them  a  size  two, 
three  or  four  times  as  large  as  natural,  projecting  as  rounded  or  convex 
bodies  into  the  opening  of  the  fauces,  crowding  sometimes  against  the 
opening  of  the  Eustachian  tube  so  as  to  interfere  with  the  passage  of  air 
to  the  middle  ear,  sometimes  causing  buzzing  and  noises  in  the  ear,  at 
other  times  slight  impairment  of  hearing.  There  is  still  a  lower  grade  of 
inflammatory  action  which  appears  often  in  the  tonsils  of  children  more 
frequently  between  the  ages  of  five  and  eight  years,  not  active  enough  to 
cause  acute  soreness,  pain  or  fever  at  any  time,  but  causing  a  little  sore- 
ness for  a  few  days  on  taking  what  is  called  a  cold  by  exposure  to  cold 
and  damp  air,  and  leading  to  a  steady  increased  growth  of  the  connective 
tissue  constituting  sclerosis  or  hardening  of  the  substance  of  the  gland  until 
it  acquires  the  size  of  a  hickory  nut,  impairing  the  tone  of  voice  and  often 
causing  sufficient  obstruction,  so  that  when  the  patient  sleeps  it  renders 
the  sleep  noisy  or  stertorous.  Frequently  the  patient  starts  out  of  his 
sleep  as  if  from  fright.  This  often  causes  both  parents  and  friends  to  be 
unduly  anxious,  fearing  that  some  serious  obstruction  in  the  respiratory 
passages  exists.  But  during  it  all,  the  patient  complains  very  little  from 
this  hypertrophy  of  the  tonsils. 

Chronic  enlargement  of  the  tonsils  almost  always  increases  during  the 
cold  season  of  the  year,  and  sometimes  occasions  impairment  of  hearing 
in  some  degree,  while  during  the  warm  season  it  recedes  sufficiently 
to  relieve  all  the  prominent  symptoms,  yet  does  not  entirely  disap- 
pear. Tonsilitis  of  any  grade  of  intensity  very  rarely  proves  fatal.  No 
such  case  has  come  under  m}^  own  observation  during  all  the  years  of  my 
experience.  I  have  met  with  several  which,  at  the  climax  or  period  of 
maturity  of  the  suppurative  process,  presented  such  symptoms  as  I  have 
described,  and  caused  a  just  apprehension  that  suffocation  would  take 
place  if  relief  was  not  obtained  by  some  means,  speedily.  In  all  such  in- 
stances I  have  proceeded  at  once  to  make  a  free  incision  into  the  most 
prominent  part  of  each  tonsil,  and  have  not  failed  to  procure  a  free  dis- 
charge of  matter,  and  a  speedy  relief  to  all  the  more  urgent  s^'mptoms. 
The  treatment  of  acute  and  subacute  tonsilitis,  when  they  come  under 
the  care  of  the  physician  in  the  incipient  or  early  stage  of  the  disease, 


TREATMENT.  509 

may  liave  for  its  object  either  an  entire  arrest  of  the  disease  by  rendering 
tlie  inflammatory  process  abortive,  or  simply  to  so  moderate  it  as  to  avoid 
extreme  distress  and  danger  to  the  patient,  until  it  had  run  more  nearly 
its  natural  course  to  spontaneous  recovery.  For  the  first  object,  if  the 
attack  has  been  ushered  in  b\  a  decided  chill,  such  rapid  development  of 
swelling,  pain  and  feverishness  as  to  indicate  a  very  acute  form  of  the 
disease,  an  immediate  application  of  five  or  six  leeches  to  the  neck  directly 
opposite  the  tonsils,  on  each  side,  if  the  patient  is  an  adult;  a  proportion- 
ately smaller  number  in  children,  may  be  made,  and  the  bleeding  encour- 
aged by  cloths  wet  in  warm  water  after  the  leeches  fall  off,  and  as  soon  as 
it  has  ceased,  the  neck  opposite  the  tonsils  should  be  kept  constantly 
covered  with  cloths  wet  in  infusion  of  aconite  leaves  in  which  is  dissolved 
muriate  of  ammonium.  Internally,  as  early  as  possible,  from  four  to  six 
decigrams  (gr.  vi  to  x)  each  of  the  compound  powder  of  opium  and 
ipecacuanha  and  the  sulphate  of  quinia  may  be  given,  and  the  same  to  be  re- 
peated if  the  patient  does  not  fall  asleep,  and  show  some  moisture  of 
the  skin,  in  four  hours.  There  are  some  cases  even  of  a  very  acute  form, 
in  which  prompt  local  bleeding  by  leeches,  the  enveloping  of  the  neck 
in  cloths  wet  in  some  anodyne  infusion,  externally,  and  one  or  two  full 
dosesof  the  quinine  and  compound  powder  of  ipecacuanha  will  be  followed 
by  a  few  hours  of  sleep,  during  which  the  patient  sweats  freely,  the  pulse 
returns  to  the  natural  standard,  and  the  soreness  that  had  rapidly  com- 
menced in  the  fauces,  with  almost  equal  rapidity  declines.  After  the 
patient  has  finished  his  sleep  the  exhibition  of  a  saline  laxative  sufficient 
to  move  the  bowels  moderately  during  the  day,  and  another  anodyne  and 
diaphoretic  powder  the  following  night,  will  complete  the  resolution  or 
arrest  of  the  inflammatory  process,  the  patient  recovering  with  little  or  no 
other  treatment.  Cases  of  a  less  degree  of  severity,  when  coming  under 
the  care  of  the  physician  directly  after  the  initial  symptoms  have  com- 
menced, may  be  rendered  abortive  by  the  same  treatment  without  the  use 
of  the  leeches  or  local  bleeding. 

But  if  this  first  stage  of  acute  or  subacute  cases  has  passed  by,  and 
forty-eight  hours  have  elapsed  before  they  come  under  the  observation  of 
the  physician,  according  to  my  experience,  it  is  useless  to  attempt  to 
abort  the  disease.  The  aim  should  then  be  simply  to  lessen  the  more 
distressing  symptoms  of  the  patient,  by  opening  the  bowels  moderately  if 
they  are  costive,  allowing  the  patient  to  either  gargle  his  throat,  or 
swallow  a  weak  solution  of  chlorate  of  potassium  in  which  is  placed  a 
small  proportion  of  belladonna  every  two  hours,  so  as  to  bring  the  remedy  in 
contact  with  the  throat  frequently.  If  there  be  considerable  headache, 
dry  skin,  moderately  full  pulse,  taking  from  six  to  eight  decigrams  of 
the  salicylate  of  sodium  dissolved  in  water  every  four  hours,  will  act  as 
an  anti-pyretic  and  very  much  relieve  all  the  symptoms  most  trouble- 
some to  the  patient.  Externally,  cloths  may  be  applied  over  the  region 
of  the  tonsils,  wet  in  the  same  infusion  I  have  already  mentioned.  In  the 
milder  cases  under  the  influence  of  these  remedies  the  inflammation  of  the 
tonsils  will  usually  reach  its  climax  in  from  three  to  five  days,  and  begin 
to  decline,  and  disappear  altogether  in  from  seven  to  ten  days.  In  the 
more  severe  cases  suppuration  will  take  place  and  the  symptoms  will 
gradually  increase  in  severity  in  all  respects  until  the  suppurative 
process  has  matured  and  the  abscesses  are  either  opened,  or  break  spon- 
taneously, which  in  most  cases  will  be  between  the  fifth  and  seventh  days 
from  the  commencement  of  the  attack.  Occasionally  the  process  may  be 
protracted  to  a  later  period.  After  this,  in  most  cases  very  little  treat- 
ment is  required,  the  patient  rapidly  recovering.     If  there  should  be  much 


510  (ESOPHAGITIS. 

debility,  loss  of  appetite,  and  inclination  to  night  sweats,  the  patient  •will 
be  benefited  by  taking  moderate  doses  of  quinine  and  iron  three  times  a 
day,  until  the  period  of  convalescence  is  passed.  You  will  occasionally 
meet  with  cases  of  subacute  tonsilitis,  in  which  after  the  first  week  the 
more  acute  symptoms  disappear  but  the  tonsils  remain  large,  redder  than 
natural  and  sufficiently  tender  to  cause  some  pain  in  deglutition,  interfering 
much  with  the  patient's  comfort  in  eating  and  drinking,  and  subjecting 
him  to  a  disagreeable  sense  of  fullness  in  the  fauces,  with  more  than  the 
natural  secretion  of  viscid  mucus. 

In  such  cases  I  have  found  three  decigrams  (gr.  v)  doses  of  the 
iodide  of  potassium  given  four  times  a  day  to  cause  a  more  rapid  decline 
in  the  enlargement  of  the  tonsils  and  an  earlier  recovery  of  the  patient. 
In  these  cases  also,  if  the  patient  has  resided  in  a  malarious  district,  and 
presents  a  more  or  less  anaemic  hue,  with  a  sense  of  lassitude,  from  two  to 
three  decigrams  (gr.  iii  to  v)  of  quinine  morning  and  evening  in  ad- 
dition to  the  iodide  of  potassium,  may  be  given  with  advantage.  When 
the  tonsils  have  become  permanently  hypertrophied  or  enlarged,  sufficient 
either  to  disagreeably  obstruct  the  fauces,  or  interfere  with  the  Eustachian 
tube,  and  render  the  sleep  of  the  patient  disturbed  and  uncomfortable,  the 
most  reliable  remedy  is  simple  excision.  For  this  purpose  an  instrument 
having  a  circular  blade  can  be  used  with  entire  ease  in  taking  off  the 
gland  to  a  level  with  the  surrounding  parts,  which  is  all  that  is  necessary. 
What  is  left  of  the  gland  after  the  most  prominent  part  has  been  thus 
excised,  shrinks  after  cicatrization  of  the  surface  and  causes  no  further 
inconvenience.  Patients  from  whom  the  tonsils  have  been  thus  excised 
very  rarely  remain  suscejDtible  to  fresh  attacks  of  inflammation  in  these 
parts.  If  there  be  objection  from  any  cause  to  excision  of  the  tonsils 
when  permanently  enlarged,  they  may  be  reduced  to  such  a  degree  as  to 
render  them  comparatively  harniless  by  persevering  applications,  either 
of  nitrate  of  silver,  sulphate  of  copper,  or  iodide  of  zinc.  These  applica- 
tions to  be  effectual  should  be  made  at  least  once  every  day,  and  of  suf- 
ficient strength  either  to  deaden  or  decidedly  cauterize  the  surface  to 
which  they  are  applied.  They  are  most  easily  applied  in  the  form  of 
strong  solutions,  with  a  camel's  hair  pencil,  the  application  being  restricted 
of  course  to  the  surface  of  the  enlarged  tonsil.  Their  effects,  generally, 
are  slow,  and  consequently  require  to  be  continued  with  much  patience 
in  order  to  obtain  success.  This  fact  of  itself,  constitutes  an  additional 
reason  for  resorting  to  excision,  whenever  the  patient  will  consent  to  it 
and  is  free  from  complications  of  a  scrofulous  tendency  or  coincident 
scrofulous  enlargement  of  the  lymphatic  glands.  In  the  last  named 
cases  excision  had  best  be  omitted  ;  first,  because  the  portion  of  the 
tonsil  remaining  will  often  slowly  increase  until  the  tumor  is  reproduced 
in  the  fauces,  and  as  troublesome  as  before  ;  secondly,  for  the  reason  that 
all  such  patients  require  careful  and  persistent  treatment,  medicinal  and 
hygienic,  for  the  removal  of  the  constitutional  scrofulous  affection,  and 
the  same  treatment  which  is  most  efficient  for  this  purpose  will  itself 
generally  remove  the  hypertrophy  of  the  tonsils. 

Inflammation  of  the  CEsophagxis. — Simple  idiopathic  inflammation  in 
any  part  of  the  oesophagus  is  of  more  rare  occurrence  than  in  any  of  the 
structures  to  which  I  have  alluded.  Nearly  all  the  cases  that  come 
under  the  care  of  the  practitioner  arise  from  the  action  of  direct  irritants  ; 
such  as  food  and  drink  taken  too  hot,  or  acrid  substances  swallowed 
without  proper  dilution,  or  the  accidental  swallowing  of  corrosive  and 
irritant  poisons.  From  any  of  these  causes  inflammation  may  take  place 
in  the  cesophagus,  varying  in  intensity  from  the  slightest  blush  of  rediies?, 


SYMPTOMS.  511 

licit  and  smartinp:  prochicetl  by  a  slight  scald  or  burn,  to  that  of  the  most 
intense  infliimniatory  action  and  even  corrosion.  The  slighter  grades  of 
inflammation  arising  frmi  swallowing  too  hot  or  slightly  irritant  substances 
usually  disappear  spontaneously  in  from  three  to  four  days,  by  having  the 
patients  simply  abstain  from  the  use  of  coarse  food  and  live  during  that 
time  upon  some  bland,  unirritating  substances,  and  perha})S  swallow  once 
in  three  or  four  hours  a  spoonful  of  simple  mucilaginous  drink,  rendered 
cold  by  ice. 

In  tlie  more  severe  inflammations  produced  by  corrosive  and  irritant  poi- 
sons usually  no  other  means  than  those  just  named,  keeping  the  patient  at 
rest,  keeping  up  nutrition  with  as  little  use  of  the  oesophagus  as  possible,  and 
having  what  does  pass  through  it,  of  the  most  bland,  unirritating  character, 
will  constitute  the  best  mode  of  treatment  that  can  be  devised.  Inflamma- 
tions excited  by  these  substances  are  very  liable  to  be  followed,  especial- 
ly when  erosion  and  destruction  of  more  or  less  of  the  lining  membrane 
has  taken  place,  by  contraction  after  cicatrization,  sufficient  to  leave  more 
or  less  stricture  of  the  oesophagus,  permanently  interfering  with  the  process 
of  deglutition,  sometimes  rendering  it  almost  impracticable  for  the  patient 
to  take  sufficient  nourishment  through  the  constricted  tube  to  prevent 
starvation.  Such  cases,  if  remedied  at  all,  must  be  remedied  by  surgical 
interference,  chiefly  through  well  directed  efforts  toward  dilating  the 
constricted  portion  of  the  tube.  There  is  a  form  of  stricture  of  the  oesoph- 
agus occasionally  met  with  dependent  upon  morbid  sensitiveness  of  the 
nerves  supplying  the  muscular  coat  of  some  portion  of  this  organ.  It  is 
seldom  idiopathic  in  its  nature,  but  is  a  reflex  form  of  disease  located 
in  some  other  part  of  the  nervous  system.  The  symotoms  in  such  cases 
are  not  such  as  to  suggest  the  idea  of  inflammation,  there  being  no  fever, 
seldom  pain  in  the  part,  and  at  times  the  patient  performs  the  act  of  deg- 
lutition without  difficulty.  But  when  he  attempts  to  take  food,  the  con- 
tact of  the  latter  with  the  sensitive  nerves  of  the  fauces,  or  com- 
mencement of  the  oesophagus,  causes  an  immediate  spasmodic  contrac- 
tion of  its  circular  fibres,  thus  making  a  temporary  stricture  sufficient  to 
irrest  the  progress  of  the  food  downward,  and  hold  it  for  a  few  seconds, 
when  not  infrequently  it  regurgitates  backward  into  the  mouth  and  is  re- 
jected, or  the   stricture   yields  and  allows  it  to   pass  into  the  stomach. 

These  cases  are  distinguished  from  inflammation  of  the  oesophagus  by  the 
absence  of  heat,  pain  and  sense  of  soreness  in  the  part,  and  by  the  absence 
Df  any  general  febrile  disturbance.  They  are  distinguished  from  per- 
manent contraction  of  the  oesophagus  from  causes  that  I  have  already 
mentioned,  or  from  development  of  malignant  growths  upon  the 
oesophagus,  by  the  fact  that  often  after  the  food  and  drink  has 
been  arrested  for  a  few  seconds  it  is  allowed  to  pass,  and  in  the 
intervals  between  taking  it  no  sense  of  obstruction  exists,  and  still 
more  by  the  fact  that  upon  exploration  of  the  oesophagus  with  a  probang, 
the  instrument  will  often  pass  unobstructed  through  the  whole  length  of 
the  tube  to  the  stomach,  or  if  its  presence  induces,  like  the  presence  of 
food,  a  spasmodic  contraction  and  arrest  of  its  progress,  simply  allowing  it 
to  remain,  with  slight  steady  pressure  the  stricture  will  usually  jneld 
and  allow  free  passage  of  the  instrument  into  the  stomach.  One  of  the 
most  singular  spasmodic  strictures  of  the  oesophagus,  coming  under  my 
own  observation,  was  that  of  a  tailor  who  in  a  quarrel  with  a  fellow  tailor 
received  a  blow  upon  the  occipital  region  of  his  head  with  a  press-board. 
The  blow  merely  stunned  him  for  a  moment,  from  which  he  recovered 
sufficiently  to  return  to  his  home  without  difficulty.  It  was  followed  by 
no  symptoms  of  cerebral  disturbance  or  febrile    reaction,  but,  immediate- 


512  GASTRITIS. 

ly  there  was  total  inability  of  the  patient  to  pass  anything  into  his  stomach. 
Everything-  given  him  would  pass  a  little  way  down  the  oesopliagus,  be 
held  for  a  few  seconds,  and  regurgitated.  The  patient  remained  in  this 
condition  from  seven  to  nine  days  without  swallowing  the  smallest  quan- 
tity of  either  food  or  drink.  Being  called  to  the  case  and  learning  its 
history,  I  caused  the  patient  to  make  an  effort  to  swallow,  but  without 
success.  Considering  the  length  of  time  he  had  been  without  nourish- 
ment, I  immediately  attempted  to  pass  the  stomach-tube  of  an  ordinary 
stomach  pump  through  the  oesophagus,  for  the  purpose  of  introducing 
nourishment  through  it  into  the  stomach.  When  the  end  of  the  stom- 
ach-tube had  reached  about  one  third  of  the  length  of  the  oesophagus 
downward,  its  progress  was  arrested.  But  on  making  steady,  moderate 
pressure,  for  perhaps  ten  seconds,  the  obstruction  seemed  to  give  way 
rather  suddenly,  and  the  tube  passed  on  to  the  stomach  without  further 
difficulty.  Through  it,  was  passed  a  little  more  than  a  pint  of  fresh 
milk,  and  the  tube  withdrawn.  In  a  few  hours  the  patient  found  that  he 
could  swallow  liquids  without  difficulty,  and  from  that  time  he  took  food 
and  drink  freely. 

Acute  and  Chronic  Gastritis. — The  word  gastritis  is  usually  applied  to 
inflammation  of  the  mucous  membrane  of  the  stomach.  The  inflamma- 
tion of  this  membrane  in  some  of  its  forms  or  degrees  of  activity  is  met 
with  frequently,  in  the  ordinary  duties  of  the  practitioner.  The  particular 
grades  or  varieties  of  the  inflammation  met  with,  are,  first,  diffuse  general 
inflammation  of  the  mucous  membrane,  which  may  be  either  acute  or  chron- 
ic; second,  follicular  inflammation  which  is  generally  of  very  limited  ex- 
tent and  chronic  in  its  grade;  and,  third,  ulcerative  inflammation  or  more 
properly  chronic  gastric  ulcer.  The  first  variety  or  difl'use  inflammation 
of  the  mucous  m  mbrane  is  rarely  met  with  in  the  acute  form,  except  as 
the  result  of  the  direct  application  of  irritating  substances,  as  in  swallow- 
ing acrid  poisons,  substances  of  too  high  a  temperature,  or  from  mechan 
ical  injuries.  But  occasionally,  cases  of  genuine  acute  gastritis  occu'' 
from  such  ordinary  causes  as  produce  other  aciite  inflammations. 

Sympfoms. — Acute  gastritis,  when  it  does  occur,  either  as  an  idiopathic 
afi'ection,  or  as  the  result  of  irritating  ingesta,  commences  with  a  burning 
pain  in  the  epigastrium  usually  becoming  early  very  intense,  like  burn- 
ing coals  of  fire  in  the  stomach,  dryness  of  the  mouth,  intense  craving 
for  cold  drinks,  a  decided  sense  of  oppression  in  the  epigastrium, 
pain,  not  infrequently  extending  through  to  the  central  part  of  the 
spine,  constant  feeling  of  nausea,  with  frequent  efi'orts  at  vomiting,  and 
the  piompt  rejection  of  food  and  almost  everything  that  is  taken,  even  of 
the  blandest  character.  Each  act  of  vomiting  is  accompanied  by  increased 
epigastric  distress  and  tenderness.  The  matters  ejected,  aside  from  what 
has  been  swallowed,  consist  of  a  thin  mucous  or  serous  fluid,  usually 
tinged  with  the  coloring  matter  of  bile,  sufficient  to  give  it  a  green  or 
vellow  hue.  The  pulse  in  the  first  stage  is  usually  quick  and  small, 
corded  and  tense,  sometimes  called  wiry;  the  skin  over  the  trunk  of  the 
body  is  hotter  than  natural,  and  dry,  and  the  extremities  often  cold.  The 
bowels  usually  are  inactive,  not  obstinately  constipated  but  simply  in- 
disposed to  move  at  the  ordinary  intervals  of  time,  and  the  quantity  of 
urine  is  usually  very  scanty  and  high  colored.  In  the  most  acute  form 
of  the  disease  the  patient  becomes  rapidly  prostrated,  the  pulse  after  the 
first  twelve  hours  becoming  thready,  small,  weak,  the  extremities  more 
cold,  often  purplish  or  bluish,  face  pinched,  eyes  sunken,  lips  thin,  mouth 
very  dry,  parched,  edges  and  tip  of  the  tongue  redder  than  natural,  the 
mind   frequently    wandering   or   incoherent,  the    abdomen    bloated   and 


SYMPTOMS.  513 

tympanitic,  epigastric  region  exceedingly  tender  to  the  touch,  so  much  so 
that  the  patient  shrinks  at  the  approach  of  the  hand,  and  in  most  instances 
will  not  bear  even  the  weight  of  a  sheet  upon  the  body. 

From  this  time  the  matters  vomited  become  larger  in  quantity;  instead 
of  a  greenish  fluid  as  at  first,  the  color  becomes  dark  brown,  mixed  with 
flakes;  and  the  efforts  at  vomiting  are  still  frequent,  exceedingly  distress- 
ing, and  are  promptly  induced  by  anything  that  is  taken  into  the  stomach. 
If  relief  is  not  afforded,  in  some  instances  the  failure  of  strength  and 
vitality  in  the  patient  is  so  rapid,  that  after  from  twenty-four  to  thirty-six 
hours  from  the  commencement  of  the  attack,  the  urine  is  entirely  sup- 
pressed, involuntary  discharges  take  place  from  the  bowels,  the  vomiting 
becomes  more  of  a  regurgitation,  throwing  out  large  quantities  of  dark 
grumous  fluid,  almost  as  black  as  the  matter  of  black  vomit  in  yellow 
fever.  In  a  little  time  the  pulse  can  no  longer  be  felt  at  the  wrist,  the 
heart  beats  rapidly,  with  paroxysms  of  tumultuous  palpitation,  the  mind 
becomes  dull  anfl  drowsy,  the  abdomen  extremely  tympanitic  and  dis- 
tended, and  before  the  end  of  another  day,  entire  collapse  and  death 
ensues.  Cases  of  acute  gastritis  have  been  known  to  terminate  fatally 
within  twenty-four  hours;  but  more  generally  the  disease,  even  in  the 
more  acute  form,  continues  from  three  to  five  days.  And  in  a  less  acute 
form  the  symptoms  that  I  have  described  may  be  protracted  over  a  period 
of  from  one  to  two  weeks,  and  yet  terminate  fatally.  In  some  instances 
the  commencement  of  an  attack  of  gastritis  is  marked  by  chilliness  of 
brief  duration;  but  in  nearly  all  the  cases  that  have  come  ui.Jer  ray  own 
observation,  no  period  of  chill  has  been  noticed.  The  symptoms  super- 
vene, as  I  have  already  described,  from  the  beginning  as  the  result  of 
extreme  gastric  sensitiveness,  the  chief  complaint  at  the  first  being  a 
burning,  broiling  pain,  and  a  most  incessant  disposition  to  vomit.  Cases 
are  met  with  that  merit  more  the  name  of  subacute  than  acute  gastritis. 
These  cases  commence  with  the  same  symptoms,  in  a  less  degree  of  inten- 
sity, accompanied  by  less  rapid  pulse,  less  activity  in  all  the  morbid 
phenomena,  and  are  protracted  usually  five  or  six  days  until  the  patient 
becomes  much  exhausted,  and  the  pulse  feeble, when  the  paroxysms  of  vomit- 
ing begin  to  be  farther  apart,  the  burning  sensation  in  the  stomach  less 
intense,  and  small  portions  of  cold,  mucilaginous,  bland  liquids  will  be  re- 
tained at  least  for  a  little  time.  The  urinary  secretion,  diminished  in  the  ear- 
lier stages,  increases  again  as  the  disease  passes  its  climax,  the  thirst  becomes 
less  urgent,  but  at  the  end  of  the  second  week,  or  from  nine  to  fourteen 
days,  the  inflammatory  action  will  have  so  far  subsided,  that  the  patient 
begins  to  show  indications  of  convalescence.  The  stomach  is  still  irri- 
table, whenever  the  patient  ventures  to  take  more  than  very  small  quan- 
tities of  bland  material  at  a  time;  but  small  quantities  are  retained  with- 
out much  distress,  and  from  day  to  day  more  is  tolerated  until  the  symp- 
toms of  undue  excitability  disappear. 

The  most  acute  form  of  gastritis  is  always  a  dangerous  disease,  and 
terminates  fatally  in  the  large  proportion  of  cases.  The  milder  attacks, 
properly  denominated  subacute,  under  any  reasonably  judicious  manage- 
ment, will  generally  terminate  in  recovery.  Two  forms  of  chronic  inflam- 
mation of  a  diffuse  character  are  met  with  in  practice.  The  first  is 
generally  the  sequel  of  a  previous  acute  or  subacute  attack.  The 
primary  subacute  disease  continuing  its  course  for  two  or  three  weeks, 
only  partially  subsides,  leaving  the  patient  with  a  feeling  of  tenderness  on 
pressure  in  the  epigastrium,  a  sense  of  heat  and  dryness  in  the  mouth 
and  in  the  stomach,  a  desire  for  cold  drinks,  usually  an  aversion  to  taking 
food,  or  loss  of  appetite,  an  inactive  condition  of  the  bowels,  slightly  dimin- 
33 


514  CHROmC   GASTETTIS. 

ished  secretion  of  urine,  with  skin  dry,  lips  unnaturally-  dry  and  parched, 
edges  and  tip  of  the  tongue  redder  than  natural,  pulse  usually  moderately 
accelerated,  varying   from  ninety  to  one   hundred,  especially  in  the  after- 
noon and  evening.     The  mind  is  usually  depressed,  gloomy  and  despondent. 
The  feeling  of  distress  and  burning  in  the  epigastrium  is  greatly  increased 
■whenever   food   of  any  kind  is  taken  into  the  stomach  ;  and  unless  it  is 
taken   in    small   quantities  and  of  a  very  easily  digestible  character,  it  is 
usually  followed  by  the  generation  of  acids,  and  often  in  from  half  an  hour 
to   an   hour   or   more  the  food  is  rejected  by  vomiting  in  a  sour  and  only 
partially    digested    state.     In    this    condition   the  patient  usually  retains 
enough  of  nourishment  to  prevent  rapid  emaciation  and  loss  of  strength, 
and  may  consequently   continue   to  suffer  frim  the  disease  an   indefinite 
period  of  time.     In   a   few   instances  that  have  come  under  my  care,  the 
patients   have  been  afflicted    with    a    chronic  form  of  inflammation  of  the 
mucous   membrane  through  periods  varying  from  one  to  three  years.     In 
these    old    cases,  the   patients  have  uniformly  been  much  emaciated,  skin 
exceedingly   dry   and   husky,  lips  thin,  pale   and   more  or  less  retracted, 
the    countenance  anxious  and  depressed  in  its  expression,  the  puise  small 
but  firm  under  the  finger,  respirations  about  normal,  the  urinary  secretion 
prettv  uniformly   scanty   and  high  colored,  the  tongue  in  these  cases  has 
presented   a  glossy   reddened    appearance  over  nearly  its  whole  suri'ace, 
with     frequent,     small,     apthous,     irritable     ulcers     along    its     margin, 
and    sometimes    in    other    portions  of  the    mouth.     The    abdomen    has 
usually  presented   a    concave    or   empty    condition,    the    bowels    seldom 
moving  oftener   than   once   in   three   or  four   days,  unless   disturbed   by 
artificial   means,  while   everything  in   the  form   of  ingesta  taken  into  the 
stomach  is   foUowe'i    either  by  prompt  rejection   by  vomiting,  or  being 
retained  it  soon    creates   that   distress   and   feeling  of  heat   and  burning 
that  lasts  usually  from  two  to  three  hours,  sometimes  ending  in  vomiting 
of  a   sour  acrid   liquid,  the    food  itself  having  disappeared;  and  when  no 
vomitino"   occurs  it  gradually  subsides  by  the  apparent  discharge  of  what 
had   been   taken   through  the  pyloric  orifice   into  the  parts   below,  leav- 
ino-  the    stomach   empty.     The    other  form  of   chronic  gastritis  to   which 
I   alluded    is   perhaps    more    properly    designated    as    a     hyp'rsesthesia 
or  morbid  sensitiveness  of  the   mucous    membrane  than   a  true  chronic 
jntiammation.     Its    symptoms     are     undue     sense  of    heat  and    tender- 
ness   in    the    epigastric    region,    increased     by    taking    any    kind    of 
nourishment,  a  tendency  either  frequently,  in  a  few  minutes,  to  reject  what 
has  been  taken,  or  when  retained  a   gradual  increase   of   the    burning, 
and    sense    of    distension,    more    or    less    nausea,    and     generally     the 
generation    of    sufficient    acid   material  to  cause  either  the  whole  to   be 
rejected  in  from  half  an  hour  to  an  hour,  or  eructations  of  acid  to  come  up 
the  oesophagus  to  the  pharynx,  causing  an  acrid  sour  taste  in    the   mouth 
until   the    contents    of   the    stomach    pass       through  the  pyloric  orifice, 
when    the  active   symptoms  gradually  subside,   till  further  ingesta  are 
taken.     In  most  of  these   cases,  however,  the   patients   reject   the   larger 
part  of  what  they  eat  within  a  few  minutes  after  it  is  taken,  and  before  it 
has  had  time  to  undergo  any  appreciable   change.     In  these   cases   when 
the  stomach  is  allowed  to  be  entirely  empty  there  is  a  vague  sense  of  un- 
easiness accompanied  by  a  gnawing  or  desire   for  food,  but   no  sooner  is 
the  food  taken  than,  as  I   have  already  remarked  ;  it  is   either   promptly 
rf^jected,  or  It  aggravates  the  suffering  of  the  patient  until  it  pass  s  through 
the  pylorus. 

Follicular  Inflammation. — The  prominent  symptoms  occasioned  by 
inflammation  of  a  chronic  character,  limited  to  the  follicles  of  the  mucous 


SYMPTOMS.  515 

membrane,  are  usually  of  a  milder  character  than  those  I  have  described  for 
the  preceding  forms  of  disease.  In  most  of  the  cases  of  this  class,  the  pa- 
tients exhibit  no  marked  febrile  symptoms,  neither  the  pulse,  respiration 
nor  temperature  varying  much  from  the  natural  standard.  The  secretions 
generally  are  but  little  interfered  with,  although  the  bowels  are  usually 
constipated  or  decline  to  move  without  prompting.  The  patients  do  not, 
usually,  complain  of  epigastric  tenderness,  or  if  so  it  is  slight.  In  most 
instances  they  take  food  with  comparative  relish,  and  for  one  or  two  hours 
after  eating,  they  experience  no  other  inconvenience  than  a  slight  feeling 
of  heaviness.  Indeed,  most  of  this  class  of  patients  say  promptly,  that 
they  feel  better  for  the  next  hour  or  two  after  they  take  food,  than  they 
do  at  any  other  time.  But,  in  from  an  hour  and  a  half  to  two  hours  after 
they  eat,  they  begin  to  experience  a  feeling  of  moderate  heat,  undue  full- 
ness, and  oppression  in  the  epigastrium,  which  increases  steadily  until 
the  next  meal.  Others  have  a  turn  of  vomiting  by  which  they  will  reject 
from  one  to  five  ounces  of  a  thin  serous  fluid,  sometimes  a  little  sour  or 
acrid,  but  more  generally  tasteless  ;  after  which  they  are  relieved.  In 
other  instances  they  do  not  vomit,  but  continue  to  feel  more  and  more 
uneasy  in  the  epigastric  region  until  the  next  meal,  when  on  taking  food 
all  uneasiness  quickly  vanishes,  and  as  before,  from  one  to  two  hours  of 
comparative  comfort  ensues,  when  the  same  tendency  to  distress,  heavi- 
ness, burning  and  gnawing  sensations  return  and  increase  steadily  until 
either  vomiting,  or  the  time  for  the  next  supply  of  food  occurs. 

In  the  milder  cases  of  this  class,  the  patient  on  rising  from  bed  in  the 
morning,  and  sometimes  even  before  they  get  out  of  bed  on  first  awaking, 
will  feel  a  very  decided  sense  of  oppression  and  fullness  in  the  epigastrium, 
with  a  constan.t  nausea  and  disposition  to  vomit,  which  ends  in  the  ejection 
by  vomiting  of  a  few  ounces  of  the  same  thin  serous  fluid,  to  which  I  have 
before  alluded;  most  generally  tasteless  and  odorless,  but  in  some  instances 
slightly  acrid,  and  in  others  a  little  acid.  After  rejecting  this,  they  take 
their  breakfast  with  comparative  relish,  experience  no  inconvenience 
until  near  the  time  of  the  next  meal,  when  they  feel  oppressed,  the 
stomach  has  a  disagreeable  sensation  that  they  call  gnawing  or  hunger, 
which  ends  only  with  their  taking  food.  In  some  instances  the  feeling 
of  distress  and  hunger  will  return  in  the  middle  of  the  night  to  such  an 
extent,  that  the  patient  can  appease  it  in  no  other  way  than  by  taking  a 
small  quantity  of  food,  and  then  it  quickly  disappears.  When  the  disease 
is  more  active,  and  a  larger  proportion  of  the  follicles  or  gastric  tubules 
are  involved  in  the  inflammatory  action,  the  food  is  usually  dissolved  and 
passed  out  of  the  stomach  by  absorption,  or  into  the  duodenum  in  a 
remarkably  short  time.  The  secretion  and  accumulation  of  fluid  after 
the  food  is  digested  and  has  passed  out  of  the  stomach,  is  so  rapid  that 
vomiting  of  a  watery  substance  occurs  pretty  regularly,  an  hour  or 
two  before  the  time  for  the  next  meal;  but  it  is  never  mixed  with  any  of 
the  food  that  has  been  taken.  This  has  been  previously  dissolved,  and 
rapidly  passed  out  of  the  stomach,  and  what  is  vomited  is  only  the 
secretion  from  the  follicles  or  gastric  tubules  of  the  mucous  membrane 
itself.  A  large  proportion  of  these  cases  are  of  the  milder  class  ;  and  the 
vomiting  only  occurs  in  the  morning.  They  are  popularly  styled  cases  of 
pyrosis  or  water-brash.  They  are  far  more  frequently  met  with  in  persons 
addicted  to  the  use  of  alcoholic  drinks  than  in  any  other  class,  although 
not  restricted  exclusively  to  them.  Occasionally  the  phenomena  I  have 
described  occur  during  pregnancy,  but  not  often. 

If  you  study  the  phenomena  of  this  form  of  gastric  disease  carefully,  you 
will  readily  perceive  that  they  indicate  just  that  grade  of  irritation  or  in- 


516  GASTRITIS. 

flammatory  action,  which  causes  an  increased  secretion  of  serous  fluid, 
composed  usually  of  a  mixture  of  the  serous  exudation  from  the  irritated 
follicles,  and  of  the  true  gastric  juice,  showing  that  the  irritation  involves 
both  the  follicular  structures  and  the  gastric  tubules.  In  the  natural  or 
healthy  condition  of  these  structures,  especiall}'-  of  the  gastric  tubules,  the 
secretion  of  gastric  juice  only  takes  place,  actively,  during  the  reception 
and  the  presence  of  food  in  the  stomach,  and  ceases  as  soon  as  the  stomach 
becomes  empty.  But  in  these  cases  the  morbid  condition  of  the  structures 
causes  the  secretion  to  be  continuous,  and  consequently  it  tends  rapidly 
to  accumulate  in  the  stomach,  when  there  is  no  food  present  with 
which  it  can  be  mixed  and  united  as  in  the  process  of  digestion.  The 
patient  takes  food,  and  while  the  food  is  in  the  stomach,  it  mixes  and 
more  or  less  chemically  unites  with  the  ingredients  of  the  secretion,  and 
consequently  relieves  the  patients  from  his  morbid  sensations.  The  food 
IS  thus  rapidly  converted  into  chyme,  and  passed  out  of  the  stomach.  But 
the  secretion  goes  on  the  same,  and  hence  very  soon  begins  to  be  a 
cause  of  increased  irritation  and  distress,  and  sometimes  vomiting. 


LECTURE    LII. 


Gastritis.  Acute  and  Chronic.  Continued— Gastric  Ulcer— Anatomical  Cliange?  In  all  Grades  of 
Gastritis— Diagn.J^is,  Prognosis  and  Ti  eatment— Duodenitis,  etc. 

GENTLEMEN:  The  only  remaining  form  of  inflammatory  disease  in 
the  stomach  requiring  notice  is  called  the  gastric  ulcer.  The  symp- 
toms in  the  early  stage  can  hardly  be  distinguished  reliably  from  those 
belonging  to  cases  of  ordinary  indigestion  or  slight  irritation  of  the 
mucous  membrane.  There  is  no  continuous  pain,  tenderness  in  the  epi- 
gastrium or  febrile  phenomena;  but  for  several  months  after  the  com- 
mencement of  the  disease,  the  patient  will  occasionally,  after  taking  more 
food  than  usual,  be  troubled  with  some  feeling  of  soreness,  acid  eructa- 
tions, some  burning  in  the  stomach  for  an  hour  or  two,  but  by  being 
more  cautious  in  taking  food  he  experiences  so  little  inconvenience 
that  no  importance  is  attached  to  the  case.  After  the  continuance  of  these 
vague  symptoms  an  indefinite  period  of  time,  perhaps  suddenly,  without 
any  previoias  warning,  the  patient  feels  a  sense  of  distension  and  warmth 
in  the  stomach,  soon  developing  into  nausea,  and  then  copious  vomiting, 
by  which  he  ejects  a  large  quantity  of  dark  and  partially  coagulated 
blood.  The  quantity  of  blood  varies  much  in  difi"erent  cases.  In  some  it 
will  be  small,  not  more  than  an  ounce  or  two,  but  in  the  majority  of  cases 
the  quantity  will  amount  to  from  eight  to  thirty  ounces,  filling  an  ordinary 
wash-bowl  half  full.  It  is  always  dark-colored,  free  from  any  intermix- 
ture of  air  bubbles,  and  very  generally  partially  coagulated.  These 
features  distinguish  it,  at  once,  from  blood  coming  from  the  lungs,  which 
is  always  brighter  colored  and  more  or  less  mixed  with  air.  The  first 
attack  of  haematerresisor  vomiting  of  blood  will  generally  be  of  very  short 
duration,  but  it  leaves  the  patient  paler,  the  pulse  slightly  quickened,  the 
stomach  more  sensitive  to  the  contact  of  food  or  drink,  and  with  some  slight 
epigastric  tenderness.  — 


SYMPTOMS.  517 

By  rest  and  abstinence  from  all  but  bland,  simple  nourishment,  these 
syraj3toms  subside  in  a  few  days,  and  the  patient  appears  the  same 
as  before  the  hgemorrhage,  except  that  his  color  usually  remains  of  a  more 
anaemic  hue.  The  patient  seldom  recovers  the  fresh  natural  color  of  the 
lip,  that  he  had  before.  Most  generally,  after  the  first  turn  of  vomiting 
blood,  during  the  tw^o  or  three  hours  following  each  meal  the 
patient  continues  to  experience  a  little  more  distinct  feeling  of 
heaviness,  ur  discomfort.  Many  days  this  will  only  be  slight,  at  other 
times  it  will  be  more  marked,  and  usually,  after  a  few  months,  the  symptoms 
of  indigestion  become  more  constant,  accompanied  by  eructations 
of  gas,  and  sometimes  acrid  or  sour  liquids.  There  will  remain  also 
a  vague  sense  of  tenderness  in  the  epigastrium,  more  readily  increased 
by  pressure  than  in  the  earlier  stage.  These  symptoms,  however,  are  only 
those  that  often  characterize  common  cases  of  functional  disturbance  of 
the  stomach;  but,  usually  in  a  period  varying  from  one  to  six  months 
another  hemorrhage  will  occur  of  the  same  character  as  the  first.  The 
patient  spontaneously  vomiting  pretty  copious  quantities  of  dark,  par- 
tially coagulated  blood,  the  first  ejected  being  mixed  in  most  cases  with 
the  contents  of  the  stomach.  This  leaves  the  patient  still  more  anaemic 
than  after  the  first,  but  usually  does  not  prevent  him  from  again  recover- 
ing so  far  as  to  resume  more  or  less  his  ordinary  duties  of  life,  and  to 
retain  most  of  his  food  and  drink.  Thus  he  may  pass  one,  two 
or  three  years,  the  hemorrhages  occurring  at  long  intervals  at  first,  but  in- 
creasing in  frequency  with  each  return,  until  the  red  corpuscles  of  the 
blood  become  very  deficient,  and  the  strength  much  impaired,  when  with- 
out loss  of  flesh  or  weight,  he  is  seized  with  an  acute  or  intensely  sharp 
pain,  in  the  region  of  the  stomach.  More  frequently,  the  pain  is  felt  in 
the  left  hypochondrium  as  if  proceeding  from  the  larger  curvature  of  the 
stomach;  but  the  location  may  vary  in  different  cases,  from  near  the  epi- 
gastrium, to  the  extreme  left  curve  of  the  stomach.  This  acute  sudden 
pain  is  followed  immediately  by  a  sense  of  weakness,  exhaustion,  pallor 
of  the  countenance,  small,  thready  pulse,  cold  extremities,  and  in  a  little 
while  by  vomiting.  He  throws  off  whatever  is  on  the  stomach  at  the  time, 
and  promptly  rejects  whatever  drinks  are  taken,  the  abdomen  becomes 
rapidly  tumefied,  tympanitic,  the  urinary  secretion  lessened  or  suppressed, 
the  matter  rejected  by  vomiting  more  copious,  watery,  first  tinged  with 
green  from  the  coloring  matter  of  the  bile,  subsequently  by  the  action  of 
the  acids  in  the  stomach,  changed  to  a  dark  brown,  or  black,  and  gulped 
up  more  by  regurgitation  than  by  acts  of  vomiting.  There  is  extreme 
distension  of  the  abdomen,  a  purplish  or  leaden  hue  of  the  extremities, 
entire  collapse  and  death.  The  latter  takes  place  in  from  twelve  to  twenty- 
four  hours  from  the  time  of  the  attack  of  acute  severe  pain.  Such  is  the 
general  history  and  termination  of  what  is  denominated  chronic  gastric 
ulcer. 

The  explanation  of  these  phenomena  consists  in  the  fact,  that,  from 
the  beginning  the  ulcer  had  been  established  in  some  portion  of  the  mu- 
cous membrane  of  the  larger  curvature  of  the  stomach,  which  gradually 
increased  in  size  with  thickened  elevated  edges,  at  the  same  time  progress- 
ing deeper  into  the  structure  of  the  stomach  and  at  various  times  during 
its  progress  eroding  some  blood  vessels  of  sufficient  size  to  occasion  the 
hemorrhages  that  I  have  described.  Ultimately  it  perforates  all  the  coats 
of  the  stomach,  opening  into  the  peritoneum,  giving  rise  to  the  last  sudden 
severe  pain,  and  allowing  some  of  the  contents  of  the  stomach  to  es- 
cape into  the  peritoneal  cavity,  inducing  rapid  general  peritonitis,  col- 
lapse and  death.     In  some  of  these  cases  the  amount  of  blood  vomited  is 


518  GASTRITIS. 

very  large.  In  one  case,  coming  under  my  own  observation,  I  think 
without  exaggeration  of  statement,  the  patient  vomited  in  the  course  of 
cwenty-four  hours  between  one  and  two  litres  (three  and  four  pints)  of 
blood.  And,  yet,  these  hemorrhages  very  seldom  prove  fatal  by  direct 
exhaustion  of  the  patient.  Far  the  larger  proportion  of  cases  end  in  per- 
foration and  peritonitis,  instead  of  dying  from  the  quantity  of  blood   lost. 

Anatomical  OSanrjes  and  Post-mortem  A2y2)earances. — The  anatomical 
changes  produced  by  the  different  varieties  of  inflimmation  I  have 
described,  vary  with  the  intensity,  extent,  and  duration  of  the 
inflammatory  process.  In  fatal  cases  of  acute  gastritis  the  mucous 
membrane  appears  intensely  injected,  somewhat  tumefied,  and  vaiy- 
ing  in  color  from  an  intense  bright  red  to  a  dark  brown;  tlie 
latter  giving  rise  to  the  idea  sometimes,  of  a  gangrenous  condition. 
There  is  almost  always  more  or  less  softening  of  the  membrane,  and  fre- 
quently the  redness  and  increased  vascularity  presents  a  stellated  appear- 
ance, as  though  radiating  in  lines  £iom  a  common  center.  Examined 
more  closely  with  the  microscope  the  same  changes  are  found  here  as  in 
almost  all  other  acutely  inflamed  structures,  namely,  exudation  of  the  liquor 
sanguinis  and  white  corpuscles  into  the  texture  of  the  membrane,  prolif- 
eration or  increase  of  the  epithelial  cells  Vjelono'ing  to  the  surface,  and  some 
hj'pertrophy  of  the  connective  tissue — all  of  which  tend  to  make  the  mem- 
brane appear  thicker  and  more  tumefied  than  natural,  and  of  various 
shades  of  increased  redness.  In  places  there  is  detachment  of  much  of 
the  epithelial  la'  er,  and  a  loosening,  or  softening  of  the  texture.  In 
some  instances  this  softening  amounts  almost  to  actual  disorganization  of 
the  texture.  It  is  this  loss  of  tone,  or  partial  disorganization  of  the  mem- 
brane in  the  last  stages  of  the  acute  form  of  the  disease  that  allows  co- 
pious exudation,  carrying  with  it  more  or  less  of  the  red  corpuscles  of  the 
blood,  changed  to  a  blackish  hue  by  the  acids  of  the  stomach,  which  con- 
stitutes the  dark  grumous  material  that  is  thrown  up  in  such  quantities 
about  the  time  the  patient  is  passing  into  final  collapse.  The  same  fluid  is 
not  infrequently  found  in  considerable  quantity  in  the  stomach  after  death. 

In  many  of  the  subacute  cases  of  the  disease,  especially  those  which  run 
a  more  protracted  course,  and  finally  terminate  fatally,  some  portions  of  the 
mucous  membrane  will  be  found  intensely  red  and  tumefied,  with  all  the 
changes  that  I  have  previously  mentioned,  except,  that  instead  of  softening, 
the  exudative  material  will  have  sufficient  plasticity  to  give  it  increased 
hardness  or  density;  while  other  portions  being  less  involved  in  the  inflam- 
mation, are  simply  reddened  or  more  vascular,  with  but  little  change  either 
in  the  direction  of  induration  or  softening.  In  the^jurely  chronic  grade  of 
inflammation,  there  is  generally  a  very  unequal  degree  of  change  in 
different  parts  of  the  membrane.  Some  portions  will  be  thickened, 
hardened,  more  red  and  vascular  than  natural,  and  the  surfaces  will 
be  studded  with  abrasions  or  superficial  ulcerations,  caused  by  the 
d'sapp^arance,  in  patches,  of  the  epithelial  layer  of  the  membrane.  Other 
portions  will  be  simply  increased  in  vascularity,  slightly  thickened, 
tumofi  'd  and  indurated,  without  any  appearance  of  the  abrasions  upon 
the  surface,  and  the  redness  will  be  of  a  brighter  hue.  The  cases  which  I 
have  described  as  follicular,  will  present,  usually,  patches  here  and  there, 
unequally  distributed  over  the  surface  of  the  mucous  membrane,  of 
simply  hypertrophietl  or  enlarged  follicles  and  tubules,  giving  to  such 
places  a  slightly  reddened  and  elevated  appearance,  sometimes  granular 
or  mammillated,  and  when  they  are  examined  more  closely,  especially 
under  the   microscope,  they  will  be   found   to  coa-iist  of  hypertrophied 


DIAGNOSIS.  519 

tubules  and  follicles,  possessing  all  the  characteristic  changes  of  a  low 
grade  of  iuflmninatory  action.  After  death  from  chronic  gastric  ulcer, 
examination  of  the  stomach  usually  discloses  one,  and  occasionally  two  or 
three  distinct  isolated  ulcers  ;  more  generally  but  one,  and  this  may  vary 
in  size  from  five  to  twenty-five  lines  in  diameter.  The  edges  are  very 
generally  elevated  and  a  little  rounded,  though  sometimes  excavated  and 
irregular.  The  greater  part  of  the  base  of  the  ulcer  is  usually  the  naked 
fibers  of  the  muscular  coat  of  the  stomach.  In  places  these  fibers  may 
have  disappeared,  causing  the  base  of  the  ulcer  to  rest  upon  the  con- 
nective tissue  between  the  muscular  fibers  and  peritoneal  covering 
externally.  If  the  patient  has  died  from  perforation,  in  one  of  these 
deeper  indentations  will  be  found  a  small  opening  directly  through 
into  the  peritoneal  cavity,  through  which  matters  have  escaped, 
inducing  the  final  rapid  and  fatal  peritonitis.  Usually  both  the 
edges  and  base  of  the  ulcer  are  harder  or  more  dense  than  the 
natural  texture,  with  a  moderate  degree  of  redness  and  increased 
vascularity  surrounding  them.  But  in  many  instances  the  remainder  of 
the  raucous  membrane  will  vary  but  little  from  its  normal,  healthy 
appearance.  Such  are  the  changes  of  structure  and  the  appearances,  that 
are  usually  presented  on  post-mortem  examination,  from  the  various  degrees 
and  stages  of  inflammation  in  the  mucous  membrane  of  the  stomach. 

Diagnosis. — In  the  great  majority  of  instances  there  is  little  difficulty 
in  making  a  correct  diagnosis  of  these  different  grades  of  gastritis.  In  the 
acute  and  subacute  forms  of  the  inflammation,  the  intensity  of  the 
burning  or  sense  of  hjat  in  the  stomach,  the  acute  tenderness  on  pressure, 
the  prompt  and  persistent  vomiting,  aggravated  by  every  attempt  to  take 
nourishment,  accompanied  by  a  distinct  general  febrile  condition,  suf- 
ficiently distinguish  these  cases  from  any  form  of  functional  disease. 
There  is  more  difficulty  in  keeping  the  line  of  diagnosis  clear  between 
the  lower  grades  of  chronic  gastritis  and  some  of  the  more  active 
functional  disturbances  of  the  stomach.  If  you  remember,  hovvever,  that 
true  chronic  gastritis,  is  uniformly  aggravated  by  taking  food,  and  that 
the  chief  symptoms  of  which  the  patient  will  complain  in  the  exacerbations, 
are  burning,  broiling  in  the  epigastrium,  dryness  in  the  mouth,  a  pretty 
uniform  reddening  of  the  edges  and  tip  of  the  tongue,  and  disposition 
sooner  or  later  to  eject  whatever  is  taken,  by  vomiting,  with  more  or  less 
sourness,  the  almost  invariable  absence  of  gaseous  eructatioi.s,  with  loss 
of  flesh,  slight  quickening  of  the  pulse,  an  increase  of  one  or  two  degrees 
of  temperature,  you  will  have  but  little  difficulty  in  making  an  accurate 
diagnosis.  It  is  the  association  of  burning  and  tenderness,  persistent 
from  week  to  week,  with  actual  dryness  of  skin,  slight  acceleration  of 
pulse,  and  elevation  of  temperature,  that  especially  distinguish  the  chronic 
form  of  gastritis  from  any  of  the  forms  of  functional  disease.  The 
follicular  form  of  the  disease  has  these  special  diagnostic  features:  that  the 
morbid  setisations  are  relieved  for  a  time  by  taking  food,  aggravated  as 
soon  as  food  disappears,  and  there  is  a  characteristic  vomit  that  is  called 
"  water- brash"  or  pyrosis,  as  I  have  already  stated,  when  speaking  of  the 
symptoms. 

Gastric  ulcer  can  seldom  be  distinguished, from  functional  disturbance 
with  certainty,  in  the  early  stage  of  its  progress.  But  the  first  hemorrhage 
that  occurs,  if  it  be  properly  interpreted,  will  at  once  satisfy  the  practitioner 
that  he  has  a  positive  lesion  in  the  coats  of  the  stomach  to  contend  with, 
and  thus  the  preceding  obscure  history  becomes  an  element  to  add  to  the 
certainty  of  the  diagnosis,  and  to  fix  it  as  a  true  chri^nic  form  of  ulcer- 
ation. 


520  GASTEIC   ULCER. 

Prognosis. — The  more  severe  attacks  of  acute  gastritis  always  involve 
some  danger  to  the  life  of  a  patient.  Experience  has  shown  that  the 
larger  proportion  of  them  terminate  fatally.  The  milder  cases  of  the 
acute  and  most  of  the  subacute  attacks,  under  judicious  managemerir, 
tend  to  recovery.  In  the  earlier  stage  of  chronic  gastritis  the  chances 
of  recovery  are  usualh'  good.  But  when  the  disease  has  been  of  long 
standing,  causing  much  thickejiing  and  induration  of  portions  of  the 
mucous  membrane  and  subjacent  connective  tissue,  with  permanent  con- 
traction of  the  muscular  coat,  in  such  a  way  as  to  lessen  the  capacity  of 
the  stomach,  it  is  rare  that  recovery  takes  place:  although  the  symptoms 
of  the  patient  may  be  much  mitigated  by  judicious  treatment,  and  life 
may  be  prolonged  through  a  considerable  period  of  time.  Most  of  the 
cases  of  recent  follicular  inflammation  of  the  raucous  membrane  of  the 
stomach  tend  to  recovery  under  judicious  management;  but  some  are 
very  persistent,  and  occasionally  end,  either  in  such  changes  in  the 
follicles,  or  atrophy  of  the  gastric  tubules,  as  to  present  an  incurable  con- 
dition. Such  cases  interfere  with  the  proper  assimilation  of  food,  and 
lead  to  a  slow,  but  persistent  loss  of  flesh  and  strength,  and  usually 
require  several  years  to  reach  a  fatal  result.  The  chronic  gastric  ulcer, 
if  diagnosticated  early,  and  if  the  patient  is  placed  under  the  most  favorable 
circumstances  in  regard  to  diet  and  remedial  agents,  is  susceptible  of 
recovery;  but  when  it  has  been  of  considerable  duration,  has  attained 
considerable  size,  with  elevated  and  somewhat  hardened  edges,  it  is  most 
liable  to  resist  all  efi"orts  to  induce  reparation,  and  to  lead  ultimately  to  a 
fatal  termination. 

Treatment. — The  special  objects  to  be  accomplished  in  the  treatment 
of  acute  and  subacute  cases  of  inflammation  of  the  mucous  membrane  of 
the  stomach,  are  the  same  as  are  presented  to  us  in  the  management  of 
all  acute  inflammations.  But  we  are  here  met  with  a  peculiar  difficult.-, 
from  the  fact  that  the  very  structure  on  which  we  ordinarily  rely  for  intro- 
ducing remedies  into  the  sj'stem,  is  now  the  seat  of  the  inflammation, 
causing  a  disposition  to  reject  all  remedies  almost  as  soon  as  they  are  per- 
mitted to  touch  the  membrane.  When  called  to  a  case  of  acute  gastritis 
within  a  few  hours  after  its  commencement,  the  patient  not  having  been 
previously  debilitated  by  any  special  disease  or  constitutional  impairment, 
I  have  \isually  directed  the  application  of  from  eight  to  twelve  leeches  to 
the  epigastrium,  in  adults,  promoting  the  bleeding  froki  the  bites  by  warm 
wet  cloths,  after  the  leeches  have  fallen  off",  and  subsequently  allowing 
the  part  to  be  covered  with  warm  narcotic  fomentations.  Free  local 
bleeding  by  leeches  in  the  very  early  stage  of  the  disease,  has  seemed  to 
me  to  exert  a  very  beneficial  influence  in  checking  its  progress,  and 
making  the  action  of  other  agents  more  certain. 

At  the  same  time  of  ordering  the  leeches,  I  direct,  if  possible,  the  pro- 
curement of  ice,  to  be  cut  in  suitable  pieces,  and  the  patient  allowed  to 
take  a  small  piece,  holding  it  in  the  mouth  until  the  angles  are  a  little 
rounded  and  swallowing  it  at  frequent  intervals,  in  place  of  taking  any 
other  drink.  As  tliere  is  intense  burning  heat  in  the  stomach,  and  craving 
for  cold  drinks,  the  use  of  the  ice  is  very  grateful  to  the  patient,  and 
serves  the  purpose  both  of  acting  as  a  sedative  in  diminishing  the  vascu- 
larity of  the  mucous  membrane,  with  which  it  comes  in  contact  when 
swallowed,  and  of  satisfying  the  patient  without  the  use  of  drinks,  which 
would  only  increase  the  distress  and  efforts  to  vomit.  To  help  allay  the 
extreme  morbid  sensitiveness  of  the  mucous  membrane,  and  lessen  the 
accumulation  of  blood  in  the  vessels,  I  also  direct  at  the  beginning,  a 
powder  composed  of  the  mild  chloride  of   mercury,  six    centigrams  (^jr.  i) 


TREATMENT.  521 

the  sulphate  of  morphia  one  centigram  (gr,  1-6),  with  three  decigrams 
(gr.  v)  ofsaccharura  alba,  to  be  given  mixed  with  just  enough  syrup,  or  a 
lew  drops  of  water,  to  moisten  it,  every  one  or  two  hours,  allowing  a  bit 
of  ice  to  be  taken  immediately  after,  in  place  of  any  drink.  Although 
the  vomiting  will  cause  the  rejection  of  a  portion  of  these  small  doses  of 
calomel  and  morphine,  still  experience  shows  that  some  portion  of 
each  dose  attaches  itself  to  the  coats  of  the  stomach,  and  is  retained.  By 
their  frequent  repetition  in  from  six  to  eight  hours,  the  patient  will  usually 
begin  to  exhibit  the  anodyne  effects  of  morphine,  in  getting  more  rest, 
longer  intervals  between  the  paroxysms  of  vomiting,  and  at  the  end  of 
twenty-four  hours  in  many  of  the  cases,  the  patient  will  be  catching  periods 
of  from  half  an  hour  to  an  hour  of  sleep,  and  vomiting  much  less  fre- 
quently. If  during  the  first  twenty-four  hours  of  the  treatment,  there  has 
been  no  evacuation  of  the  bowels,  I  cause  the  administration  of  an  ene- 
ma of  warm  water,  containing  a  little  common  salt,  or  sulphate  of  mag- 
nesia, the  quantity  of  water  being  sufficient  to  fill  up  the  rectum,  which 
will  usually  be  followed  by  a  moderately  free  movement  of  the  bowels. 
Instead  of  continuing  the  powders  of  calomel  and  morphine  I  now  give  a 
solution  of  carbolic  acid,  tincture  of  gelseminum,  and  camphorated  tincture 
of  opium,  in  the  yjroportions  I  have  already  stated  in  previous  lectures.  (See 
p.  138.)  After  the  patient  has  had  the  alterant  and  anodyne  powders,  which 
I  have  mentioned,  for  twenty-four  hours,  and  the  bowels  have  been  moved 
])y  enemas,  with  a  continuation  of  the  fomentations  of  a  narcotic  character 
over  the  epigastrium  and  abdomen  following  the  leeching,  the  powders 
should  be  discontinued  and  the  carbolic  acid  solution  given  every  two  or 
three  hours.  This  treatment  has  usually  been  followed  by  a  pretty  rapid 
subsidence  of  all  the  inflammatory  symptoms,  after  which  the  intervals 
between  the  doses  of  the  mixture  should  be  lengthened  to  three  or  four 
hours,  still  being  exceedingly  cautious  of  the  amount  of  fluid  and  nourish- 
ment that  the  patient  takes.  In  nearly  all  the  milder  cases  of  acute  gas- 
tritis and  in  all  of  those  of  a  subacute  character  so  often  met  with  in  chil- 
dren, this  plan  of  treatment  has  been  almost  uniformly  successful. 

The  patients  are  kept  entirely  quiet  in  the  recumbent  position.  No 
attempt  at  the  administration  of  nourishment  is  usually  made  for  the  first 
thirty-six  or  forty-eight  hours;  but  after  that,  simply  one  or  two  table- 
spoonfuls  of  lime-water  and  milk,  one  part  of  the  first  and  two  of  the 
second  are  given  at  short  intervals.  Sometimes  the  animal  broths,  such 
as  beef  tea,  chicken  broth,  and  mutton  broth,  may  be  given  in  similar 
small  doses,  either  alternately  with  the  milk  and  lime-water,  or  as  a  sub- 
stitute for  them.  But  the  great  leading  object  of  the  whole  treatment 
should  be  to  lessen  the  extreme  excitability  of  the  inflamed  membrane  by 
cooling,  anodyne  and  slightly  alterant  influences,  keeping  all  food  from 
contact  with  it  during  the  first  one  or  two  days,  and  allowing  the  use  of 
only  very  small  quantities  of  drink  at  any  one  time.  In  some  instances, 
where  the  vomiting  and  epigastric  distress  are  found  to  be  extremely 
severe,  and  after  one  or  two  days  it  becomes  evident  that  the  little  pow- 
ders of  calomel  and  morphine  are  not  retained  in  sufficient  quantity  to 
allay  the  morbid  excitability,  their  effects  ma}'  be  aided  by  the  use  of  a 
hypodermic  injection  of  morphine.  Better  effects  probably  will  be  ob- 
tained, and  at  least  less  liability  to  have  secondary  nausea  and  depression 
follow  the  anodyne  influence  of  morphine,  if  when  used  hypodermically, 
it  is  conjoined  with  a  small  quantity  of  atropia.  In  using-  hypodermic  in- 
jections of  morphine,  I  always  prefer  to  use  minimum  doses  at  first,  and 
incur  the  inconvenience  of  repeating  it  at  proper  intervals,  rather  than  the 
r.sk  of  suddCiily  and  too   strongly  narcotizing  the  patient  by  larger  doses. 


522  GASTllITIS. 

In  a  few  instances  after  the  first  twenty-four  hours  have  passed,  and  the 
time  come  to  procure  a  movement  of  the  bowels,  the  use  of  enemas  has 
failed  to  procure  the  necessary  evacuations,  and  yet  the  abdomen  has 
become  largely  distended  with  gases.  Under  such  circumstances  I  have 
occasionally  found  the  administration  of  a  single  powder,  containing  three 
decigrams  each  (gr.  v)  of  calomel  and  bicarbonate  of  soda,  followed  in 
two  hours  by  small  but  repeated  doses  of  the  liquid  citrate  of  magnesia, 
to  result  in  moving  the  bowels  freely.  My  observations,  however,  have  led 
me  to  avoid  the  administration  of  cathartics  by  the  mouth,  while  there  is 
any  considerable  inflammation  of  the  mucous  membrane  of  the  stomach 
still  existing  in  the  more  acute  attacks,  unless  it  becomes  absolutely 
necess.ry  from  the  failure  of  enemas,  when  they  have  been  properly  used. 
After  the  acute  symptoms  have  passed  by,  the  febrile  action  ceased  and 
the  patient  is  capable  of  taking  aiid  retaining  small  quantities  of  bland, 
simple  nourishment,  the  greatest  care  is  necessary  to  avoid  all  errors  in 
diet,  such  as  allowing  the  patient  too  early  to  return  to  the  use  of  solid 
food,  or  to  indulge  with  any  degree  of  liberality  in  the  use  of  drinks. 
It  is  also  necessary  to  avoid  too  early  a  return  to  active  exercise.  Rest 
and  extreme  care  in  the  regulation  of  the  ingesta,  will  contribute  very 
much  to  shorten  the  period  of  convalescence;  and  render  the  patient's  re- 
covery much  more  perfect  than  it  would  be  were  he  indulged  in  an  ear- 
lier return  to  more  food,  and  more  exercise.  When  the  inflammation  of 
the  mucous  membrane  has  assumed  a  chronic  form,  presenting  the  symp- 
toms I  have  described  as  characterizing  that  stage  of  the  disease,  it  is  sel- 
dom that  much  benefit  can  be  obtained  from  local  bleeding  or  from  the 
use  of  v.'hat  are  called  alterative  medicines.  In  the  great  majority  of  cases 
of  diffuse  chronic  inflammaiion  of  the  mucous  membrane,  I  have  succeeded 
in  affording  much  relief  to  the  patient,  by  the  use  of  nitrate  of  Silver  in  the 
form  of  pills,  usually  in  combination  with  the  extract  of  hyoscyamus  and 
opium.  A  pill  composed  of  six  centigrams  (gr.  i)  of  the  extract  of 
hyoscyamus,  three  centigrams  (gr.  ^)  of  pulverized  opium,  and  two 
centigrams  (gr.  ^)  of  nitrate  of  silver  given  each  morning,  noon,  tea- 
time  and  bed- time,  will  usually  produce  a  markedly  beneficial  effect.  In 
some  of  these  cases,  I  think  the  carbolic  acid  solution  to  which  I  have 
already  alluded  giveii  in  doses  of  four  cubic  centimeters  (fl.  3i)  just  before 
each  meal  time,  and  one  of  the  pills  of  nitrate  of  silver,  opium  and  hyos- 
cyamus given  half  an  hour  after  breakfast,  dinner  and  at  bed-time,  has 
produced  better  results  than  either  of  these  combinations  given  alone. 
So  far  as  jDracticable,  during  the  treatment  of  chronic  gastriti  ,  the  neces- 
sar^r  intestinal  evacuations  should  be  procured  by  the  use  of  enemas  given 
at  stated  intervals,  once  a  da}^,  or  once  in  two  days,  instead  of  laxatives 
administered  by  the  mouth.  In  many  cases  of  the  milder  grades  of  chronic 
gastritis  of  considerable  duration  and  accompanied  by  habitual  consti- 
pation of  the  bowels,  I  have  used  a  pill  composed  of  the  sulphate  of  iron 
extract  of  h^^oscyamus,  and  extract  of  Scutellaria,  each  six  centigrams  i 
(arr.  i)  with  two  centigrams  (gr.  -g-)  of  gum  aloes,  and  two  of  blue  mass, 
given  at  each  meal-time  either  before  taking  nourishment  or  within  half 
an  hour  after,  with  a  good  effect  upon  the  mucous  membrane  of 
the  stomach,  greatly  lessening  the  distress  after  taking  food,  and  in  a 
few  days  establishing  a  regular  and  natural  condition  of  the  evacuations 
from  the  bowels.  By  taking  from  one  to  three  of  these  pills  daily,  with 
careful  regulation  of  he  diet,  drink,  and  exercise  of  the  patient,  they  have 
been  followed  by  recovery  in  many  instances.  Of  course,  I  allude  now, 
to  those  cases  of  a  mild  but  persistently  chronic  character  in  which  the  in- 
flammatory action  is  barely  sufficient  to   cause   every  meal,  or  supply  of 


TEEATMENT.  523 

food  to  be  followocl  by  a  sense  of  heat,  fullness,  more  or  less  nausea,  and 
either  eructations  or  occasional  vomiting  of  the  food  in  a  sour  condition. 
These  symptoms  with  some  degree  of  tenderness  on  pressure,  I  regard  as 
indicating  a  low  grade  of  inflammatory  action  in  the  mucous  raemtjrane. 

In  mnny  of  this  same  class  of  cases  I  have  succeeded  well  by  giving  the 
carbolic  acid  solution  immediately  before  each  meal  and  one  of  the  same  pills 
that  I  have  just  alluded  to,  only  with  the  aloes  increased  to  six  centigrams 
(gr.  i)  instead  of  two  (gr.  ^)  in  each  pill,  at  bed-time.  In  such  cases  the 
carbolic  acid  mixture  (see  formula  on  p.  138)  exerts  a  beneficial  influence 
in  directly  allaying  the  morbid  excitability  of  the  membrane  and  by 
its  antiseptic  properties  lessening  the  tendency  to  sourness  and  acidity, 
while  the  pill  with  the  increased  amount  of  aloes  taken  at  night  serves  to 
regulate  the  evacuations  from  the  bowels.  In  many  cases  of  chronic  gas- 
tritis, persistent  in  their  tendency,  and  accompanied  by  considerable  epi- 
gastric tenderness  to  pressure,  some  advantage  may  be  gained  by  mild 
but  protracted  counter-irritation.  This  may  be  accomplished,  either  by 
a  succession  of  small  blisters  over  the  epigastrium,  or  perhaps  better  and 
with  less  annoyance  to  the  patient  by  the  application  of  a  mixture  of  cro- 
ton  oil  one  part,  tincture  of  iodine  two  parts,  sulphuric  ether  two  parts. 
This  painted  over  so  much  of  the  surface,  as  you  wish  to  make  sore,  at 
first  twice  in  twenty-four  hours,  will  usually  in  two  or  three  days  produce 
an  eruption  of  vesicles  sufficient  to  constitute  a  mild  form  of  counter-irri- 
tation. After  the  eruption  has  taken  place,  it  may  be  kept  up  by  repeat- 
ing the  application  once  a  day,  or  once  in  two  days,  for  such  length  of  time 
as  may  be  desirable.  The  treatment  which  I  have  usually  found  most 
efficient  in.  relieving  those  cases  which  I  have  described  as  follicular  in- 
flammation of  the  stomach  has  consisted  in  the  use  of  sub-nitrate  of  bis- 
muth in  doses  of  from  three  to  five  decigrams  (gr.  v  to  viii )  either 
alone,  or  combined  at  first  with  some  anodyne,  of  which  lupulin  and  hyos- 
cyamus  are  the  best.  Opiates  in  these  cases,  while  they  may  temporarily 
help  to  allay  irritation,  seldom  fail  to  induce  within  a  few  days,  not  only 
constipation,  but  a  secondary  nausea  and  depression  that  adds  to  the  suf- 
fering of  the  patient,  instead  of  affording  any  curative  influence.  The 
bismuth  may  be  taken  either  immediately  before  the  patient  takes  nour- 
ishment, or  from  fifteen  to  thirty  minutes  afterward.  In  cases  in  which 
there  is  a  tendency  to  acid  feimentation  after  taking  food,  I  have  thought 
it  better  to  give  bismuth  in  combination  with  an  equal  quantity  of  the 
bi-carbonate  of  soda,  from  fifteen  to  thirty-five  minutes  after  taking  food. 
In  some  of  these  cases,  the  oxalate  of  cerium,  in  doses  of  from  two  to 
three  decigram^  (gr.  iii  to  v)  given  before  each  meal-time,  pi'oduces 
belter  effects  than  bismuth.  There  are  still  other  cases,  in  which  I  have 
found  bismuth,  oxalate  of  cerium,  and  oxide  of  zinc,  all  to  fail  in  produc- 
ing any  permanent  beneficial  results;  and  yet  the  patients  have  been 
much  relieved,  and  for  a  while  entirely  restored,  by  the  use  of  pills  com- 
posed of  extract  of  hyoscyamus  six  centigrams  (gr.  i  )  ,  and  nitrate  of 
silver  two  centigrams  (gr. -J)  given  just  after  each  meal.  In  all  these 
cases,  whether  using  bismuth,  oxalate  of  cerium,  or  nitrate  of  silver,  due 
attention  should  be  given  to  the  procurement  of  regular  evacuations  from 
the  bowels.  In  some  instances  the  regular  use  of  an  enema,  at  a  given 
time  each  day,  will  prove  sufficient  to  obviate  constipation,  but  in  others 
it  will  be  found  ineffectual;  and  in  such  cases  what  I  have  called  the  tonic 
and  laxative  pill  consisting  of  six  centigrams  (gr..  i)  each  of  extract  of 
hyoscyamus,  sulphate  of  iron,  pulverized  aloes,  and  blue  mass,  given  at 
bed-time,  each  night,  has  seldom  failed  to  establish  in  a  few  days  a  regular 
and  natural  evajuation    once  each   day.      The  tonic  properties  ot  these 


524  CHRONIC   GASTRITIS. 

pills  may  be  increased  by  adding  two  centigrams  (gr.  -J)  of  the  extract 
of  nux  vomica,  or  two  milligrams  (gr.  1-30)  of  strychnia  to  each 
pill.  It  is  hardly  necessary  to  add,  that  in  all  these  cases  of  follicular 
inflammation,  however  chronic  they  may  be,  and  whatever  may  be  the  im- 
pression of  agents  administered  for  their  relief,  it  is  necessary  that  the 
patient  be  cautious  in  the  use  of  food  and  drinks;  abstaining  rigidly  from 
all  rich,  highly  seasoned  dishes,  coarse  and  indigestible  vegetables  or 
fruit,  and  taking  only  the  plainer,  simpler,  and  more  easily  digestible  ar- 
ticles at  regular  intervals  and  in  only  moderate  quantities. 

It  is  necessary,  also,  that  strong  tea  and  coffee  be  avoided.  A  cup  of 
light,  or  weak  tea  or  coffee  taken  at  meals,  in  many  cases  produces  no  per- 
ceptible inconvenience.  All  alcoholic  drinks  or  remedies  should  he  care- 
fully excluded;  especially  is  this  important  in  those  cases  of  follicular 
disease  that  have  originated  in  individuals  addicted  to  the  habitual  use 
of  alcoholic  drinks.  My  own  observation  does  not  enable  me  to  agree 
with  those  writers,  who  in  this  particular  class  of  cases  especialU^  sanction 
a  very  moderate  use  of  some  of  the  lighter  wines,  under  the  impression 
that  they  enable  the  patient  to  i^etain  nourishment  better  than  they  would 
without  it.  While  this  is  apparently  the  case  sometimes  for  a  temporary 
period,  I  have  never  known  it  to  be  continued  two  weeks  in  succession 
without  being  followed  by  an  aggravation  of  the  symptoms;  neither  have 
I  ever  known  a  patient  to  continue  the  use  of  any  variety  of  wine  or  beer, 
that  obtained  such  kind  of  relief  as  enabled  him  to  dispense  with  its  use. 
In  other  words  the  apparent  benefits  derived  from  them  have  been  either 
simph'  from  the  temporary  anaesthetic  effect  of  the  small  portion  of  alco- 
hol upon  the  morbidly  sensitive  condition  of  the  gastric  nerves,  or  they 
have  produced  no  benefits,  but  a  direct  and  positive  injury:  consequently 
I  have  long  since  insisted  upon  their  entire  discontinuance  in  all  this 
class  of  cases,  and  more  particularly  those  which  have  originated  prima- 
rily during  their  habitual  use.  In  the  treatment  of  the  chronic  gastric 
ulcer,  the  only  other  form  of  disease  that  I  have  included  in  the  list  of  in- 
flammations of  the  gastric  mucous  membrane,  I  have  more  evidence  of  the 
curative  effects  of  nitrate  of  silver  given  in  combination,  either  with  hy- 
oscyamus  or  small  doses  of  opium,  than  of  any  other  remedy.  I  have  no 
doubt  that  when  the  disease  is  diagnosticated  early,  and  the  patient 
put  upon  a  judiciously  regulated  diet,  excluding  all  stimulating  drinks, 
and  irritants  of  every  kind,  and  required  to  take  nitrate  of  silver,  com- 
mencing in  doses  of  two  centigrams  (gr.  -g)  combined  with  six  centi- 
grams (gr.  i)  of  the  extract  of  hyoscyamus,  in  the  form  of  a  pill,  at 
each  meal-time,  and  the  doses  of  the  silver  gradually  increased  from  time 
to  time,  until  it  reaches  from  three  to  five  centigrams  (gr.  ^  to  f),  the 
patient  will  usually  find  his  obscure  symptoms  of  indio-estion,  epigastric 
lieaviness  after  taking  food,  gradually  disappear,  until  there  is  no  evidence 
of  any  derangement  left.  But  in  order  to  insure  the  entire  success  of 
remedies,  the  treatment  must  be  continued  a  considerable  length  of  time, 
usually  not  less  than  three  or  four  months.  Small  doses  of  sulphate  of 
copper,  given  in  the  same. combination  as  I  have  mentioned  for  the  nitrate 
of  silver,  have  also  sometimes  proved  equally  beneficial,  and  in  particular 
patients,  more  so  than  the  nitrate  of  silver. 

At  the  time  of  hemorrhage  from  gastric  ulcer,  I  have  found  no  remedy  so 
speedilv  successful  in  arresting  the  further  oozing  of  blood,  as  suitable 
doses  of  persulphate  of  iron.  I  have  usually  given  it  in  doses  of  from 
six  to  twelve  centigrams  (gr.  i  to  ii)  dissolved  in  eight  cubic  centimeters 
(fl.  3ii)  of  water,  repeated  at  first  every  thirty  minutes,  till  the  flow  of  blood 
appears  to  be  checked,  then  at  intervals  of  one  hour,  gradually  extending 


TEEATMENT.  525 

the  time  to  two,  three  or  four  hours.  If  no  return  of  the  bleeding'  occurs  for 
forty-eight  hours,  it  may  be  discontinued.  During  the  next  week  follow- 
ino-  these  attacks  of  l)lceding,  I  have  used  a  pill,  consisting  of  the  sulphate  of 
iron,  six  centigrams,  (gr.  i)  with  an  equal  quantity  of  the  extract  of 
hyoscyamus  at  each  meal-time,  and  the  same,  to  which  was  added  one 
grain  of  aloes,  at  bed-time;  the  latter  for  the  purpose  of  inducing  a  reg- 
ular condition  of  the  intestinal  evacuations.  I  have  thought  the  use  of 
the  sulphate  of  iron  for  one  or  two  weeks,  following  attacks  of  hemorrhage 
from  2:astric  ulcer,  rendered  the  patient  more  secure  against  the  return  of 
hemorrhage,  and  prepared  the  way  for  the  subsequent  use  of  the  nitrate  of 
silver,  with  much  better  results  than  when  the  nitrate  of  silver  was  re- 
sorted to  immediately  after  the  cessation  of  the  hemorrhage.  But  the 
proper  regulation  of  the  patient's  diet,  in  these  cases  of  gastric  ulcer  is  of 
quite  as  much,  if  not  mor>',  importance  than  the  medicines  to  be  adminis- 
tered. All  coarse  and  indigestible  articles  of  food,  and  those  of  a  heat- 
ing, stimulating  nature,  should  be  rigidly  excluded.  The  best  diet  in 
most  instances,  is  that  composed  principally  of  light-bread  and  milk,  oat- 
meal and  milk,  rice  and  milk,  or  other  farinaceous  articles.  For  variety, 
meat  broths  may  be  allowed,  but  when  used,  they  should  always  be  sea- 
soned with  salt  to  suit  the  taste  of  the  patient,  and  not  taken  fresh  or 
without  salt.  I  have  spoken  of  the  administration  of  the  persulphate  of 
iron  as  the  best  remedy  for  the  immediate  arrest  of  hemorrhage  from 
gastric  ulcer;  but  there  are  many  other  remedies  that  may  be  used,  and 
often  with  prompt  relief  to  the  patient.  From  six  to  twelve  centigrams 
(gr.  i  to  ii)  of  the  acetate  of  lead  may  be  given  ever}-  twenty  or  thirty 
minutes,  during  the  time  of  the  flow  of  blood,  and  then  continued  at 
longer  intervals  for  twenty-four  or  forty-eight  hours,  to  prevent  its  recur- 
rence. Vegetable  astringents,  such  asgaliic  acid,  fluid  extract  of  rhatany, 
or  the  geranium  maculatum  root,  may  be  used  ;  but  so  far  as  my  own  ob- 
servations go,  these  vegetable  astringents  are  much  less  reliable  for  the 
speedy  arrest  of  this  variety  of  hemorrhage,  than  either  the  acetate  of 
lead,  or  the  persulphate  of  iron.  Ergotin  is  another  remedy  that,  in  re- 
cent times,  has  been  used  in  this,  as  in  many  other  varieties  of  hemorrhage, 
and  sometimes  with  apparently  prompt  beneficial  effects.  It  must  not  be 
forgotten,  however,  in  estimating  the  effects  of  remedies,  that  in  the  large 
majority  of  these  cases  of  gastric  ulcer,  the  hemorrhage  tends  to  cease 
spontaneously,  within  a  brief  period  of  time.  Many  patients,  when  at- 
tacked, living  a  few  miles  from  their  physician,  have  found  the  flow  of 
blood  to  have  ceased  entirely  before  the  physician  has  arrived,  and  with- 
out the  agency  of  any  remedies  calculated  to  exert  an  influence  over  it. 
Simple  rest  in  the  recumbent  position,  avoiding  all  ingesta  except  the 
swallowing  of  pieces  of  ice  or  small  doses  of  cold  water  now  and  then,  has 
seemed  to  facilitate  the  arrest  of  the  hemorrhage. 

Duodenitis. — The  m.ucous  membrane  of  the  next  section  of  the 
alimentary  canal,  called  the  duodenum,  is  much  less  liable  to  attacks  of 
an  inflammatory  character,  than  that  lining  the  stomach.  Yet  occasional 
instances  of  all  the  various  grades  of  inflammation,  to  which  I  have  called 
your  attention,  as  occurring  in  the  stomach,  are  met  with  in  the  duodenum, 
and  the  changes  that  are  produced  during  their  progress,  anatomically 
and  symptomatically  are  identical  with  those  which  occur  in  the  corre- 
sponding grades  of  inflammatory  action  in  the  membrane  lining  the 
stomach.  The  chief  difference  in  the  symptoms  consists  in  the  fact,  that 
when  the  inflammation  exists  in  the  duodenum,  the  ingesta  that  the 
patient  takes,  whether  food,  drink,  or  medicine,  does  not  produce  its 
irritant   effects  so  speedily.     There  is  usually  a  brief  period  of  time  after 


526  DUODENITIS. 

it  is  swallowed,  more  generally  extending  to  thirty  miimtes  and  sometimes 
longer,  before  the  nausea,  burning  or  distress  of  any  kind,  or  the  dis- 
position to  vomit  is  induced.  Not  only  is  the  effect  of  taking  ingesta 
later  in  its  development  of  the  nausea,  but  that  constantly  existing  does 
not  culminate  in  efforts  at  vomiting,  so  frequently  as  in  the  more  active 
grade  of  gastritis.  Perhaps  there  is  also,  in  nearly  all  the  cases,  a  less 
intense  bu-ning  quality  to  the  pain,  and  more  of  a  dull,  heavy,  oppressive 
feeling.  These  differences  are  simply  what  would  naturally  be  inferred 
from  the  fact  that  the  food  being  first  taken  into  the  stomach  requires  a 
little  time  to  be  passed  through  that  organ  into  the  duodenum,  where  it 
will  come  in  contact  with  the  inilatned  surfaces.  It  is  due  also  somewhat 
further  to  the  fact,  that  the  duodenal  membrane  is  not  apparently  supplied 
as  liberally  with  nerves  of  acute  sensibility  as  the  gastric  membrane. 
Another  difference  consists  in  the  fact,  that  the  duodenal  inflammations, 
whether  acute  or  chronic,  are  liable  to  involve  that  portion  of  the  mem- 
brane connected  with  the  openings  of  the  hepatic  and  pancreatic  ducts, 
and  sometimes  to  extension  of  the  inflammatory  process  into  the  lining 
of  thepe  ducts  by  continuit}'-,  from  the  membrane  in  the  duodenum. 
When  this  occurs  the  tumefaction  of  the  membrane  consequent  upon  the 
increased  accumulation  of  blood,  and  of  inflammatory  exudations  into  its 
texture  will  sometimes  so  far  obstruct  the  flow  of  these  fluids  as  to  cause 
their  accumulation  in  the  ducts,  and  sometimes  their  reabsorption.  This, 
so  far  as  the  jDancreatic  fluid  is  concerned,  gives  no  alteration  of  color  and 
consequently  affords  us  but  little  opportunity  for  determining  with  certainty 
what  part  it  plays  in  the  symptoms  of  the  patient.  But  the  obstruction 
in  the  opening  of  the  hepatic  ducts  preventing  the  free  flow  of  bile  into 
the  intestine  causes  reabsorption  from  the  over-full  ramifications  of  the 
ducts  in  the  lobules  of  the  liver,  and  speedily  produces  yellowness  of 
the  conjunctiva  of  the  eye  and  subsequently  of  the  whole  cutaneous 
surface,  with  a  dark  brownish  hue  of  the  urine,  and  all  other  phenomena 
which  are  usually  included  under  the  term  jaundice.  When  inflammation, 
either  acute,  chronic,  follicular,  or  ulcerative  is  restricted  to  the  membrane 
lining  the  duodenum,  it  not  only  produces  the  same  changes  pathologically 
that  we  have  described  as  taking  place  in  parallel  grades  of  inflammatory 
action  in  the  mucous  membrane  of  the  stomach,  but  they  are  amenable  to 
the  same  modes  of  treatment  in  all  respects  ;  consequently,  I  need  not 
repeat  in  reference  to  them  what  I  have  only  just  detailed  as  applicable 
to  the  inflammations  in  the  stomach.  There  is,  however,  one  form  of  in- 
flammation commencing  in  the  duodenum,  and  giving  rise  to  an 
assemblage  of  symptoms  which  most  writers  have  included  under  the 
name,  gastro-hepatic  catarrh,  which  requires  some  notice. 

Duodeno- Hepatitis. — But  my  own  observation,  aided  by  one  or  two  op- 
portunities for  post-mortem  examinations,  has  convinced  me  that  nearly 
all  these  cases  of  disease  commence  as  subacute  inflammation  of  the 
membrane  lining  the  duodeitttrn,  and  extend  by  continuity  into  the  hepatic 
ducts,  often  following  that  membrane  to  their  ramifications  in  the  central 
portion  of  the  liver,  and  therefore  meriting  the  name  not  of  gastro-hepatic 
catarrh,  but  of  duodeno-hepatic  catarrh,  or  preferably  duodeno-hepatitis. 
Attacks  of  this  grade  of  inflammation  are  most  apt  to  be  met  with  during 
the  early  part  of  adult  life,  and  almost  invariably  during  the  transition  of 
the  seasons,  spring  and  autumn,  coincident  with  the  prevalence  of  cold, 
wet,  sleety,  and  changeable  weather.  In  some  seasons  during  the  months 
of  October  and  November,  and  in  others,  though  more  rarely  "in  March  and 
Af)ril,  I  have  met  with  so  many  of  these  cases  as  to  constitute  a  moderate 
epidemic.     Some  cases  aie  met  with  every  autumn.     They  have    seemed 


SYMPTOMS.  527 

to  me  to  originate  almost  wholly  from  the  impression  of  cold,  (lamp  air, 
upon  the  cutaneous  and  pulmonary  surfaces,  restricting  the  exhalation  of 
(jtfete  or  waste  matter  through  these  outlets,  and  inducing,  by  i-eflex  iti- 
fluence  in  part,  and  in  part  by  direct  action  of  the  retained  effete  mate- 
rials, irritation  and  congestion  of  the  mucous  membrane  of  the  duodenum 
and  hepatic  ducts.  That  the  chief  cause  is  exposure  to  cold,  damp,  and 
frequent  changes  is  rendered  more  evident  from  the  fact  that  they  not 
only  occur  at  the  seasons  of  the  year  when  these  conditions  of  the  atmos- 
phere are  predominant,  but  they  occur  far  more  frequently  in  the  male 
than  in  the  female,  and  among  laboring  men  or  those  whose  employments 
cause  them  to  take  free  outdoor  exposure. 

Symptoms. — The  symptoms  in  these  cases  vary  much  in  accordance 
with  the  degree  of  severity  of  the  attacks.  In  the  large  majority  of  those 
that  have  come  under  my  own  observation,  the  first  symptoms  of  which 
the  patient  complains,  are  a  sense  of  heaviness,  with  an  obscure  feeling  of 
soreness  in  the  lower  part  of  the  epigastric  region,  and  indifference  to  taking 
food,  although  in  many  instances,  after  commencing  to  eat,  a  fair  quantity 
is  taken.  Accompanying  the  local  symptoms  are  the  general  feelings  of 
depression  and  indisposition  to  exertion. 

From  half  an  hour  to  an  hour  after  food  is  taken,  the  feeling  of  fullness 
in  the  abdomen  is  increased,  and  generally  accompanied  l)y  a  sense  of 
nausea,  which  lasts  usually  one  or  two  hours,  but  passes  off  till  food  is 
again  taken.  Accompatjying  these  early  symptoms,  the  urinary  secretion 
is  usually  diminished,  an  i  redder  than  natural.  In  many  cases  there  is  a 
white  thin  coat  upon  the  tongue,  there  is  very  slightly  increased  heat  of 
skin,  a  little  dry  look  of  the  lips,  but  the  pulse  is  hardly  disturbed  from  its 
natural  frequency.  The  symptoms,  however,  increase,  and  in  aliout  three 
days  from  their  commencement  there  will  be  a  moderate  general  feverish- 
ness  often  accompanied  by  dull  pains  in  the  head  and  back;  the  skin  becomes 
dryer  than  natural,  pulse  accelerated  ten  or  twelve  beats  faster  than  normal, 
an  increased  coating  upon  the  tongue, with  still  greater  dryness  in  the  mouth, 
and  a  more  constant  feeling  of  heaviness  or  weight,  and  some  degree  of 
tenderness  to  pressure  over  the  region  of  the  duodenum.  This  heavy 
weight  or  load,  as  the  patients  call  it,  is  much  increased  after  taking 
food,  and  is  usually  accompanied  by  nausea,  which  is  also  uniformly 
increased  by  pressure  over  the  epigastrium.  In  the  more  active  class  of 
cases,  a  little  pressure  with  the  hand  will  not  only  excite  nausea,  but  at- 
tempts at  vomiting;  and  after  food  is  taken  it  is  apt  to  be  rejected  by 
vomiting  in  from  half  to  three  quarters  of  an  hour.  Usually,  the  food 
thus  ejected  is  more  or  less  sour  and  mixed  with  some  mucus.  The  bowels 
are  usually  moderately  constipated,  the  urinary  secretions  still  more  scanty 
and  higher  colored  than  at  first;  not  merely  redder,  but  now  tinged  with 
a  reddish  yellow  hue,  from  intermixture  of  the  coloring  matter  of  bile. 
Close  examination  at  this  time  or  a  day  later,  will  discover  a  yellow  hue  of 
the  conjunctiva  of  the  eye,  often  a  bitter  taste  in  the  mouth,  a  feeling  of 
dryness,  and  usually  an  entire  loss  of  appetite.  If  the  case  is  not  inter- 
fered with  by  the  end  of  a  week  after  the  patient  begins  to  complain,  in 
the  large  majority  of  cases  the  skin  and  eyes  generally  present  a  deep 
yellow  color,  and  all  the  outward  aspect  of  a  full  jaundiced  condition  from 
the  retention  and  diffusion  of  the  coloring  matter  of  the  bile,  through  all 
the  tissues  of  the  body.  The  urine  now  iDecomes  dark  brown,  or  yellow- 
ish brown,  and  in  bad  cases  very  scanty  in  quantity.  The  sense  of  heavi- 
ness and  weight  in  the  epigastrium,  accompanied  by  some  increased  full- 
ness, is  quite  distressing  to  the  patient  and  usually  compels  him  to  keep 
a  recumbent  or  semi-rccumbent  position.     Under  proper  hygienic  regula- 


528  DUODENO-HEPATITIS. 

tions  and  mild  treatment,  most  of  these  cases  reach  the  dim "x  of  their 
severity  in  from  seven  to  nine  days;  after  which  a  very  gradual  improve- 
ment takes  place,  consisting  in  less  distress  on  taking  food,  less  disposi- 
tion to  vomit,  and  an  increased  secretion  of  urine,  with  the  disappearance 
of  the  moderate  grade  of  feverishness  that  had  existed  previously,  and  a 
steady  diminution  of  the  yellow  hue  of  the  skin  and  conjunctiva  of  the 
eye,  until  in  from  two  to  three  weeks  the  patient  usually  returns  to  his 
natural  condition  both  in  general  feelings  and  in  the  color  of  the  surface. 
Occasionally  a  case  is  met  with  of  such  a  degree  of  severity  that  the  local 
symptoms  of  fullness,  tenderness  to  pressure,  nausea  and  vomiting  when 
anything  is  taken  into  the  stomach,  become  more  constant  and  distressing, 
especially  after  the  first  three  or  four  days. 

The  matters  ejected  by  vomiting,  aside  from  the  food  and  drink  which 
may  be  taken,  are  almost  exclusively  mucus,  sometimes  glairy  and  tena- 
cious, at  other  times  more  thin  or  serous.  At  first  it  may  be  tinged  with 
the  coloring  matter  of  bile,  but  after  the  first  twenty-four  or  forty-eight 
hours  there  will  cease  to  be  any  yellow  or  greenish  hue  to  the  matters 
vomited,  and  if  the  bowels  are  moved  the  evacuations  are  uniformly  of  a 
whitish  or  clay  color,  exhibiting  no  traces  of  the  coloring  matter  of  bile. 
The  skin  and  eyes  become  early  intensely  yellow,  the  urine  more  nearly 
the  color  of  beer  and  much  diminished  in  quantity.  These  more 
severe  cases  also  present  much  drowsiness,  dry  lips,  deficient  mois- 
ture in  the  mouth,  coated,  and  sometimes  dry  tongue.  In  three 
cases  that  came  under  my  observation  during  one  season  when  these 
attacks  were  sufficiently  numerous  to  constitute  an  epidemic,  before  the 
end  of  the  first  week  the  urine  was  nearly  suppressed,  there  being  no 
more  than  five  or  six  ounces  discharged  in  twenty-four  hours  ;  the  patients 
hardly  susceptible  of  being  aroused  from  their  stupor,  pupils  dilated, 
breathing  slow  and  sometimes  irregular,  pulse  soft,  easily  com- 
pressed, abdomen  somewhat  distended  and  tympanitic,  frequent 
attempts  at  vomiting  especially  when  anything  was  taken  even  ot  the 
blandest  character.  In  one  of  these  cases,  ai)out  the  middle  of  the 
second  week  of  the  progress  of  the  disease,  the  patient  being  about  six 
months  advanced  in  pregnancy,  uterine  pains  commenced  and  proceeded 
until  the  foetus  and  after-birth  were  both  expelled,  while  the  patient 
was  so  stupid  apparently  from  the  toxaemic  effects  of  the  retained 
elements  of  bile,  that  she  was  wholly  unaware  of  what  was  taking  place. 
No  hemorrhage  followed,  and  the  uterus  remained  firmly  contracted  after 
the  expulsion  of  its  contents.  But  coincident  with  this,  the  secretion  of 
urine  became  entirely  suppressed,  the  use  of  the  catheter  finding  none  in 
the  bladder.  In  about  twelve  hours  after  the  expulsion  of  the  foetus,  the 
matters  ejected  by  vomiting  or  rather  by  regurgitation,  became  dark 
grumous,  resembling  very  much  the  peculiar  vomit  of  yellow  fever.  The 
pulse  failed  rapidly,  the  extremities  became  cold  ;  and  entire  collapse  and 
death  followed  on  the  second  day  after  the  expulsion  of  the  foetus,  or 
about  nine  days  from  the  commencement  of  the  disease.  Another  of  the 
three  to  which  I  alluded  was  a  female  but  not  in  a  pregnant  condition,  and 
although  during  the  second  week  the  kidneys  secreted  no  more  than 
from  two  to  six  ounces  in  the  twenty-four  hours,  and  the  patient  remained 
so  much  stupefied  as  to  be  incapable  of  giving  any  answers  to  questions, 
with  the  extremities  cold,  pulse  feeble,  mouth  entirely  dry,  skin  more  of  a 
bronze  than  a  yellow  hue,  abdomen  soinewhat  tumid  and  tympanitic, 
nevertheless,  after  lying  in  this  condition  for  three  or  four  days,  she 
began  gradually  to  improve  and  finally  recovered. 

The  third  case  was  a  man  in  the  middle  period  of  life  and  was  under 


ANATOMICAL    CHANGES.  529 

the  care  of  a  neighboring  physician.  I  saw  him  only  in  consultation 
during  the  last  stage  of  the  disease,  when  he  presented  symptoms  almost 
identically  the  same  as  those  of  the  other  two  patients  just  described, 
and  the  case  terminated  fatally  about  the  end  of  the  second  week.  In 
this  case  a  post-mortem  examination  was  permitted;  the  results  of  which 
I  will  mention  when  speaking  of  the  pathological  changes  produced  by 
this  form  of  disease.  The  milder  class  of  cases  will,  many  of  them,  not 
show  any  jaundiced  condition  or  diffusion  of  bile  in  the  system  until 
sometime  during  the  second  week  after  the  commencement  of  the  attack. 
The  patient  complains  throughout  the  whole  course  of  the  disease  only  of 
dullness,  indisposition  to  exertion,  dryness,  and  bitterness  of  taste  in  the 
mouth,  moderate  constipation  of  the  bowels,  scanty  and  dark  colored 
urine,  indifference  to  nourishment,  and  a  heavy,  dull  feeling  in  the  lower 
part  of  the  epigastric  region,  and  some  nausea.  This  inclination  to  nausea 
is  uniformly  increased  by  any  pressure  upon  the  part,  the  heaviness  and 
nausea  are  usually  also  increased  for  two  or  three  hours  after  any  nourish- 
ment is  taken  into  the  stomach.  In  these  milder  cases  there  is  seldom 
actual  vomiting  unless  very  decided  errors  are  committed  in  allowing  too 
much  food  and  drink.  During  the  first  week  the  discharges  from  the 
bowels  are  tardy  and  lighter  colored  than  natural;  but  if  vomiting  is  pro- 
voked, there  may  be  evidences  of  bile  mixed  with  the  matters  vomited. 
But  after  the  middle  of  the  second  week  even  in  the  mildest  cases  that 
have  come  under  my  observation,  the  conjunctiva  becomes  yellow  with 
the  coloring  matter  of  bile,  the  urine  becomes  a  peculiar  brownish  yellow, 
and  there  appears  some  degree  of  yellowness  of  th-^  skin  generally.  This, 
however,  is  often  only  moderate,  and  continues  only  for  a  few  days  before 
it  again  begins  to  decline.  Most  of  these  mild  cases  will  complete  their 
whole  course  in  from  two  to  three  weeks  ending  in  entire  recovery,  often 
with  but  little  other  treatment  than  a  judicious  regulation  of  the  patient's 
food  and  drink. 

Atiatomical  Changes. — The  general  symptoms  which  I  have  detailed 
as  characterizing  the  commencement  of  the  diseases  grouped  under  the 
head  of  duodeno-hepatitis,  are  such  as  plainly  to  indicate  an  interference 
with  the  functions  both  of  the  duodenum  and  the  liver,  or  rather 
the  ducts  of  the  liver.  You  will  have  noticed  that  all  the  earlier 
symptoms  point  to  derangement  of  the  functions  of  the  duodenum, 
and  that  from  two  to  eight  or  ten  days  elapse  be 'ore  there 
are  evidences  of  interference  with  the  flow  of  bile.  This  is,  of 
itself,  sufficient  to  indicate  that  the  disease  commences  in  the  mem- 
brane lining  the  duodenum,  and  extends  subsequently  to  the  ducts  of 
the  liver,  or  in  some  way  involves  an  obstruction  of  these  ducts,  and  that 
all  the  symptoms  attributable  to  retention  of  bile  are  secondary  in  their 
relations.  The  fatal  case  to  which  I  alluded,  on  which  a  post-mortem 
examination  was  made,  presented  no  important  symptoms  of  disease  in 
any  of  the  organs  or  structures  of  the  body,  except  two  or  three  limited 
patches  of  slight  inflammatory  injection  of  the  membrane  lining  the 
lower  part  of  the  stomach,  and  the  whole  lining  membrane  of  the  duo- 
denum, and  the  hepatic  ducts,  up  to  their  ramifications  into  the  interior  of 
the  liver. 

In  this  case  the  entire  raucous  membrane  of  the  duodenum  was  in- 
tensely injected,  some  portions  of  it  of  a  dark  brownish  color,  and  much 
softened,  and  other  portions  of  a  brighter  red  and  less  impaired  in  texture. 
The  membrane  lining  the  common  duct,  and  all  the  larger  branches  was  also 
in  a  similar  state  of  intense  injection,  with  tumefaction  sufficient  to  close 
up  the  duct,  and  render  it  impervious,  or  at  least  nearly  so,  to  the  passage 
34 


530  DUODEN^O-HEPATITIS.. 

of  bile.  The  gall-bladder  was  moderately  distended  with  bile  but  nearly 
natural  in  colo;-,  the  central  portion  of  the  liver  surrounding  the  entrance 
of  the  large  vessels  was  tinged  a  paler  more  olive  hue,  slightly  softened 
in  texture,  and  apparently  undergoing  fatty  degeneration.  Nearly  all 
of  the  smaller  bile  ducts,  as  they  are  connected  with  individual  lobules  of 
the  liver,  were  distended  with  bile.  The  whole  organ  was  moderately  in- 
creased in  size.  No  part  of  it  had  that  injected  condition  of  its  vessels 
or  exudations  of  an  inflammatory  character,  corresponding  with  inflamma- 
tion of  the  structure  of  the  liver.  The  inflammatory  process  was  appar- 
ently limited  to  the  mucous  membrane  lining  the  ducts  and  the  whole  of 
the  duodenum  with  the  limited  patches  which  I  have  mentioned,  in  the 
stomach.  The  swelling  and  enlargement  of  the  liver,  and  the  changes 
which  it  presented,  appear  to  be  attributable  more  to  the  continued  en- 
gorgement of  the  bile  ducts,  and  consequent  interference  with  the  molecu- 
lar movements,  than  to  any  inflammation  in  the  hepatic  structures.  The 
results  of  this  examination,  together  with  the  clinical  history  of  all  this 
class  of  cases,  render  it  obvious  that  the  disease  is  essentially  a  mild  grade 
of  inflammation,  involving  primarily  the  mucous  membrane  of  the  duode- 
num, and  sometimes  limited  to  it;  but  in  the  large  majority  of  instances 
entering  enough  into  the  hepatic  duct  to  ciuse  tumefaction  and  obstruc- 
tion to  the  flow  of  bile,  thereby  adding  the  phenomena  of  jaundice  to 
those  of  the  duodenal  disease.  It  is  very  rare  that  cases  of  this  kind  ter- 
minate fatally.  The  only  one  directly  under  my  own  care  thu?  terminat- 
ing, was  the  woman  whose  case  I  have  already  briefl\'  described. 

Diagnosis. — The  three  conditions  with  which  the  disease  u  der  consid- 
eration may  be  confounded,  are  a  moderate  degree  of  gastritis  on  the  one 
hand,  a  torpid  or  inactive  condition  of  the  liver,  allowing  the  elements  of 
bile  to  accumulate  in  the  blood,  until  more  or  less  of  a  jaundiced  hue  is  in- 
duced, and  direct  obstruction  of  the  hepatic  duels,  from  biliary  calculi,  the 
pressure  of  tumors,  or  any  other  mechanical  impediment.  From  the  first 
of  these  it  is  distinguished  chiefly  from  the  fact,  that  there  is  much  less 
sense  of  burning  heat  in  the  epigastrium,  the  increase  of  heaviness,  pain 
and  nausea,  are  decidedly  later  after  taking  food  than  in  cases  of  gastritis; 
all  of  the  symptom.s  are  of  a  more  dull  and  obscure  character.  If  vomit- 
ing occurs,  instead  of  occurring  promptly  after  taking  ingesta,  as  in  gastritis, 
it  is  more  generally  from  half  an  hour  to  an  hour  later.  From  the  second, 
or  true  torpor  of  the  liver,  it  may  be  distinguished  by  simply  noting 
the  order  in  which  the  symptoms  are  presented,  namely:  the  occurrence 
of  weight  or  heaviness  in  the  lower  part  of  the  epigastrium,  with  no  sen- 
sations of  either  tenderness,  weight  or  fullness  in  the  right  hypochondriac 
region,  as  is  generally  the  case  when  there  is  any  failure  in  the  secretory  ac- 
tion of  the  liver,  either  from  congestion  or  from  any  other  mode  of  arrest- 
ing the  action  of  the  secreting  cells. 

The  distinction  is  further  developed  by  the  fact  that  in  the  duodenal 
afi'ection  there  are  symptoms  of  a  feverish  character,  and  it  progresses 
more  decidedly  as  an  inflammatory  afi'ection,  reaching  its  culmination 
usually  within  a  few  days;  while  simple  torpor  or  inactivity  of  the  liver 
is  usually  accompanied  by  no  febrile  phenomena,  only  an  obscure  feeling  of 
heaviness  or  weight  in  the  right  hypochondrium,  rarely  any  nausea,  dis- 
position to  vomit,  or  any  sense  of  tenderness  on  pressure  over  the  lower 
portion  of  the  epigastric  region.  Then  again,  simple  torpor  of  the  liver, 
sufficient  to  prevent  the  evolution  of  the  bile  from  the  blood,  allowing  its 
elements  to  remain,  is  a  very  rare  form  of  disease;  so  rare  that  I  have  met 
with  very  few  unmistakable  cases  in  the  whole  period  of  my  practice. 
From  primary  obstruction  of  the  hepatic  ducts,  either  through  formation 


PROGNOSIS.  061 

of  biliary  calculi,  or  other  mechanical  causes,  the  duodeno-hepatic  disease 
is  distinguished  by  the  primary  symptoms  being  located  in  the  region  of 
the  duodenum  rather  than  in  the  right  margin  of  the  epigastrium,  and  exT 
tending  farther  to  the  right,  and  by  the  almost  uniform  absence  of  febrife 
symptoms  in  connection  with  the  formation  of  biliary  calculi.  The  latter 
are  usually  slow  in  their  formation,  causing  no  active  disturl)ance  of  the 
functions  of  the  stomach  and  duodenum,  and  often  giving  rise  to  no  symp- 
toms which  attract  the  attention  of  tiie  patients  until  suddenly  they  are 
seized  with  pain,  generally  in  the  region  of  the  gall-bladder,  and  which, 
in  cases  of  much  severity,  after  a  period  varying  from  an  hour  to  one  or 
two  days,  ceases  as  suddenly  as  it  commenced,  and  leaves  as  a  result 
more  or  less  yellowness  of  the  conjunctiva  and  of  the  skin,  and  a  dark, 
reddish  brown  color  of  the  urine,  but  at  no  time  is  it  accompanied  by  febrile 
symptoms,  or  any  other  of  the  phenomena  that  I  have  described  as  be- 
longing to  duodeno-hepatic  disease. 

After  the  paroxysm  of  pain  is  passed,  all  the  symptoms  disappear,  even 
the  yellowness  of  the  skin  continues  only  two  or  three  days,  and  the 
patient  appears  to  be  reasonably  well  until  another  paroxysm  occurs, 
which  may  be  in  a  few  weeks,  or  not  in  as  many  months.  Cases  of 
mechanical  obstruction  produced  by  tumors  or  morbid  growths  in  the 
abdomen  are  readily  distinguished  from  cases  of  duodeno-hepatitis  by  the 
manifest  presence  of  the  tumors  as  felt  through  the  abdominal  walls. 
Yet,  notwithstanding  the  apparent  readiness  with  which  the  disease 
under  consideration  may  be  differentiated  from  either  torpidity  of  the 
liver,  or  mechanical  obstruction  of  the  hepatic  ducts,  from  the  causes  to 
which  I  have  alluded,  a  large  proportion  of  the  cases  are  regarded  by  the 
patients  as  bilious  attacks,  and  not  infrequently  the  physician  when 
called  is  also  induced  to  regard  the  dull,  heavy  feelings  of  the  patient,  and 
more  or  less  yellow  appearance  of  the  skin  and  eyes,  as  evidences  of  con- 
gestion, or  inactivity  of  the  liver.  I  have  known  very  man}'  of  this  class 
of  cases,  that  have  been  placed  under  active  treatment  for  supposed 
hepatic  congestion,  and  sometimes  subjected  to  the  action  of  a  very  in- 
jurious amount  of  cholagogues  and  purgatives,  which,  instead  of  pro- 
ducing the  desired  bilious  evacuations  from  the  bowels,  only  hastened 
the  patient  into  a  diarrhoea,  from  extension  of  the  irritation  to  the  mucous 
membrane  of  the  lower  bowels  causing  extreme  prostration,  from  which 
recovery  took  place  very  slowly. 

Prognosis. — From  what  I  have  already  said  when  speaking  of  the 
general  course  of  the  disease,  and  the  almost  uniform  tendency  to 
recovery,  you  will  have  already  inferred,  that,  with  the  exception  of  very 
rare  cases,  the  prognosis  is  favorable.  In  at  least  seventy-five  per  cent  of 
all  the  cases  that  have  come  under  my  observation,  simply  the  restriction 
of  the  patient  to  a  very  mild  diet,  gently  opening  the  bowels  once  or 
twice  with  saline  laxatives,  and  rest,  recovery  has  taken  place  in  from  one 
to  three  weeks.  Of  the  remaining  twenty-five  per  cent,  nearly  all  with 
judicious  treatment  aided  by  rest  and  proper  regulation  of  the  diet  have 
also  reached  recovery  in  from  two  to  four  weeks.  Very  rarely  the 
retention  of  the  cholestrine  and  other  elements  of  bile  has  caused  an 
accumulation  of  these  elements  to  such  an  extent  as  to  produce  fatal 
poisoning  of  the  cerebral  centers  ;  which  is  usually  preceded  by  entire 
suppression  of  urine,  and  indeed,  of  almost  all  secretions. 

I  have  seen  a  few  instances  in  which  the  disease,  either  from  neglect 
or  mismanagement  in  the  early  stage  has  assumed  a  chronic  form  and 
continued  for  several  weeks,  in  one  twelve  weeks,  and  in  four  or  five 
other  cases,  periods  varying  from  eight  to  ten  weeks.     When  it  assumes 


532  DUODENO-HEPATITIS. 

a  chronic  form  the  patient  usually  becomes  entirely  free  from  any  fever  or 
increased  heat,  Ijut  rather  presents  a  cool  skin,  cold  extremities,  a  pinched 
or  haggard  appearance  of  the  face,  deep  yellow  or  bronzed  hue  of  the 
skin  and  eyes,  and  almost  always  accoinpanied  by  an  eruption  of  prurigo 
upon  the  surface,  attended  by  the  most  intolerable  itching.  This  latter 
symptom  is  often  so  troublesome  to  the  patients  that  they  complain  of  it 
more  severely  than  of  all  the  other  symptoms  of  the  disease.  Throughout 
this  protracted  period  in  the  chronic  form,  the  heaviness  and  weight  in 
the  epigastrium  continues,  with  obscure  tenderness  on  pressure;  the  lat- 
ter almost  invariably  accompanied  also  by  a  sense  of  nausea.  The  bow- 
els are  generally  costive  but  free  from  tympanitis.  The  patients  are 
mentally  dull,  despondent,  and  gloomy,  usually  but  little  disposed  to  take 
food,  and  always  in  from  half  to  three  quarters  of  an  hour  after  taking  it 
comj^lain  that  it  increases  their  sense  of  distress.  Occasionally  when  they 
have  taken  a  little  more  than  usual,  in  from  one  to  two  hours  it  will  be  re- 
jected by  vomiting.  Almost  invariably  when  vomiting  thus  occurs,  there 
is  more  or  less  mucus  with  the  matters  ejected,  while  food  appears  only 
partially  digested  and  sour.  None  of  these  chronic  cases  terminated  fa- 
tally. 

Treatment. — If  what  I  have  stated  in  regard  to  the  nature  of  these 
cases  is  true  the  first  indication  for  treatment  is  obvious,  namely:  the 
adoption  of  such  measures  as  are  calculated  directly  to  lessen  the  mor- 
bid sensitiveness  and  vascular  fullness  of  the  vessels  in  the  mucous  mem- 
brane of  the  duodenum.  If  this  is  done  early  and  effectually,  there  will 
occur  no  obstruction  to  the  flow  of  bile,  and  consequently  no  subsequent 
jaundice,  and  the  patient  will  recover  by  the  end  of  the  first  week  from 
the  beginning  of  the  attack.  But  unfortunately,  the  great  majority  uf 
patients  will  not  seek  for  the  services  of  a  physician  until  the  first  three  or 
four  days  have  passed,  and  the  disease  has  already  entered  more  or  less 
into  the  hepatic  ducts.  This  does  not  alter  the  indication  for  treatment. 
For  you  will  observe  the  obstruction  here  is  from  the  inflammation  and 
consequent  tumefaction  of  the  lining  of  the  duct;  and  the  only  rational 
mode  of  removing  the  obstruction  is  by  removing  the  inflammation  itself. 
The  retention  of  the  coloring  matter  of  bile  and  other  elements,  so  far 
from  being  evidence  that  the  liver  is  torpid,  and  affording  indications  for 
remedies  to  act  especially  upon  the  secreting  function  of  that  organ,  are 
evidences  of  just  the  reverse.  For  the  secretion  is  carried  on  with  the 
us^^al  activity,  the  absence  of  any  appearance  of  bile  in  the  evacuations, 
and  its  diffusion  through  the  system,  are  evidences  that  while  being  se- 
creted with  the  proper  activity,  it  fails  to  pass  through  its  natural  channels 
into  the  intestines,  and  is  re-absorbed.  Consequently,  all  remedies  that 
are  calculated  to  increase  the  secretion  of  bile,  without  at  the  same  time 
removing  the  obstruction  in  the  bile  ducts,  will  only  add  to  the  amount 
re-absorbed  and  diffused  through  the  system;  and  consequently  to  an 
increase   of  the  jaundice. 

The  treatment  which  I  have  found  most  efficient  for  these  cases  has 
usually  been  as  follows  :  If,  on  inquiry,  I  find  the  bowels  have  not  moved 
for  the  preceding  twenty-four  or  forty-eight  hours,  I  give  the  patient 
a  sufficient  quantity  either  of  the  liquid  citrate  of  magnesia,  the  sulphate 
of  magnesia,  or  the  Rochelle  salts,  to  procure  a  moderate  movement  of 
the  bowels.  This  is  done  more  for  the  purpose  of  freeing  the  alimentary 
canal  from  accumulations  of  fgeces,  than  for  any  other  purpose,  although 
these  saline  remedies  undoubtedly  have  some  influence  in  directly  deplet- 
ing, and  thereby  lessening  the  fullness  of  the  vessels  of  the  mucous  mem- 
brane, as  well  as  to  empty  the  bowels.     If  the  bowels,  however,  have  been 


TREATMENT.  533 

moved  sufficiently  either  by  medicmes  that  the  patient  has  taken,  or  spon- 
taneously, I  do  not  give  a  laxative  atthe  beginning,  but  place  the  patient 
directly  upon  the  use  of  a  powder  composed  of  three  decigrams  (gr.  v) 
of  the  compound  powder  of  opium  and  ipecacuanha  (pulv.  Uov.),  and  an 
equal  quantity  of  nitrate  of  potassium.  Sometimes  I  add  to  this  six  centi- 
o-rams  (gr.  i)  of  calomel,  but  more  frequently  it  is  omitted.  If  the  latter  is 
added,  it  is  only  to  the  first  four  doses.  One  of  these  powders  is  given 
every  four  hours,  until  from  four  to  six  have  been  taken.  In  the  mean- 
time^ the  patient  Is  kept  at  rest,  taking  only  liquid  nourishment,  such  as 
beef-tea,  oatmeal  gruel,  sometimes  milk,  or  milk  with  lime-water,  and  at 
the  end  of  this  time,  I  administer  another  mild  saline  hixative.  In  the 
large  proportion  of  cases,  the  evacuations  following  this  laxative  will  be 
freely  colored  with  the  presence  of  bile.  If  so,  it  Is  almost  always  the 
case,  that  all  disagreeable  symptoms  are  decidedly  relieved.  By  giving 
one  of  the  same  powders  morning  and  evening  for  two  subsequent  days, 
and  a  mild  laxative  when  required,  the  patient  will  reach  the  beginning  of 
convalescence.  If  there  is  no  further  suffering  after  taking  food,  if  the 
secretions  from  the  kidneys  are  natural,  the  skin  moist,  tongue  clean,  and 
In  all  respects,  the  patient  is  free  from  feelings  of  sickness  except  a  cer- 
tain degree  of  debility  and  some  yellowness,  no  more  medication  Is  usu- 
ally required,  but  simply  judicious  regulation  of  the  diet,  and  caution 
about  returning  too   soon  to  active   mental  and  physical  labor. 

But  in  some  of  the  more  severe  cases,  although  the  treatment  Is  carried 
far  enough  to  cause  the  operation  of  the  saline  laxative,  after  the 
exhibition  of  from  four  to  six  of  the  powders  I  have  named,  there 
will  be  no  appearance  of  bile  In  the  evacuations,  and  only  a  mod- 
erate lessening  of  the  fullness,  heaviness,  and  distress  in  the  epigastrium. 
If  such  Is  the  case,  Instead  of  giving  the  povpders  subsequent  to  this 
every  morning  and  evening,  repeat  them  at  the  same  Intervals  as  at  first, 
namely:  once  In  four  or  five  hours,  putting  at  the  same  time  fomentations 
over  the  epigastric  region,  either  by  poultices,  or  by  cloths  wet  in  warm 
water  or  in  some  warm  narcotic  Infusion.  J\\  cases  of  more  decided 
severity  I  apply  a  blister  over  the  most  tender  part  of  the  abdomen,  and 
with  very  good  results.  After  this,  simply  keeping  the  bowels  soluble,  so  as 
to  have  them  move  once,  or  at  most  twice  in  the  twenty-four  hours,  carefully 
guarding  against  excessive  purging,  and  If  the  urine  Is  still  scanty,  giving 
the  mixture  pf  liquor  ammonia  acetatls,  and  nitrous  ether,  in  doses  of  a 
teaspoonful  diluted  with  water,  three  or  four  times  a  day,  will  be  sufficient 
to  conduct  the  patient  to  convalescence.  In  the  cases  which  have  as- 
sumed a  decided  chronic  form,  there  has  been  some  difficulty  In  affording 
them  relief.  One  of  the  most  obstinate  that  came  under  my  observation 
finally  recovered  under  the  continuous  use,  for  three  weeks,  of  a  prescrip- 
tion containing  muriate  of  ammonium,  and  bichloride  of  mercury,  dis- 
solved in  the  sj'rup  of  licorice,  in  such  proportions  that  In  giving  four 
cubic  centimeters  or  a  teaspoonful  of  the  solution,  the  patient  would  get 
four  decigrams  (gr.  vl)  of  the  muriate  of  ammonium,  and  two  milligrams 
(gr.  1-30)  of  the  bichloride;  this  quantity  was  given  three  times  a 
day.  He  had  used  a  great  variety  of  remedies,  during  the  preceding 
two  months,  with  but  little  advantage.  1  have  used  the  same  combination, 
in  the  same  manner,  In  four  or  five  other  cases  that  assumed  a  chronic 
form,  but  of  less  duration  than  the  one  to  which  I  alluded.  In  the  major- 
ity of  these,  it  produced  also  favorable  results;  but  in  two  of  them  it 
added  somewhat  to  the  burning  and  irritation  of  the  mucous  membrane, 
which  caused  some  nausea  and  subsequently  vomiting.  These  two  patients 
ultimately  recovered  under  the  influence  of  moderate  doses  of  the  sub-ni- 


534  ENTERITIS. 

trate  of  bismuth,  bicarbonate  of  soda,  and  a  small  proportion  of  the  com- 
pound powder  of  opium  and  ipecacuanha,  with  an  occasional  laxative  to 
move  the  bowels.  In  some  of  these  cases  of  a  chronic  character,  counter- 
irritation  by  the  application  of  the  combination  of  croton  oil,  tincture  of 
iodine,  and  ether,  applied  over  the  epigastrium  appeared  to  do  good. 


LECTURE   LIIL 


Enteritis,  Acute  and  onronic— Varieties,  Causes,  Symptoms,  Anatomical  changes,  Diagnosis,  Prog- 
nosis and  1  reatmeut. 

GENTLEMEN  :  I  shall  next  direct  your  attention  to  the  inflam- 
mations occurring  in  the  small  intestines  under  the  general  name  of 
enteritis.  The  first  section  of  the  small  intestine  caWed  jejunum  is  rarely 
involved  in  inflammation.  The  second  section,  called  ileum.,  is  much 
more  frequently  the  seat  of  disease.  Attacks  of  inflammation  may  be 
limited  entirely  to  the  mucous  membrane  or  to  the  muscular  and 
peritoneal  coats  ;  or  they  may  involve  all  these  structures  at  once. 
The  inflammation  appears  to  commence  in  the  middle  and  lower  section 
of  the  ileum,  in  proximity  to  the  ileo-coecal  junction  more  frequently  than 
in  the  upper  part.  Sometimes  it  commences  in,  and  may  be  restricted 
during  its  course  to  the  coecum,  and  the  ileo-coecal  junction,  and  is  then 
called  typhlitis,  to  distinguish  it  from  the  more  general  inflammation  of 
the  ileum.  In  another  class  of  cases,  the  inflammation  either  commences 
primarily  or  soon  extends  to,  the  areolar  tissue  exterior  to  the  ccecum  and 
ileo-coelic  junction  causing  tenderness,  pain  and  swelling  with  more  or  less 
soreness  directly  above  Poupart's  ligament,  in  the  right  iliac  fossa.  Such 
cases  are  called  peri- typhlitis.  Attacks  of  inflammation  in  all  parts  of 
the  small  intestine  occur  more  frequently  in  the  warm  seasons  of  the  year, 
and  in  autumn,  than  in  the  winter  and  spring.  They  are  met  with, 
however,  occasionally  at  all  seasons  of  the  year.  They  occur  more 
frequently  in  children  and  youth,  than  during  the  adult  period  of  life. 
They  are  especially  rare  in  old  age.  Still,  cases  are  met  with  at  all 
periods  of  life,  and  perhaps  with  nearly  equal  ratio  in  both  sexes.  Under 
my  own  observation,  however,  more  cases  have  occurred  in  males  than  in 
females.  Aside  from  the  influence  of  the  seasons  of  the  year,  and  that  of 
age  and  sex,  perhaps  exposure  to  sudden  and  severe  atmospheric  changes, 
particularly  to  cold  and  wet,  constitutes  the  most  frequent  exciting- 
cause.  ]n  typhlitis,  it  has  been  supposed  that  the  inflammation  has  its 
origin  in  the  coecum,  or  appendix  vermiformis,  as  in  many  cases  post- 
mortem examination  has  revealed  the  existence  sometimes  of  hardened 
fseces,  more  frequently  of  such  foreign  bodies  as  cherry  stones,  apple 
Seed,  unbroken  kernels  of  grain,  that  had  been  swallowed  sometimes  at  a 
considerable  time  previously.  In  peri-typhlitis,  the  cause  has  been  traced 
in  some  instances  to  the  lodgment  of  similar  bodies,  primarily  in  the 
appendix  vermiformis,  which  apparently  became  inflamed  and  ulcer- 
ated, thereby  setting  up  inflammation  in  the  areolar  tissue  immediately 
around  it. 

Symptoms. — As  the  word  enteritis  is  applicable  alike  to  inflammation 
in  any  of  the  coats  of  the  intestine,  and  as  the  symptoms  vary  much  in 
accordance  with  the  variations  in  the  particular  seat  of  disease,  it  becomes 


SYMPTOMS.  535 

necessary  to  describe  the  symptoms  of  inflammation  of  the  mucous  mem- 
brane, as  distinct  from  those  of  inflammation  of  the  muscular  and 
peritoneal  structures.  For  the  purpose  of  exactness,  or  to  avoid  being 
riiisunderstood,  I  shall  denominate  such  cases  as  mucous  enteritis^  those 
involving  the  muscular  coat,  as  muscular  or  rheumatic  enteritis,  and  when 
primarily  located  in  the  peritoneal  covering  of  the  intestines,  as  peritoneal 
enteritis.  The  symptoms  of  acute  and  subacute  mucous  enteritis 
usually  commence  gradually,  consisting  at  first  of  a  sense  of  heat, 
irregular  peristaltic  motion  in  the  abdomen,  slight  feelings  of  soreness 
particularly  on  sudden  motion  of  the  body,  or  from  the  jar  of  walking. 
The  sense  of  soreness,  however,  and  tenderness  on  pressure  in  the  begin- 
ning of  this  form  of  inflammation  is  usually  slight.  In  the  course  of 
twelve  or  twenty-four  hours  there  will  be  more  or  less  general  febrile 
movements,  indicated  by  a  moderately  increased  heat  and  dryness  of  the 
skin,  and  acceleration  of  the  pulse,  which  is  at  the  same  time,  usually  firm 
under  the  finger,  small  and  corded.  The  respirations  are  usually  slightly 
accelerated,  the  pain  in  the  abdomen  increased,  especially  the  burning  or 
sense  of  heat,  and  the  temperature  of  the  abdomen  externally  appears 
higher  than  the  rest  of  the  body  and  extremities.  The  pain  is  seldom  of 
an  acute  lancinating  character,  but  dull  and  accompanied  by  frequent, 
irregular  peristaltic  movements  of  the  intestines,  these  movements  being 
often  accompanied  by  pains,  which  are  called  griping,  but  momentary  in 
their  duration,  and  usually  accompanied  by  a  sensation  as  though  the 
bowels  would  move.  During  the  last  part  of  the  first  twenty-four  hours, 
intestinal  evacuations  begin  to  occur.  The  first  one  or  two  passages  will 
asuall}'-  be  ftecal,  the  first  firm  or  consistent,  the  second  softer,  but  yet 
not  fluid.  From  this  time  the  intestinal  evacuations  occur  more  frequently, 
varying  from  three  to  six  or  eight  times  a  day,  usually  nearly  fluid  in 
Consistence,  sometimes  of  a  gray  or  ash  color,  more  frequently  brownish, 
or  reddish  brown.  Not  infrequently  the  discharges  contain  little  specks 
of  a  whitish  substance,  consisting  of  flakes  of  lymph,  and  detached 
epithelium.  In  most  instances,  each  evacuation  from  the  bowels  is  pre- 
ceded for  a  minute  or  two  by  irregular  abdominal  pains.  These  vary, 
very  much  in  severity  in  different  cases.  Sometimes  they  are  almost 
entirely  absent.  The  tongue  and  mouth  are  less  moist  than  natural,  the 
first  usually  covered  or  partially  covered  with  a  whitish  coat  in- the 
beginning,  the  tip  and  edges  looking  slightly  redder  than  natural.  If  the 
disease  continues  three  or  four  days  without  interference,  the  pulse 
becomes  smaller,  softer  and  more  frequent,  the  extremities  cooler,  but 
the  abdomen  and  trunk  of  the  body  maintain  a  higher  temperature,  the 
mouth  is  more  dry,  the  lips  looking  parched  and  a  little  thin;  countenance 
shrunken,  and  often  a  strip  in  the  middle  of  the  tongue,  dry  and  more 
brown. 

In  some  instances  the  abdomen  becomes  somewhat  tympanitic,  but 
more  frequently  not  fuller  than  natural,  and  exhibits  but  little  gaseous 
distension  or  tympanitis  on  percussion.  To  the  touch  or  pressure  there 
is  almost  invariably  more  or  less  tenderness.  In  mild  cases  the  symp- 
toms consist  of  a  moderate  grade  of  general  fever,  accompanied  by 
diarrhoeal  discharges,  continuing  with  but  little  change  from  five  to  seven 
days,  when  if  the  patient  has  siaiply  been  at  rest,  abstaining  from  promis- 
cuous food,  taking  only  bland  and  light  nourishment,  the  symptoms  begin 
to  abate,  the  discharges  become  less  frequent,  the  sense  of  heat  in  the 
abdomen  and  dryness  of  the  mouth  diminish,  the  tongue  becomes  more 
moist,  and  free  from  coating,  and  the  urinary  secretion  returns  more 
nearly  to  its  natural  condition,  and  by  the  middle  of  the  second  week  the 


536  ENTERITIS. 

patient  is  convalescent.  The  bowels  either  remain  entirely  quiet,  or  if 
discharges  take  place,  they  present  a  natural  appearance.  It  is  thus  that 
very  many  cases  of  moderate  mucous  enteritis,  every  summer,  run  their 
course  and  terminate  favorably  in  from  seven  to  ten  days,  with  little 
other  treatment  than  simple  rest,  and  proper  regulation  of  the  ingesta. 
But  in  more  severe  cases  of  an  acute  character,  the  symptoms  at  the  end 
of  the  first  week  are  liable  to  become  aggravated.  The  tongue  becomes 
more  completely  dry,  the  abdomen  moderately  tympanitic,  more  sensitive 
and  tender  on  pressure,  the  discharges  dark  brown,  and  sometimes  mixed 
with  blood,  the  little  masses  of  mucus  occasionally  contain  sufficient 
blood  to  tinge  the  whole  discharge  of  a  distinctly  reddish  hue;  pulse 
becomes  soft,  quicK  and  irregular,  the  extremities  cold  and  a  little  leaden 
or  purplish  hue,  the  eyes  sunken,  lips  thin  and  retracted,  a  tendency  for 
sordes  to  gather  along  the  edges  of  the  lips  and  exposed  parts  of  the  teeth, 
the  patient's  mind  is  often  wandering,  causing  especially  muttering  in  sleep; 
when  left  alone,  he  is  inclined  to  be  drowsy  and  dull,  and  the  urine  very 
scanty.  If  no  change  is  made  by  treatment  such  a  case  will  sometimes 
proceed  rapidly  from  this  point  to  complete  collapse  and  death  by  exhaus- 
tion. The  patient  continues  simply  to  grow  weak,  the  extremities  colder, 
pulse  feebler,  the  mind  more  dull  or  wandering,  until  the  sphincters  relax, 
the  discharges  become  involuntary,  the  chiii  drops,  tongue  falls  back,  breath 
becomes  more  and  more  irregular  and  obstructed  by  the  relaxation  of  the 
muscles  of  the  pharynx,  and  death  ensues  from  pure  asthenia.  Within 
my  own  observation  such  results  are  of  rare  occurrence,  and  confined 
almost  entirely  to  those  patients  who  are  living  in  bad  sanitary  surround- 
ings, and  failing  to  procure  either  reasonably  good  nursing  or  any  suitable 
medical  attendance.  Occasionally  during  the  highest  temperature  of 
summer,  attacks  will  occur  among  children  especially,  having  much  the 
appearance  of  cholera  morbus  and  cholera  infantum  at  the  outset,  the 
more  violent  symptoms  of  which  soon  abate,  leaving  a  genuine  mucous 
enteritis  which  sometimes  progresses  rapidly  to  a  fatal  termination. 
Between  the  two  classes  of  cases  I  have  described,  one  tending  spontane- 
ously to  recovery,  the  other  sometimes  proceeding  to  a  fatal  result,  you 
will  meet  with  a  large  number  presenting  symptoms  of  a  severe  character 
during  the  first  week  of  their  progress,  abating  during  the  first  half  of 
the  second  week  as  though  convalescence  was  approaching,  and  at  the  end 
of  three  weeks,  nearly  all  the  more  active  symptoms  will  have  disappeared, 
leaving  the  bowels  stiil  loose,  with  considerable  impairment  of  flesh  and 
strength,  but  not  so  much  as  to  prevent  the  patients  from  being  up  some 
each  day.  These  are  cases  commencing  as  acute  or  subacute  inflamma- 
tion, and  which  terminate,  not  in  recovery,  but  in  the  chronic  form  of  the 
disease.  They  are  liable  to  continue  an  indefinite  period  of  time.  Some 
of  them  under  favorable  circumstances,  after  continuing  three  or  four 
weeks,  gradually  improve  until  they  end  in  recovery.  Others,  however, 
after  continuing  nearly  stationery  for  three  or  four  weeks,  during  which 
the  patients  are  able  to  be  up  and  dressed,  again  begin  to  retrograde; 
losing  flesh  and  appetite,the  discharges  becoming  more  frequent,  sometimes 
giving  indications  of  intermixture  of  maco-purulent  material  in  the  first 
portion  of  the  evacuations,  either  with  or  without  a  tinge  of  blood,  a  re- 
newal of  moderately  increased  temperature,  especially  of  the  abdomen, 
small  weak  pulse,  cold  extremities,  rather  haggard  expression  of  counte- 
nance, and  finally  fatal  exhaustion.  Intermediate  i)etween  those  that  thus 
run  to  a  fatal  termination,  and  those  continuing  five  and  six  weeks  and 
ending  spontaneously  in  recovery,  there  is  still  a  class  that  maintain  a 
moderate  degree   of  diarrhoea,   sufiicient   to  continue   the  impairment   of 


ANATOMICAL    CHANGES.  537 

sti'ength  and  prevent  a  return  to  the  active  duties  of  life,  and  yet  not 
sufficient  to  cause  any  rapid  degree  of  exhaustion,  and  in  which  condition 
the  patients  may  remain  one,  two  or  more  years,  with  but  little  change 
from  month  to  month.  The  symptoms  and  progress  of  these  cases  as  I 
have  stated  them,  represent  the  natural  progress  of  th(^  disease  when  not 
actively  interfered  with  by  judicious  medication.  When  the  latter  is 
brought  to  the  aid  of  the  patient,  there  are  very  few  cases  of  those  that 
have  jissumed  a  decidedly  chronic  form,  but  that  may  be  conducted  to  an 
ultimate  recovery. 

Anatotnical  Changes. — The  anatomical  changes  which  take  place  dur- 
ing the  progress  of  acute  and  subacute  mucous  enteritis,  correspond  in 
all  respects  with  the  changes  that  1  have  already  described  as  taking 
place  in  the  mucous  membrane  of  the  stomach  and  duodenum.  In  the  first 
stage,  there  is  intense  congestion,  causing  redness  and  more  or  less  tume- 
faction of  the  membrane,  with  subsequent  increase  as  the  disease  progress- 
es, the  redness  changing  more  to  a  brown  or  dark  hue  in  many  places,  with 
softening  or  impairment  of  the  texture  and  detachment  of  much  of  the 
epithelial  layer,  leaving  abrasions  or  superficial  ulcerations.  In  the  sub- 
acute cases  and  especially  those  that  run  a  more  protracted  course,  exuda- 
tion of  liquor  sanguinis,  or  plastic  material  of  the  blood,  takes  place,  into 
the  su'>mucoas  or  connective  tissue,  and  into  the  texture  of  the  membrane 
as  well  as  upon  the  free  surfaces.  In  such  cases,  instead  of  softening  of  the 
membrane  it  becomes  more  thickened  and  hardened,  but  generally  presents 
the  same  disturbance  of  the  epithelial  layer,  and  the  same  marked  abra- 
sions upon  the  surfaces  as  in  the  more  acute  cases.  When  the  disease  as- 
sumes a  chronic  form,  the  diffused  redness  that  accompanies  the  acute 
and  subacute  stages  subsides  over  the  larger  part  of  the  membrane, 
allowing  it  to  return  to  a  more  natural  color  and  appearance;  only 
patches  remain  red,  thickened,  more  or  less  hardened  in  texture, 
and  pretty  uniformly  present  distinct  and  deep  ulcerations  upon 
their  surface.  Some  of  these  ulcers  in  cases  of  Jong  continuance 
have  been  found  to  extend  more  deeply  into  the  coats  of  the 
intestines,  destroying  not  only  the  mucous  membrane,  and  sub- 
mucous areolar  tissue,  but  also  the  muscular  coat  to  the  peritoneum. 
Sometimes,  though  quite  rarely,  the  peritoneum  itself  is  perforated, 
bringing  on  acute  general  peritonitis  as  the  immediate  cause  of  the  death  of 
the  patient.  In  many  of  these  cases,  both  of  a  chronic  and  acute  form,  where 
death  has  resulted,  there  is  a  more  or  less  injected  and  reddened  con- 
dition of  the  peritoneal  membrane  over  those  parts  of  the  intestine  that 
are  most  involved  in  the  disease.  The  changes  which  I  have 
described  will  explain  to  you  the  progress  of  those  cases  that  commence 
in  the  acute  form  and  terminate  in  the  chronic.  The  subsidence  of  the 
more  severe  symptoms  marking  the  termination  of  the  acute  stage,  is  the 
time  when  inflammation  undergoes  resolution  and  disappears  from  a  large 
portion  of  the  mucous  membrane;  leaving  only  limited  patches  where, 
from  the  thickening  and  induration,  and  more  decided  ulcerative  changes 
of  the  surface,  resolution  can  not  take  place  as  readily;  and  in  consequence 
of  this,  the  discharges  in  their  milder  form  are  continued  after  the  gen- 
eral symptoms  have  undergone  the  improvement  I  have  mentioned.  In 
many  of  the  cases,  these  patches  continue  slowly  to  improve,  the  abra- 
sions are  repaired,  while  the  exudative  material  is  removed  by  disintegra- 
tion and  absorption,  and  convalescence  is  reached  in  from  four  to  five  weeks, 
while  in  those  cases  that  linger  longer,  little  or  no  reparative  action 
takes  place  in  the  inflamed  and  ulcerated  patches,  the  ulcerations  tend- 
ing to  increase  instead  of  cicatrizing.  It  is  thus  they  run  a  more  protract- 
ed course  and  the  patients  ultimately  die  from  exhaustion. 


538  ENTERITIS. 

• 

Diagnosis. — Mucous  enteritis  presents  syrhptoms,  as  you  will  have  no- 
ticed, sufficiently  characteristic  to  distinguish  it  from  nearly  all  other  af- 
fections of  the  alimentary  canal.  From  typhoid  fever  it  is  distinguished 
by  the  well  marked  prqdromic  or  forming  stage  of  the  latter,  followed  as 
it  usually  is  by  a  progressive  development  of  fever,  and  rise  of  tempera- 
ture day  by  day,  neither  of  which  correspond  with  the  beginning  and 
progress  of  simple  enteritis.  Cases  of  the  latter  have  none  of  the  dull  heavy 
expression  of  countenance,  suffused  flush  of  the  face,  and  steadily  in- 
creasing temperature  that  belongs  to  the  general  fever.  And  during  its 
subsequent  progress  the  dry  bronchial  rales  so  generally  present  in  the 
second  st  -ge  of  the  typhoid  disease  are  absent,  as  are  also  the  rose  colored 
spots  upon  the  cutaneous  surface.  From  dysentery  or  inflammation  of  the 
colon  it  is  distinguished  by  the  lower  degree  of  fever,  the  less  frequent 
and  painful  character  of  the  discharges,  and  the  less  intermixture  of 
niucus  and  blood  with  the  evacuations.  From  peritonitis,  either  of  that 
part  of  the  peritoneum  covering  the  intestines,  or  lining  the  abdominal 
parietes,  raucous  enteritis  is  distinguished  by  the  lower  grade  of  fever  and 
especially  by  the  absence  of  lancinating,  sharp  pains,  excessive  tenderness 
to  pressure  or  to  any  free  motions  of  -  the  body,  and  of  early  and  decided 
distension  of  the  abdomen.  Of  the  prognosis  in  mucous  enteritis  in  its 
different  degrees  of  severity,  I  have  already  spoken  sufficiently  when 
giving  its  clinical  history. 

Treatment. — The  leading  objects  to  be  accomplished  in  the  treatment  of 
riiucous  enteritis  are,  to  directly  diminish  the  morbid  sensitiveness  of  the 
raucous  membrane,  lessen  the  frequency  of  the  discharges,  and  promote 
the  natural  eliminations  from  the  skin  and  kidneys.  Cases  may  be  raet 
with,  though  they  are  certainly  rare,  in  which  sufficient  enteric  irritation 
exists  to  produce  more  or  less  diarrhoeal  discharges,  and  yet  the  first 
part  of  the  ileum  remain  filled  with  consistent  or  hardened  faeces.  If 
such  a  case  should  present  itself,  it  is  evident  that  a  moderate  movement 
of  the  bowels  by  such  laxatives  as  would  be  likely  to  produce  the  least 
griping  or  local  irritation  in  the  inflamed  parts,  should  constitute  the  first 
item  in  the  treatment.  Experience  has  shown  that  the  fgeces  very  rarely 
accumulate  and  remain  stationery  in  the  upper  part  of  the  ileum  or  any 
part  of  the  jejunum.  Indeed,  the  contents  of  the  bowels  rarely  become 
consistent  until  Xhe^y  have  passed  below  the  middle  portion  of  the  ileum; 
and  I  have  no  recollection  of  ever  seeing  a  case  of  raucous  enteritis,  in 
which  I  could  detect,  either  from  the  history  of  the  case,  or  from  the  con- 
dition of  the  abdomen,  the  retention  of  hard  faeces  in  any  part  of  the  ali- 
mentary canal.  And  I  ara  fully  satisfied  that  the  practice  of  many,  to 
commence  the  treatment  by  a  saline  laxative,  merely  for  the  purpose  of 
being  sure  that  the  contents  of  the  bowels  have  been  removed,  is  calcu- 
lated to  do  more  harm  than  good.  I  pretty  uniformJy  prescribe, 
first,  a  combination  of  some  anodyne  with  an  alt  rant,  and  give  sufficient 
to  first  place  the  patient  at  ease  from  pain,  and  the  alimentary  canal  in  a 
condition  of  quietude,  with  a  view  of  keeping  it  at  rest,  for  at  least  eight- 
een or  twenty-four  hours.  At  the  sarae  time  remedies  are  given  for  the 
purpose  of  gently  promoting  the  action  of  the  skin  and  kidneys. 

For  all  these  purposes  I  have  generally  directed  a  powder  composed  of 
pulverized  opium  six  centigrams  (gr.  i),  pulverized  ipecac  uanha,  one  to  two 
decigrams  (gr.  i  to  iii  ),  mild  chloride  of  mercury  six  centigrams  (  gr.  i) 
to  be  given  every  three  hours;  and  an  equal  mixture  of  liquor  am- 
monii  acetatis  and  nitrous  ether,  of  which  four  cubic  centimeters 
(fl  3i  )  fire  given  diluted  with  a  little  water,  between  each  of  the  pow- 
ders.    The  latter  will  usually  promote  the  action  of  the  kidneys  and  skin, 


TKEATMENT.  539 

while  the  former  will  control  the  intestinal  evacuations  and  allay  the  pain, 
to  such  an  extent,  that  in  most  cases,  at  the  end  of  twenty-four  hours,  the 
patient  is  found  quiet,  oiten  inclined  to  sleep,  with  the  abdomen  nearly 
free  from  tenderness,  the  skin  moist,  the  pulse  a  little  quicker  than  nat- 
ural, and  the  temperature  one  or  two  deo^rees  above  the  natural  standard. 
If  this  be  the  case  I  discontinue  the  further  use  of  the  powders,  and 
simply  leave  the  patient  upon  the  use  of  the  liquid  preparation, 
once  in  three  hours  until  eighteen  hours  more  have  passed,  when  if  spon- 
taneous evacuations  from  the  bowels  do  not  occur,  I  promote  a  movement 
by  an  enema  of  warm  water;  or  if  this  can  not  be  conveniently  used,  I  give 
a  mild  dose  of  sulphate  of  magnesia  or  Rochelle  salts,  aiming  to  give  only 
enough  to  procure  one  or  two  evacuations  :  and  always  leaving  instruc- 
tions to  give  the  patient  either  three  or  five  decigrams  ( gr.  v  to  viii) 
of  the  compound  powder  of  opium  and  ipecacuanha,  or  its  equivalent  of 
some  other  opiate,  as  soon  as  the  bowels  have  been  moved  the  second 
time,  if  the  discharges  are  free,  or  the  third  time  if  they  are  only  moder- 
ate. The  anodyne  is  to  be  repeated  every  lime  the  bowels  move  subse- 
quently, until  they  again  become  quiet.  By  such  a  course  of  treatment, 
accompanied  by  entire  rest  of  the  patient  in  a  recumbent  position,  and 
restriction  to  bland,  simple  nourishment,  such  as  lime  water  and  milk,  very 
thin  wheat  flour  and  milk  gruel,  sometimes  beef  tea,  or  mutton,  and  chick- 
en broth  in  small  quantities;  the  use  of  cold  mucilaginous  drinks,  also  lim- 
ited in  quantity,  or  if  the  patient  be  very  thirsty  during  the  early  part  of 
the  treatment,  allowing  bits  of  ice  to  be  used  instead  of  much  drink,  in  near- 
ly all  cases  that  come  under  treatment  in  the  early  stage,  the  disease  is  arrest- 
ed, the  symptoms  of  inflammation  rapidly  disappearing,  and  the  patient  be- 
coming convalescent  in  from  three  to  five  days.  But  if  the  disease  has 
been  in  progress  longer  before  it  has  come  under  observation,  having  al- 
ready passed,  in  the  acute  cases,  either  to  the  stage  of  softening  with  more 
or  less  abrasion  of  the  membrane,  or  in  those  of  a  milder  grade  to  the 
commencement  of  the  chronic  stage,  it  is  not  possible  to  procure  so  prompt 
and  early  an  arrest  of  the  disease:  and  such  remedies  must  be  chosen  for 
further  treatment,  as  are  calculated  to  procure,  in  addition  to  the  necessary 
anodyne  and  alterative  influence,  an  effect  upon  the  capillary  vessels  of 
the  mucous  membrane,   different  from  that  of  mere  astringency. 

For  this  purpose,  I  have  found  no  combination  of  remedies  better,  in 
the  majority  of  cases,  than  the  emulsion,  containing  oil  of  turpentine, 
tincture  of  opium,  gum  arable  and  sugar.  The  formula  I  have  generally 
used  is  the  same  that  I  have  mentioned,  when  speaking  of  the  treatment 
of  the  middle  and  advanced  stages  of  typhoid  fever,  and  consists  of  the 
oil  of  turpentine  twelve  cubic  centimeters  (fl.  3iii),  oil  of  wintergreen 
two  cubic  centimeters  (fl.  3ss),  tincture  of  opium  fifteen  cubic  centimeters 
(fl.  3iv ),  pulverized  gum  arable  and  white  sugar,  each  twenty 
grams  (3v),  ru'nbed  well  together,  with  the  addition  of  water, 
one  hundred  and  twenty  cubic  centimeters  (fl.  |iv).  If  the  in- 
gredients are  well  mixed,  they  make  a  uniform  or  homogeneous 
emulsion,  of  which  four  cubic  centimeters  (fl.  3i)  may  be  given  at  a  dose, 
and  repeated  every  four  or  six  hours,  according  to  the  frequency  of  the 
evacuations,  or  the  degree  of  quieting  effect  that  is  desired.  If  the  urine 
remains  scanty  and  the  skin  dry,  the  patient  may  take  suitable  doses  of 
an  equal  mixture  of  liquor  ammonii  acetatis,  and  nitrous  ether,  between 
each  of  the  doses  of  the  emulsion.  Under  the  influence  of  these  remedies, 
nearly  all  the  cases  will  improve  regularly  from  day  to  day  until  the 
evacuations  from  the  bowels  become  natural.  When  this  occurs,  the 
emulsion  should  be  suspended,  allowing  only  the  diaphoretic  mixture  to 


540  ENTEEITIS. 

be  continued  until  convalescence  is  complete.  If,  during  tlie  treatment, 
the  patient  has  been  allowed  little  or  no  ingesta,  but  the  wheat  flour  and 
milk  gruel  in  small  quantities  frequently  repeated,  alternated  sometimes 
with  animal  broths,  such  as  beef  tea,  it  will  be  found  almost  iiniforra^y, 
that  the  symptoms  of  the  inflammation  of  the  mucous  membrane  subside, 
the  discharges  become  natural,  the  febrile  symptoms  disappear,  the  tongue 
becomes  clean  and  the  patient  is  convalescent,  in  from  four  to  six  days. 
Oocasioually  you  may  meet  with  a  case  of  this  variety  of  infl.immation 
of  the  membrane  lining  the  ileum,  in  which  the  turpentine  and  laudanum 
emulsion  will  not  be  tolerated  by  the  stomach.  In  such  instances  I  have 
found  a  pill  composed  of  carbolic  acid  fifteen  milligrams  (gr.  :^),  pul- 
verized ipecac,  thirteen  centigrams  (gr.  ii),  pulverized  opium  six  cen- 
tigrams (gr.  i),  a  good  substitute  for  the  emulsion,  giving  one  pill 
under  the  same  circumstances,  and  with  the  same  frequency,  that 
the  doses  of  the  emulsion  were  recommended,  and  they  have  rarely 
produced  either  nausea,  or  any  unpleasant  symptoms.  On  the 
contrary,  they  have  been  followed  by  a  steady  lessening  of  the 
pain  and  restlessness,  and  the  discharges  have  improved  in  their  number, 
and  in  their  quality,  until  in  a  few  days  convalescence  was  established. 
When  inflammation  ia  the  ileum  assumes  a  chronic  form,  either  as  the 
sequel  of  an  acute  attack,  or  primarily,  it  is  seldom  advantageous  or 
necessary  to  give  the  patient  alterative  doses  of  the  mercurials  in  con- 
nection with  the  opium,  as  I  have  stated  in  the  beginning  of  the  acute 
form  of  the  disease.  The  greater  part  of  the  cases  that  have  come  under 
my  observation,  have  cither  resulted  from  severe  attacks  of  a  more  acute 
character,  or  have  followed  as  the  sequel  of  typhoid  or  typho-malarial 
fever.  During  the  progress  of  the  war  for  the  suppression  of  the  rebellion, 
when  there  were  large  numbers  of  soldiers,  who  were  more  or  less  under 
the  influence  of  causes  productive  of  diarrhoeas,  dysenteries,  typhoid  fever, 
and  scorbutus,  there  occurred  many  cases  of  the  most  severe  and  pro- 
tracted form  of  chronic  diarrhoea  as  the  sequel  of  attacks  of  acute  general 
diseases.  Many  of  the  cases  belonging  to  the  two  first  classes  that  I 
have  mentioned,  yielded  readily  to  the  proper  regulation  of  the  diet,  and 
the  use  of  the  turpentine  and  laudanum  emulsion,  or  the  pills  of  carbolic 
add,  ipecac,  and  opium;  only  being  careful  to  adjust  the  frequenc}^  of  the 
doses  to  the  degree  of  frequency  of  the  discharges.  In  most  instances 
it  is  sufficient  to  give  four  doses  of  either  of  these  prescriptions  in  the 
twenty-four  hours.  There  are  some  cases  in  which  a  prescription 
contauiing  aromatic  sulphuric  acid,  sulphate  of  magnesia,  and  tincture  of 
opium,  each  four  cubic  centimeters  (tt.  31)5  to  thirty  cubic  centimeters 
(fl.  ?i)  of  water,  given  to  adults  in  doses  of  four  cubic  centimeters  (fl.  31), 
will  be  found  equally  efficient  with  either  of  the  other  prescriptions  that 
I  have  named,  and  may  be  given  more  freely  to  such  cases  as  are  inclined 
to  secondary  nausea  from  the  effects  of  opiates.  The  cases  that  follow 
typhoid  fever  are  mostly  dependent  on  the  ulcerations  of  Peyer's  glands, 
which  have  remained  after  the  subsidence  of  the  general  fever.  It  is 
particularly  in  this  class  of  cases  that  the  nitrate  of  silver  is  to  be  re- 
garded as  a  valuable  remedy.  I  have  used  it  in  many  of  the  cases  in 
the  form  of  a  pill,  usually  in  doses  of  two  centigrams  (gr.  -J),  combined 
with  six  centigrams  (gr.  i)  of  opium,  at  first;  but  when  the  discharges 
were  held  more  in  check,  I  have  reduced  the  opium  to  half  that  quantity. 
A  pill  containing  these  ingredients  may  be  given,  at  first,  every  four 
hours.  If  the  effect  is  favorable  and  some  relief  is  obtained,  the  time  can 
be  subsequently  extended  to  six  hours,  or  even  to  eight  hours.  It  is  an 
object  of  importance,  in  these  cases   to  regulate   the  diet  of  the  patient. 


TREATMENT.  541 

The  principle  on  which  the  diet  should  be  regulated,  is  that  of  using  such 
articles  of  food  as  will  be  sufficient  in  their  composition  to  afford  the 
patient  the  elements  necessary  to  give  complete  nutrition,  and  in  a  form 
to  be  taken  up  as  perfectly  as  possible  in  the  stomach  and  first  part  of 
the  alimentary  canal,  leaving  the  least  possible  residue  to  pass  through 
the  middle  and  lower  bowels. 

In  the  great  majority  of  cases,  I  have  been  able  to  find  nothing  that  an- 
swers the  purpose  better  than  well  prepared  wheat  flour  and  milk  gruel. 
Sometimes  oatmeal  gruel,  soft  boiled  rice  and  arrow-root,  with  moderate 
quantities  of  the  animal  broths,  will  be  well  borne,  and  may  be  used  to  a 
limited  extent  alternately  with  the  flour  and  milk.  But  every  time  this 
class  of  patients  indulge  in  taking  promiscuously  the  coarser  articles  of 
food,  the  discharges  become  more  Irequent,  with  more  pains  in  the  abdo- 
men and  an  aggravation  of  all  the  symptoms.  That  class  of  cases,  which 
I  met  with,  chiefly  during  and  a  few  years  subsequent  to  the  war, 
among  the  soldiers,  presented  some  conditions  that  were  diff"erent  from 
ordinary  chronic  diarrhoeas.  The  patients  pretty  uniformly  presented 
a  very  pale,  bloodless  or  anaemic  aspect;  a  clean  state  of  the  tongue, 
frequently  a  slightly  oedematous  condition  of  the  feet  and  ankles,  a  very 
variable  state  of  the  appetite,  and  a  pretty  uniform  increase  of  the  per.- 
staltic  motion  and  discharges  soon  after  eating.  Very  generally  these  dis- 
charges were  thin,  reddish  brown,  or  of  a  pale  ash  gray  color.  In  most  in- 
stances if  the  intestinal  discharges  were  allowed  to  stand  a  little  time  in  the 
vessel  and  the  thinner  part  poured  off,  the  thicker  part  in  the  bottom  would 
contain  small  masses  of  mucus  and  specks  of  red  blood,  with  more  or  less 
muco-purulent  material.  But  this  was  not  present  in  all  cases.  The  habit 
of  evacuating  the  bowels  speedily  after  taking  food  seemed  to  keep  the  in- 
testines habitually  empty.  And,  I  observed,  very  uniformly,  that  whenever 
remedies  were  administered  sufficient  to  arrest  peristaltic  motion,  even  for 
eighteen  or  twenty-four  hours,  the  patients  became  very  uneasy  from  the 
sense  of  distension  or  undue  fullness  of  the  abdomen,  creating  the 
idea  that  the  discharges  had  been  stopped  too  suddenly.  This  dis- 
agreeable sense  of  fullness  was  not,  by  any  means,  accompanied  by  an 
actual  fullness.  In  very  many  of  them  there  was  no  distension  of  the  ab- 
domen, but  rather  a  lank  condition  and  yet  the  sensation  of  the  patient 
was  that  of  overfullness.  Similar  results  almost  invariably  followed  the 
use  of  the  more  astringent  class  of  remedies  in  connection  with  opiates. 
And,  if  the  restraining  influence  of  the  opium  and  astringents  was  contin- 
ued for  thirty-six  or  forty-eight  hours,  no  decided  absorption  of  the  con- 
tents of  the  bowels  took  place,  but  increased  discharges  occurred  as  soon 
as  the  eflect  of  the  medicine  had  ceased — the  quantity  being  propor- 
tioned to  the  length  of  time  they  had  remained  quiet. 

Very  few  of  this  class  of  patients  were  benefited  permanently,  by  any 
variety  or  combination  of  astringents  and  anodynes  that  I  could  devise. 
Some  of  them  were  benefited  and  ultimately  cured  by  the  careful 
regulation  of  their  diet,  and  the  protracted  use  of  the  nitrate  of  silver  and 
opium  pill;  usually  given  at  first  four  times  in  twenty-four  hours  diminish- 
ing the  number  according  to  the  improvement  that  took  place.  A  larger 
number,  however,  were  benefited,  and  some  of  them  ultimately  cured,  by 
using  a  powder  composed  of  sub-nitrate  of  bismuth,  three  decigrams 
(gr.  v),  sub-carbonate  of  iron  thirteen  centigrams  (gr.  ii),  and  pulver- 
ized opium  six  centigrams  (gr.  i),  usually  given  just  before  each  meal 
and  at  bed-time,  diminishing  the  number  according  to  the  degree  of 
restraining  efi"ect  produced.  It  was  during  the  time  that  these  soldiers 
were  returning  from   the  army   with  this  form  of  diarrhoea  and  coming 


542  TYPHILITIS. 

freqiiently  under  my  observation,  that  I  was  led  to  use  bromine  as  a 
remedy  in  their  treatment.  It  was  first  suggested  to  me  by  a  medical 
officer  in  charge  of  the  military  hospital  at  Rock  Island  during  a  visit  to 
that  encamjDment,  and  I  found  it  a  very  valuable  remedy  in  manv  of  this 
class  of  cases,  as  well  as  in  cases  of  chronic  dj^sentery  originating  under 
similar  circumstances.  The  formula  ttiat  I  then  used  was  bromine  one 
cubic  centimeter  (min.  xv),  bromide  of  potassium  twelve  grams  (3iii)' 
distilled  water  one  hundred  and  twenty  cubic  centimeters  (fl.  fiv),  of 
which  four  cubic  centimeters  (fl.  3i),  vvere  given  (further  diluted  with 
water  at  the  time  of  administration)  four  times  a  day.  This  remedy  uniform- 
ly caused  an  alteration  in  the  color  of  the  passages,  to  a  bright  yellow, 
and  usually  was  followed  by  a  gradual  diminution  in  their  number,  with 
increase  of  consistency,  until  in  from  one  to  two  weeks  some  cases  of  long 
standing  were  brought  very  nearly  to  a  natural  condition.  The  greatest 
objection  to  the  remedy  is  the  extreme  pungency  of  the  bromine,  and  the 
difficulty  of  concealing  it  sufficiently  to  prevent  its  being  annoying  to  the 
patient  during  its  administration. 

Typhlitis. — Owing  probably  to  the  greater  tendency  of  ffeces,  and, 
perhaps,  of  foreign  bodies  or  indigestible  substances  to  accumulate  in  the 
CEecum,  until  they  become  sources  of  irritation,  inflammation  of  limited 
extent  has  been  found  to  occur  more  frequently  in  that  part  of  the  in- 
testine and  in  the  ileo-Ccecal  junction,  than  in  any  other.  When  it  has 
been  thus  limited,  it  manifests  itself  by  pains  and  soreness  in  the  right 
iliac  region,  and  has  been  termed  typhlitis  to  distinguish  it  from  the  more 
general  inflammation  of  the  mucous  membrane  of  the  ileum.  But  the  con- 
sequences of  inflammation  here,  in  all  its  different  grades,  are  the  same  as 
in  any  other  part  of  the  membrane,  and  it  requires  no  difference  in  its 
management.  When  the  patient  is  attacked  with  symptoms  pointing  to 
inflammation  in  this  particular  place,  more  careful  examination  should  be 
made  in  reference  to  the  evidences  of  retained  faecal  accumulations,  in  the 
cfecum.  It  is  by  no  means  alwavs  the  case  that  such  accumulations 
exist.  A  majority  of  those  that  have  come  under  my  care,  neither  on 
close  examination  by  j^alpation,  nor  inquiry  into  the  nature,  amount  or 
degree  of  I'secal  evacuations  previous  to  the  commencement  of  the  pain, 
have  indicated  the  existence  of  any  accumulation  whatever.  But  when 
it  is  evident  that  either  hardened  fseces,  or  other  substances  exist  there, 
it  is  best  to  commence  treatment  by  using  large  enemas,  filling  the 
rectum  well  with  a  view  of  inviting  freer  evacuations  from  the  bowels. 
If  you  begin  by  giving  physic  by  the  mouth  and  thus  establish 
increased  peristaltic  motion  above,  it  is  liable  to  be  followed  by 
greatly  increased  pain,  and  sometimes,  the  establishment  of  irregular  con- 
traction of  the  circular  fibers  of  the  intestine,  thereby  obstructing  the 
further  motions  of  the  bowels,  instead  of  facilitating  the  evacuations  that 
are  desired. 

Having  thus  formed  an  obstruction,  all  further  administration  of  med- 
icines by  the  mouth  are  usually  followed  by  troublesome  vomiting,  and  a 
more  rapid  increase  of  all  the  local  symptoms  of  inflammation,  until  either 
the  patient  becomes  thoroughly  prostrated,  or  symptoms  closely  resem- 
bling invagination  supervene.  Such  results  can  almost  always  be  avoided 
by  relying  mjinly  upon  the  remedies  used  as  enemas  to  invite 
evacuations,  while  those  administered  by  the  mouth  are  decidedly 
soothing  or  anodyne  in  their  influence,  and  on  local  applications  of  an 
anodyne  character,  such  as  cloths  wet  in  warm  narcotic  infusions.  In  a 
few  instances  of  this  kind  where  the  local  pain  in  the  ileum  and  the  ten- 


PERITYPHLITIS.  543 

(lerness  on  pressure,  with  some  tumefaction  of  the  part,  indicated  decided 
inflammation,  the  pains  were  paroxysmal  and  severe,  and  the  movements  of 
the  bowels  entirely  arrested,  although  evacuations  had  been  free  up  to  the 
time  of  commencement  of  the  attack,  thereby  showing  that  there  was  no 
injurious  retention  of  fseces.  Yet  the  administration  of  medicines  by  the 
mouth,  of  a  laxative  character,  was  followed  by  vomiting,  until  the  sever- 
ity of  the  symptoms  created  decided  alarm,  and  apprehension  of  invagi- 
nation, or  some  permanent  intestinal  obstruction.  I  have  found  very 
gratifying  relief  by  the  administration  of  enemas  containing  hydrate  of 
chloral  and  belladonna.  Fifteen  decigrams  (gr.  xxiv)  of  the  hydrate 
of  chloral  with  fifteen  cubic  decimeters  (min.  xxiv)  of  the  tincture  of 
belladonna,  suspended  in  about  one  hundred  and  twenty  cubic  centime- 
ters (fl.  ^iv)  of  miik-warm  water  may  be  introduced  into  the  rectum  as  an 
enema,  with  instructions  to  the  patient  to  retain  it  as  long  as  practicable. 
If  retained,  it  will  be  generally  followed  within  half  an  hour  by  a  decided 
sense  of  relief  from  the  pain  the  patient  has  been  suffering,  and  more  or 
less  disposition  to  sleep.  This  relief  from  pain  and  tendency  to  rest  has^ 
in  some  instances  where  I  have  used  it,  continued  from  two  to  three  hours. 
When  the  patient  has  again  begun  to  complain  of  a  return  of  the 
paroxysms  of  pain  and  uneasiness  the  enema  has  been  repeated.  In  one 
instance,  the  second  enema  being  retained,  no  further  vomiting  nor  pain 
was  suffered  for  twelve  succeeding  hours;  but  the  patient's  pupils  became 
dilated,  mouth  somewhat  dry,  and  face  a  little  flushed  from  the  effects  of 
the  belladonna.  At  the  end  of  that  time  two  or  three  faecal  evacuations 
occurred  from  the  bowels,  followed  by  a  very  moderate  degree  of  griping 
pains  and  increased  restlessness.  Enemas  containing  half  the  quantity 
of  chloral  and  belladonna  were  given,  with  instructions  to  repeat  them 
at  intervals,  once  in  every  six  or  eight  hours,  if  pain  should  return  suffi- 
cient to  require  their  use.  During  the  succeeding  twenty- four  hours  a 
number  of  these  smaller  enemas  were  used,  followed  by  moderate  evac- 
uations from  the  bowels,  and  a  rapid  subsidence  of  all  the  inflammatory 
symptoms.  For  mention  of  several  cases  of  a  similar  character  treated 
chiefly  by  the  use  of  enemas  of  chloral  and  belladonna,  I  may  refer  you 
to  a  small  volume  of  "  Clinical  Lectures  on  Various  Important  Dis- 
eases," *  written  by  me  a  few  years  ago.  . 

Perityphlitis. — In  the  same  location  where  typhlitis  is  manifested,  we 
meet  with  cases,  not  infrequently,  in  which  patients  are  attacked  rather 
suddenly  with  more  or  less  acute  pain  in  the  ileum,  usually  just  abo^^e 
Poupart's  ligament,  sometimes  extending  higher  up  in  the  direction  of  the 
ascending  colon  or  centering  in  the  lower  part  of  the  iliac  region.  The 
pain  is  usually  acute  and  paroxysmal,  accompanied  by  manifest  tenderness 
to  pressure  externally,  and  within  twelve  to  eighteen  hours,  more  or  less 
tumefaction  or  swelling  in  the  part.  Sometimes  at  the  commencement  of 
the  symptoms,  the  patient  will  have  one  or  two  evacuations  from  the  bow- 
els, not  unnatural  in  their  character.  Very  generally,  the  bowels  have 
been  free  from  constipation,  at  least  several  days  previously,  and  no  diar- 
rhoea. The  occurrence,  however,  of  the  pain,  swelling,  and  tenderness  to 
pressure  in  the  iliac  region  is  usually  followed  by  an  arrest  of  further  in- 
testinal discharges.  And  if  the  patient  is  not  relieved,  in  most  instances 
the  pain  and  swelling  both  continue  to  increase  until  they  occupy  one 
third  of  the  lower  section  of  the  abdomen,  and  the  distension  becomes 
considerable,  with  distinct  hardness,  as  well  as  tenderness  over  the  cen- 
tral point  in  the  region  of  the  iliac  fossa.  Meantime,  the  patient  has  be- 
come restless,  pulse  quick,  respiration  more  hurried,  with  almost  constant 

♦  Second  edition,  pp.  129  to  134. 


544  PERITYPHLITIS. 

sense  of  nausea  and  prompt  vomiting  of  everything  that  ho  has  taken  in 
the  form  of  drink  or  medicine.  At  first  the  matters  vomited  are  simply 
the  contents  of  the  stomach,  sometimes  tinged  with  the  coloring  matter 
of  bile,  either  yellow  or  green,  and  more  or  less  bitter  to  the  taste.  Sub- 
sequently, they  become  more  decidedly  of  a  greenish  hue,  acid  taste;  and 
if  the  case  continues  two  or  three  days  without  relief,  the  abdomen  be- 
comes largely  distended,  as  if  peritoneal  inflammation  had  extended  over 
the  whole  surface  of  that  membrane.  The  pulse  becomes  uniformly  small, 
weak  and  quick,  the  extremities  cold,  surface  bathed  in  clammy  sweats, 
the  eyes  more  or  less  sunken,  the  mind  frequently  wandering,  dull  and 
despondent;  vomiting  and  regurgitation  from  the  stomach  of  a  dark 
grumous  fluid  takes  place;  and  at  a  little  later  period,  entire  collapse  and 
death  follow.  In  many  cases,  however,  even  with  but  little  treatment 
during  the  first  two  days  while  accompanied  by  the  symptoms  I  have  men- 
tioned, before  extreme  prostration  and  extension  of  the  symptoms  of  peri- 
tonitis over  the  abdomen  occur,  spontaneous  evacuations  take  place  from 
the  bowels,  and  most  frequently  go  to  the  extent  of  becoming  thin 
diarrhoeal  discharges:  after  which  the  tumefaction  gradually  diminishes,  the 
tenderness  also  abates,  the  pulse  improves,  and  in  three  or  four  days  the 
patient  has  reached  a  condition  of  convalescence.  In  the  greater 
proportion  of  these  cases,  the  latter  result  will  be  reached,  if  they  are 
properly  treated  from  the  commencement  of  the  attack.  But  there  is  an 
intermediate  class  of  cases,  between  those  that  go  directly  on  to  entire 
collapse  and  death,  and  those  which  recover,  either  spontaneously,  or  by 
the  aid  of  treatment,  in  which  about  the  end  of  the  first  week  of  their 
progress,  the  general  tumefaction  of  the  abdomen  ceases,  the  increase  of 
febrile  heat  gradually  diminishes,  some  evacuations  take  place  from  the 
bowels  from  day  to  day,  but  there  remains,  notwithstanding,  a  distinct 
well  defined  tumefaction  over  the  iliac  region,  more  or  less  hard  and  tender 
to  pressure,  and  in  a  few  days  more,  there  is  found  to  be  evidences  of 
deep-seated  suppuration. 

The  suppurative  process  now  continues,  and  the  patient  remains  as  in 
any  other  case  of  suppurative  inflammation,  emaciating  more  or  less  rapidly, 
losing  strength,  and  in  some  cases  the  symptoms  are  more  of  a  hectic 
type  of  febrile  movement,  accompanied  by  sweats,  particularly  dur- 
ing the  latter  part  of  the  night.  Usually  during  the  second  week  of 
the  progress  of  the  case,  or  at  longest  the  third,  the  abscess  which  has 
formed  will  spontaneously  open  into  the  intestines  and  discharge 
its  contents,  which  are  easily  recognized  as  pus,  sometimes  tinged  with 
blood  and  accompanied  by  some  ftecal  matter,  in  considerable  quanti- 
ties. Such  discharge  is  followed  by  direct  subsidence  of  the  swelling  and 
fullness  in  the  iliac  region.  In  other  cases  the  opening  instead  of  being 
into  the  intestine  will  be  into  the  peritoneal  cavity,  producing  the 
usual  rapid  development  of  general  peritonitis,  extreme  prostration,  and 
speedy  death.  Instances  are  on  record  in  which  the  abscess  has  found  its 
way  by  the  ulcerative  process,  into  the  bladder,  discharging  its  contents 
through  that  viscus  and  urethra,  with  the  urine.  But,  in  the  larger  num- 
ber of  cases,  the  tendency  of  the  abscess  is  to  the  surface.  Most  gener- 
ally during  the  third  week  in  the  progress  of  the  case  fluctuation  will  be- 
come evident  on  proper  examination,  and  by  a  free  incision  the  matter 
may  be  discharged,  and  in  most  cases  if  the  physician  is  sufficiently  care- 
ful to  give  full  drainage  to  the  abscess,  and  subsequently,  judicious  anti- 
septic treatment  with  such  nourishment  and  mild  tonics  as  will  sustain  the 
general  condition  of  the  patient,  a  slow  but  pretty  certain  recovery  takes 
place.     These  cases,  which  I  have  been  describing,  and  which  may  pro- 


TREATMENT.  545 

ceed  to  the  various  terminations  mentioned,  are  termed  in  your  books, 
perityphlitis.  They  consist  essentially  in  an  inflammation  commencing 
exterior  to  the  cascum,  in  the  connective  and  areola  tissue  surrounding 
that  portion  of  the  intestine.  The  inflammation  involves  the  coats  of  the 
intestine,  sufficient  to  cause  an  arrest  of  peristaltic  motion,  and  conse- 
quently, very  generally  an  arrest,  at  least  in  the  earlier  stage,  of  the  intes- 
tinal evacuations.  And  occasionally,  it  extends,  as  I  have  already  men- 
tioned in  speaking  of  the  symptoms,  to  the  mucous  membrane,  sufiicient 
to  develop  moderate  diarrhoeal  discharges  in  the  middle  and  latter  stages 
of  the  progress  of  such  cases.  The  inflammation,  as  you  will  infer  from 
the  symptoms  I  have  described,  in  the  milder  cases  terminates  in  resolu- 
tion, and  simple  disappearance  of  the  exudative  material,  with  no  bad 
consequences,  or  sequelm,  remaining.  In  other  instances  it  occasions 
sufficient  obstruction  to  the  intestines,  to  wholly  arrest  the  evacuations  un- 
til vomiting  becomes  excessive,  and  prostration  is  induced  to  a  degree  that 
is  dangerous  to  the  life  of  the  patient,  and  by  the  extension  of  the  inflam- 
matory process  to  the  peritoneum,  may  teiminate  fatally;  or,  as  in  a 
large  proportion  of  the  cases  is  the  fact,  instead  of  these  results,  the  in- 
flammation in  the  areolar  tissue  proceeds  to  suppuration,  the  formation  of 
an  abscess,  which  may  spontaneously  break  in  any  of  the  direc- 
tions I  have  mentioned,  but  most  generally  tends  toward  the  surface,  and 
consequently  comes  within  the  reach  of  the  practitioner  or  surgeon,  and 
if  properly  attended  to,  is  capable  of  being  relieved  in  time  for  the  resto- 
ration of  the  patient.  I  have  met  with  many  of  these  cases  of  perityph- 
litis, but  in  only  one  instance  under  my  own  care  has  the  disease  pro- 
ceeded to  a  fatal  termination.  This  was  the  case  of  a  young  man,  attacked 
with  the  disease  in  the  usual  form,  but  who  did  not  come  under  my  care 
until  the  end  of  the  first  week  of  its  progress,  when  suppuration  had  al- 
ready taken  place.  I  proposed  an  early  incision,  but  his  own  timidity  and 
that  of  his  mother  caused  it  to  be  postponed  from  day  to  day,  longer  than 
was  judicious. 

And,  although  at  the  end  of  the  second  week  of  its  progress,  it  was 
opened  and  freely  discharged  its  contents  and  for  about  one  week 
progressed  favorably  with  every  prospect  of  recovery,  yet  at  the  end 
of  that  time,  it  Avas  observed  that  the  purulent  discharge  which  had  pre- 
viously been  diminishing  began  to  be  more  copious,  assumed  a  slightly 
greenish  hue  and  became  offensive.  In  one  or  two  days  more  faeces 
were  found  to  be  mixed  with  the  pus  that  was  discharging  from  the  open- 
ing. From  this  time  on  faecal  matter  and  gases  passed  with  the  pus  from 
the  abscess,  and  notwithstanding  all  the  care  we  could  give,  the  patient 
gradually  emaciated,  and  after  lingering  three  or  four  months  he  was  re- 
moved to  his  home  in  Michigan,  where  he  died  from  asthenia,  with  the 
fistulous  opening  still  remaining. 

Treatment. — In  the  management  of  this  class  of  cases,  if  you  are  called 
early,  I  must  caution  you  against  the  common  practice  of  commencing 
the  treatment  by  the  administration  of  active  cathartics.  I  have  known 
these  cases  to  be  very  much  aggravated,  and  early  and  excessive  vomit- 
ing induced,  followed  by  inflammation  and  swelling  over  a  large  part  of  the 
abdomen  by  the  administration  of  cathartics  to  force  active  and 
free  evacuations  from  bowels.  You  must  bear  in  mind,  that  inflammation 
commencing  in  the  connective  tissue,  exterior  to  the  coats  of  the  intestine 
proper,  has  a  strong  tendency  to  induce  rigidity  or  contraction  of  the  cir- 
cular fibers  of  the  muscular  coat,  and  that  such  contraction  pre- 
sents an  obstacle  to  the  passage  of  f£eces,  consequently  all  administra- 
tion of  cathartics  while  such  contraction  remains  only  increases  the  peri- 

35 


546  PEPaTYPHLITlS. 

staltic  action  from  above  downward,  greatly  increasing  the  pain  and  add- 
ing to  the  danger  that  the  contracted  part  will  be  forced  into  the  uncon- 
tracted  part  below,  thereby  commencing  an  invagination  that  would  not 
otherwise  have  taken  place.  The  bad  results  of  the  common  practice  of 
commencing  the  treatment  of  all  such  cases  with  a  determined  effort  to 
evacuate  the  alimentary  canal  by  cathartics,  led  me  many  years  since  to 
take  an  entirely  different  course,  namely,  to  bring  the  patient  as  speedily 
as  possible  under  a  sufficient  anodyne  influence  to  place  the  whole  of  the 
upper  part  of  the  alimentary  canal  in  a  state  of  entire  rest  and  relaxation. 
For  this  purpose  the  preparations  of  opium  are  of  o;reat  service,  and  if  they 
can  be  conjoined  with  any  other  remedies  that  may  lessen  their  tendency 
to  produce  secondary  nausea  and  vomiting,  it  will  be  better  to  order  them 
so  combined,  and  given  in  sufficient  doses  to  produce  positive  relief  to 
the  pains,  and  repeated  often  enough  to  secure  as  complete  rest  for  the 
patient  as  possible,  for  at  least  twenty-four  or  thirty-six  hours.  Some  aid 
may  be  obtained  by  keeping  the  parts  covered  externally  with  warm 
narcotic  fomentations.  After  the  patient  has  been  kept  at  rest  as  fully 
as  possible,  until  the  soreness  has  much  diminished,  I  usually  administer 
enemas  of  sufficient  quantity  to  fill  the  rectum  well,  consisting  of  warm 
water  rendered  a  little  stimulating  by  the  addition  of  common  salt  or  sul- 
phate of  magnesia.  If  the  first  enema  passes  off  without  producing  any 
faecal  evacuations,  after  waiting  about  one  hour,  I  order  another. 

And  it  is  very  rare  that  I  have  had  to  repeat  the  enemas  more  than 
two  or  three  times,  before  getting  satisfactory  evacuations.  After  the 
bowels  have  been  freely  moved  if  there  is  little  or  no  return  of  the  pain 
and  much  less  tenderness  in  the  right  inguinal  region,  the  patient  should 
be  simplv  kept  at  rest  under  the  influence  of  a  mild  anodyne  for  two  or 
three  days,  and  convalescence  will  be  established.  So  long,  however,  as 
there  remains  much  pain,  tenderness  or  swe'ling,  more  decided  anodynes 
internally  and  emolient  applications  externally,  should   be  continued. 

In  addition  to  the  foreg-oing,  in  all  the  more  severe  cases  of  perityphlitis, 
I  have  seen  much  benefit  result  from  the  prompt  application  of  leeches 
directly  over  the  seat  of  the  inflammation.  In  adults  from  six  to  twelve 
leeches  may  be  applied,  and  allowed  to  take  all  the  blood  they  will, 
and  when  they  fall  off,  the  bleeding  from  the  bites  may  be  continued  by 
the  application  of  warm  cloths  and  emolient  poultices,  as  I  have  previ- 
ously indicated.  Of  course  in  children  and  young  subjects,  the  number 
of  leeches  will  have  to  be  diminished  in  proportion  to  the  age  of  the  child. 
In  a  decided  majority  of  instances,  I  should  say  at  least  three  out  of  four 
of  all  the  cases  that  have  come  under  my  observation  during  the  last 
thirty  years,  the  treatment  I  have  now  indicated  has  been  followed  by  the 
ultimate  recovery  of  the  patients.  But  in  those  cases  where  the  treat- 
ment has  been  neglected  or  inefficient  during  the  early  stage  until  it  has 
become  evident  that  suppuration  has  been  established,  the  earlier  an  in- 
cision can  be  made  with  safety  so  as  to  give  exit  to  the  matter,  the  more 
certain  will  be  the  recovery  of  the  patient.  If  you  wait  until  the  abscess  has 
become  so  large  as  to  bring  the  matter  near  the  surface,  making  a  distinct 
pointing,  with  soft  fluctuation,  it  will  be  at  the  imminent  risk  of  some  of 
those  bad  terminations,  that  I  have  already  pointed  out,  namely,  ulcera- 
tion into  the  intestines,  into  the  peritoneum,  or  into  the  bladder,  causing 
the  patient,  sometimes,  speedy  death,  and  at  others,  a  lingering  sickness 
and  death  after  many  months  of  suffering.  So  important  is  it  to  open 
these  abscesses  early,  that  some  of  our  most  eminent  authorities  have  rec- 
ommended making  incisions  in  an  explorative  manner  as  early  as  there 
are  any  just  reasons  to  suppose  the  suppurative  pro-vcss  had  commenced, 


BILIOUS   COLIC.  547 

and  without  waiting  for  any  evidences  of  fluctuation,  or  the  ability  to  de- 
tect matter  by  the  ordinary  process  of  palpation.  Drs.  Willard  Parker, 
Guerdon  Buck  and  some  others,  many  years  since,  demonstrated  the 
feasibility  in  these  cases,  of  making  an  incision  just  above  and  paral- 
lel with  Poupart's  ligament,  through  the  abdominal  parietes,  as  deeply  as 
the  fascia  covering  the  muscular  structure,  and  then  proceeding 
in  the  subsequent  steps,  to  very  carefully  sever  one  layer  after  another 
as  in  the  cutting  over  a  hernial  sac  for  the  relief  of  strangulated  hernia, 
until  they  had  reached  a  proper  depth  for  penetrating  the  abscess,  if  any 
existed;  or  when  having  made  an  incision  down  close  to  the  vicinity,  in- 
serting an  exploring  needle  still  deeper,  for  the  purpose  of  determining 
whether  an  abscess  existed  or  not,  and  the  precise  point  of  its  location. 
Several  cases  are  recorded  where  this  operative  procedure  has  been  fol- 
lowed by  the  desired  relief  in  the  discharge  of  pus,  and  the  very  early 
restoration  of  the^  patient. 


LECTURE    LIV. 


Inflammation  of  the  Intestines  Continued— Bilious  Colic,  its  Pathology  and  Treatment— Colitis 
and  Recto-Colitis  or  Dysenierj';  its  Causes,  Symptoms,  Morbid  Anatomy,  Diagnosis,  Prognosis  and 
Treatment. 

GENTLEMEN:  Before  leaving  the  subject  of  inflammation  and  irrita- 
tion affecting  the  small  intestines,  I  will  direct  your  attention  very 
briefly  to  a  class  of  cases  that  you  are  liable  to  meet  with  at  any  time  in 
practice,  occurring  more  frequently  in  persons  from  five  to  twenty  vears 
of  ao-e  than  at  an  earlier  or  later  period  of  life;  though  they  may  occur  at 
any  period  from  infancy,  even  to  old  age.  I  refer  to  cases  that  in  former 
times  were  called  bilious  colic.  The  patient  is  usually  attacked  rather 
suddenly  with  a  pain  in  some  portion  of  the  abdomen,  accompanied  by  a 
sense  of  heat  and  slight  tenderness.  The  pain  is  usually  of  an  acute 
character  and  distinctly  paroxysmal.  There  is  at  first  little  or  no  fever 
or  general  disturbance  of  the  temperature,  pulse  or  respiration,  but  simplj^ 
a  severe  paroxysmal  pain  accompanied  by  a  continuous  sense  of  heat,  and 
slight  tenderness  at  a  particular  limited  portion  of  the  abdomen,  more 
generally  near  one  or  the  other  of  the  iliac  regions;  sometimes  directly  in 
the  umbilical  region  or  central  part  of  the  abdomen.  In  three  cases  out 
of  four,  however,  it  is  in  the  region  of  the  right  iliac  fossa,  and  ascending 
colon.  But  whatever  may  be  the  particular  seat  of  the  pain,  after  it  has  once 
commenced,  there  is  generally  an  entire  suspension  of  further  evacuations 
from  the  bowels.  Although  I  have  been  in  the  habit  of  inquiring  very 
closely,  I  have  rarely  found  one  in  which  the  bowels  had  been  consti- 
pated during  any  preceding  part  of  the  time  before  the  attack,  but  they 
had  either  moved  at  regular  intervals  daily,  or  as  in  some  instances  had 
been  loose.  Very  recently  a  case  occurred  in  which  the  patient  had  two 
or  three  unusually  free  evacuations  from  the  bowels  only  a  few  hours 
before  the  attack.  Yet,  from  the  beginning  of  the  pain,  there  was  as 
usual  an  entire  arrest  of  further  evacuations.  If  these  cases  are  not  in- 
terfered with,  their  natural  tendency  is  to  induce  in  a  few  hours  more  or 
less  nausea  or  rejection  of  the  contents  of  the  stomach  by  vomiting,  after 


548  BILIOUS    COLIC. 

which  the  stomach  continues  to  reject  whatever  is  taken  in  the  way  of  in- 
gesta,  including  drinks,  nourishment,  and  very  frequently  medicine,  ac- 
companied by  a  steady  increase  of  the  tenderness,  with  some  tumefaction 
at  the  place  of  pain.  This  swelling  is  seldom  circumscribed,  as  in  peri- 
typhlitis, but  is  more  diifused  anil  not  accompanied  by  any  well-detined 
local  hardness.  The  urine  becomes  scanty  and  high-colored,  sometimes 
creating  a  burning  sensation  while  passing,  the  pulse  steadily  increases 
in  frequency  and  diminishes  in  force,  the  patient  becomes  more  and  more 
restless  until  the  end  of  the  second  or  during  the  third  day.  If  no 
relief  is  obtained  he  is  then  liable  to  have  cold  extremities,  a  pinchs<J 
and  anxious  expression  of  countenance,  great  sense  of  prostration  and 
weakness,  sighing  in  his  breathing,  like  one  tired;  pulse  small  and  thready; 
the  whole  abdomen  distended,  tympanitic,  and  more  or  less  tender  to 
pressure;  acontinuation  of  the  parox3sms  of  vomiting,  the  matters  ejected 
being  the  contents  of  the  stomach,  mixed  with  more  or  less 
mucus,  either  of  a  grass-green  or  dark-brown  color.  A  little  later 
it  presents  the  full,  coffee-ground  appearance,  and  is  thrown  up  in  large 
quantities  by  regurgitation,  entire  prostration  ensues,  relaxation  of 
the  sphincters,  and  death.  There  is,  of  course,  much  variation  in 
the  severity  of  attacks  of  this  character.  Some  of  them  are  much 
milder  than  I  have  described,  and  even  without  any  other  treatment  than 
rest  and  abstinence  from  food  and  drinks,  and  perhaps  the  use  of  such 
domestic  remedies  as  warm  cloths,  applied  over  the  abdomen,  freely,  the 
pain  before  the  end  of  twenty-four  hours  subsides  spontaneously,  evacua- 
tions from  the  bowels  occur,  and  the  patient  speedily  recovers.  But 
there  are  all  gradations  in  severity,  from  these  simple  slight  cases  up  to  the 
severe  and  dangerous  grade  that  I  have  already  described. 

The  nature  of  these  cases  is  often  misunderstood.  So  far  as  my  observa- 
tions go,  a  large  majority,  both  of  the  people  and  of  the  practitioners  who 
are  called  to  their  aid,  receive  and  act  upon  the  impression  that  the  colic  or 
pains  are  produced  by  some  irritating  suiistance  in  the  alimentary  canal, 
and  that  the  great  desideratum  in  the  treatment  is,  to  cause  its  removal 
by  obtaining  free  evacuations  from  the  bowels.  And  I  think  I  do  not  err 
in  saying  that  in  four  out  of  five  of  all  the  cases  to  which  J  have  been 
called  in  consultation,  in  the  last  twenty  years,  the  treatment  has  been 
commenced  by  giving  remedies  to  procure  evacuations.  It  is  true  that 
in  many  of  them,  anodynes  have  been  administered  to  allay  pain,  but  at 
the  same  time  the  anodynes  have  been  alternated  with  doses  of  physic, 
the  one  to  allay  pain,  the  other  apparently  to  force  an  operation  from  the 
bowels;  and  the  result  has  been,  without  exception,  that  the  administra- 
tion of  the  physic  so  far  counteracted  the  effects  of  the  anodyne,  that  the 
pains  were  continued  to  a  gre  ter  or  less  degree,  and  within  twenty-four 
hours  the  irritability  of  the  stomach  was  developed  to  such  an  extent  as 
to  reject  by  vomiting  everything  further  that  was  administered  by  the 
mouth.  In  some  instances,  seeing  the  iuadvisability  of  further  adminis- 
tering either  physic  or  anodynes  by  the  mouth  on  account  of  their  rejec- 
tion, hypodermic  injections  of  morphine  have  been  resorted  to,  and  in 
some  instances,  with  the  effect  of  speedily  relieving  the  pains  and 
putting  the  patient  at  rest.  And  had  the  rest  been  allowed  to  remain  a 
sufficient  length  of  time,  there  is  a  probability  that  it  would  have  resulted 
in  permanent  relief  to  the  patient,  especially  if  aided  at  suitable  times 
by  large  enemas,  instead  of  disturbing  the  stomach.  In  the  majority  of 
instances,  however,  still  controlled  by  the  idea  that  some  irritative  material 
must  be  removed  by  evacuations,  the  patient  has  only  been  allowed  to 
rest  for  three  or  four  hours  under  the  influence  of  anodynes,  when  active 


SYMPTOMS.  549 

doses  of  physic  were  again  administered  only  to  be  promptly  rejected, 
with  a  renewal  of  more  distress  and  persistent  vomiting  than  before,  fol- 
lowed by  greater  prostration  of  the  patient,  and  an  increase  of  all  the 
abdominal  symptoms.  I  saw  a  marked  illustration  of  this  only  a  few 
Aveeks  since,  in  the  case  of  a  youth  who  had  been  attacked  in  the  manner 
1  have  already  indicated.  He  had  three  evacuations  in  the  morning 
before  the  attack  commenced.  The  pain  coming  suddenly  and  with  great 
severity,  a  physician  was  called  without  delay  whcj  judiciously  admin- 
istered anodynes  at  first,  sufficient  to  allay  the  pain;  but  with  the  idea 
that  I  have  already  indicated,  he  deemed  it  of  paramount  importance  to 
freely  evacuate  the  alimentary  canal,  and  consequently  commenced  giv- 
ing mild  laxatives  and  alteratives  alternated  with  his  anodynes. 

The  result  was  a  failure  to  do  more  than  mitigate  the  pain,  and  to  de- 
velop active  vomiting  before  the  (  nd  of  twelve  hours.  He  then  ceased  to 
administer  medicine  by  the  mouth  and  resorted  to  hypodermic  injections 
of  morphine,  and  succeeded  in  quieting  the  patient,  procuring  considerable 
rest,  and  so  much  apparent  improvement  that  there  was  supposed  to  be 
no  longer  any  danger  in  the  case.  But  as  the  effects  of  the  anodyne  more 
completely  passed  away,  the  pains  began  to  return  and  with  the  pains 
again  came  the  idea  that  it  was  necessary  to  remove  the  contents  of  the 
bowels,  consequently  two  old-fashioned  doses  of  calomel  and  jalap,  ten 
grains  each,  were  administered  for  this  purpose.  They  were  followed  by 
prompt  vomiting,  with  a  rapid  increase  of  the  pain,  tympanitis  and  tender- 
ness over  the  whole  abdominal  region,  with  excessive  distension,  great 
prostration  of  the  patient,  and  yet  no  evacuations  that  were  supposed  to 
pass  through  the  alimentary  canal.  This  led  to  the  conviction  on  the  part 
of  the  attending  physician  that  there  was  probably  invagination  of  the 
intestine,  or  intussusception.  So  strong  was  this  conviction  that  prep- 
arations were  made  for  an  effort  to  obtain  relief  by  causing  gaseous 
distension  of  the  bowels,  through  the  use  of  enemas,  and  in  case  of  failure, 
perhaps,  to  resort  to  laparotomy  for  the  purpose  of  unfolding  the  supposed 
invagination.  These  ulterior  measures,  however,  were  not  resorted  to, 
and  the  patient  became  so  rapidly  prostrated  as  to  die  on  the  third  day 
after  the  time  of  the  administration  of  the  calomel  and  jalap.  And  yet  on 
careful  post-mortem  examination,  no  invagination  of  the  intestines  was 
found,  and  no  positive  mechanical  obstruction.  At  two  points  there  were 
contractions  of  the  circular  fibers  of  the  muscular  coat,  of  the  intestine,  suf- 
ficient, perhaps,  to  diminish  the  caliber  of  the  intestine  at  those  points 
more  than  one  half.  They  appeared  to  be  the  only  mechanical  impedi- 
ments to  the  movement  of  the  bowels.  Death  was  plainly  the  result  of 
intense  inflammation,  commencing  in  the  muscular  and  peritoneal  cover- 
ings of  the  intestines  and  extending  over  the  whole  peritoneal  surface.  I 
regard  this  class  of  cases  as  dependent  on  primary  irritaton  causing 
irregular  contraction  of  the  circular  fibers  of  the  muscular  coat  of  a  limited 
part  of  the  intestine  by  which  the  natural  peristaltic  motion  is  arrested, 
and  the  severe  pains  induced.  Such  irritation  may  result  from  reflex 
nervous  action  or  from  the  direct  presence  of  undigested  material  in  the 
bowels.  Some  of  these  cases  I  have  traced  directly  to  the  presence  of 
indigestible  material,  or  other  substances  that  had  been  swallowed  by  the 
patient.  In  one  of  the  earliest  cases  that  came  under  my  care,  the  attack 
appeared  to  be  provoked  by  a  long  walk  after  eating  an  abundance  of 
pop-corn,  some  of  which  was  swallowed  without  chewing.  It  was  in  the 
person  of  a  woman,  who  had  been  confined  less  than  two  weeks  previously, 
but  had  gotten  up  from  her  confinement  well.  Having  taken  the  corn  as 
I  have  mentioned,  she  walked  about  a  mile  and  a  half  carrying  her  baby, 


550  BILIOUS   COLIC. 

and  before  the  next  morning,  was  seized  with  all  the  symptoms  I  have 
described  as  characterizing  the  more  severe  cases  of  the  class  under  con- 
sideration. In  this  case  the  symptoms  proceeded  to  an  extreme  degree; 
the  abdomen  became  enormously  distended  from  tympanitis.  There  was 
tenderness  over  its  whole  surface,  pulse  small,  thready,  vomiting  constant, 
the  matters  ejected  being  first  green  and  later  of  a  brownish  hue;  ex- 
tremities cold,  and  altogether  presenting  an  aspect  that  had  caused  her 
physician  to  regard  the  case  as  hopeless,  and  the  friends  were  collected 
to  see  her  die.  No  evacuations  had  taken  place  from  the  time  of  the 
attack  of  pains,  except  such  faeces  as  were  then  in  the  lower  part  of  the 
bowels.  Being  requested  to  see  the  patient  at  this  stage  of  her  difficulty, 
and  learning  minutely  the  history  of  the  case,  I  advised,  as  a  forlorn  hope, 
the  administration  of  an  enema  consisting  of  an  infusion  of  tobacco,  under 
the  impression  that  the  disease  was,  what  I  have  already  indicated,  namely, 
direct  contraction  of  the  circular  fibers  of  a  limited  portion  of  the  intestine 
without  invagination;  and  consequently  if  that  contraction  could  be  re- 
laxed, evacuations  would  occur.  Knowing  of  no  more  powerful  relaxant 
of  general  muscular  tone  or  of  tonic  contraction  than  tobacco,  Avhen  its 
full  sedative  effects  are  obtained,  I  advised  its  administration  in  the  form 
of  an  enema.  The  amount  given  was  sufficient  to  cause  very  decided 
effects  upon  the  nervous  and  muscular  systems  of  the  patirnt. 

Within  twenty  minutes  she  became  pale,  the  surface  covered  with  a 
sweat,  and  a  feeliiig  as  though  she  was  dying.  The  pulse  was  very  soft 
and  weak  and  the  mind  wandering,  but  this  state  was  followed  in  the  next 
twenty  minutes  by  a  copious  evacuation  from  the  bowels,  filling  the  bed 
with  fasces,  before  the  patient  could- give  any  warning,  and  in  less  than 
an  hour,  two  additional  evacuations  followed;  greatly  lessening  the  ab- 
dominal distension,  and  under  the  influence  of  a  little  carbonate  of  am^ 
monia  and  camphor  as  restoratives,  the  stomach  became  quiet,  the  pulse 
improved,  and  the  patient  went  on  to  subsequent  recovery  without  the 
necessity  of  any  other  treatment  than  simple  anodynes  to  restrain  the  ex- 
cess of  the  evacuations  during  the  day  foijowing  the  administration  of  the 
tobacco  enema.  This  case  to  which  I  have  alluded  occurred  more  than 
thirty  years  since;  and  from  that  time  to  the  present  I  have  regarded  these 
attacks  as  consisting  essentially  in  a  grade  of  irritation,  involving  the 
muscular  coat  of  the  intestine  primarily  and  inducing  an  arrest  of  peri- 
staltic motion  or  a  contraction  of  the  circular  fibers  at  one  or  more  parts 
and  the  development  of  inflammation  only  as  a  secondary  consequence.  The 
case  which  I  have  just  detailed  showed  in  the  evacuations  an  abundance 
of  the  identical  corn  in  kernels  apparently  as  whole  as  when  they  were 
swallowed  a  week  previously.  But  there  are  many  of  these  cases  in 
which  no  traces  of  any  foreign  substance  can  be  found  in  the  evacuations 
to  explain  why  they  occurred.  And  some  of  the  patients  manifest  a  pe- 
culiar susceptibility  to  such  attacks,  having  them  recur  once  or  twice  a 
year  for  several  years  in  succession.  Entertaining  the  views  I  have  just 
explained,  in  relation  to  their  pathology,  I  have  uniformly  adopted  the 
practice  of  giving  such  remedies  only,  at  first,  as  were  calculated  to  pro- 
duce full  relaxation  of  the  muscular  fibers  and  to  relieve  the  pain;  and  to 
continue  this  influence  long  enough  to  render  it  reasonably  certain  that 
the  irritability  of  the  structures  involved  had  been  fully  overcome;  care- 
fully abstaining  from  the  administration  of  cathartics  of  any  kind  dur- 
ing the  first  two  or  three  days  of  the  treatment.  When  the  pain  and  irri- 
tability have  been  fairly  checked  by  the  prompt  use  of  anodynes,  I  have 
found  the  administration,  first,  of  large  injections  of  warm  water  not  only 
to  be  useful  in  provoking  evacuations,   but  apparently  exerting   more  or 


TKEATMENT.  551 

less  soothing  influence  as  indicated  by  the  sense  of  relief  following  their 
use. 

After  giving  two  or  three  enemas  of  warm  water  sufficient  to  invite 
evacuations,  if  they  fail  to  produce  that  effect,  and  the  pains,  with  more  or 
less  abdominal  distension,  begin  to  return,  then  I  think  there  are  no  reme- 
dies more  certain  to  induce  the  necessary  relaxation,  and  relief  from  pain,, 
than  injections  either  of  the  hydrate  of  chloral  and  belladonna,  or  of  the 
infusion  of  tobacco,  as  I  have  already  indicated  when  speaking  of  other 
forms  of  intestinal  obstruction.  The  latter  I  have  had  used  many  times 
in  cases,  where,  previous  to  being  called  in  consultation,  the  attending 
physician  has  been  led  to  conclude  with  much  positiveness,  that  an  invag- 
ination of  the  intestines  had  taken  place,  and  yet  with  speedy  and  entire 
relief  to  the  patient.  Consequently,  I  urge  upon  you  in  treating  all  these 
cases  to  divest  yourselves  of  the  idea  that  you  must  procure  by  cathartics, 
earlv  evacuations  from  the  bowels,  whether  you  have  reason  to  suppose  the 
patient  has  taken  some  indigestible  material  or  not.  And,  for  the  simple 
reason  that  if  there  is  indigestible  material  or  some  foreign  substance  in 
the  alimentary  canal,  it  having  already  induced  circular  contraction  of  the 
intestines,  and  arrested  the  peristaltic  motion,  all  efforts  to  excite  further 
cathartic  action  will  only  cause  still  closer  contraction,  and  speedily  in- 
duce inversion  of  intestinal  motion,  vomiting,  and  consequently  much 
additional  distress  and  danger  to  your  patient.  On  the  contrary,  if  you 
first  administer  such  remedies  as  will  allay  pain,  dull  the  morbid  sensi- 
bility of  the  part,  and  induce  ultimate  relaxation  of  the  walls  of  the  con- 
tracted portion  of  the  intestine,  then  an  efficient  use  of  enemas  or  even 
of  mild  laxatives  will  succeed  in  procuring  all  the  evacuations  that  are 
necessary,  and  with  entire  safety  to  the  patient. 

On  the  contrary,  nothing  is  more  clear  than  that  if  a  tube  like  the  in- 
testine is  contracted  at  one  point  by  a  band  of  circular  fibers,  while  above 
and  below,  it  remains  uncontracted,  or  of  the  usual  size,  the  more  you 
provoke  movements  that  are  calculated  to  force  a  passage  downward,  the 
more  certain  you  will  be  to  carry  the  contracted  portion  into  the  uncon- 
tracted part  below,  and  thereby  produce  an  invagination,  which  would 
not  have  taken  place,  if  your  efforts  had  been  directed  to  the  prevention 
of  such  motion  until  the  unnatural  contraction  had  ceased.  Consequently, 
whether  we  view  the  matter  theoretically,  or  as  demonstrated  by  experi- 
ence, the  rational  mode  of  treatment  is  first  to  so  far  destroy  the  morbid 
sensibility  and  irregular  contraction  as  to  remove  the  resistance  to  the 
passage  of  the  contents  of  the  bowels  before  you  insist  on  efforts  to  pro- 
cure such  passages.  I  have  thus  dwelt  upon  this  class  of  cases  because 
they  are  of  comparatively  frequent  occurrence,  and  because  I  am 
satisfied  that  both  the  pathological  relations  I  have  pointed  out,  and 
the  indications  for  treatment,  are  of  much  practical  value. 

Recto-colitis  or  Dysentery. — Inflammation  of  the  mucous  membrane  of 
the  large  intestine  and  rectum  are  met  with,  of  all  grades  of  severity, 
from  the  most  acute  and  rapidly  progressive  to  the  most  chronic  or  pro- 
tracted in  duration.  Inflammation  of  the  membrane  lining  this  part  of 
the  alimentary  canal  very  generally  extends  more  or  less  to  the  muscular 
coat.  And  while  it  often  occupies  the  whole  extent  of  the  colon  and  rec- 
tum, it  is  more  frequently  limited  to  certain  portions,  or  at  least  is  more 
intensely  developed  in  certain  parts,  as  the  cascum,  the  right  and  left 
angles  of  the  colon,  and  the  sigmoid  flexure,  than  in  the  transverse  por- 
tion. It  prevails  more  or  less  everv  season,  and  is  then  called  spo- 
radic, or  simply  acute  dysentery.  At  some  periods  of  time,  and  in  some 
localities,  it  prevails  to  such  an  extent,  as  to  present  all  the  characteristics 


•552  DYSENTERY. 

of  an  epidemic;  and  occasionally  extends  from  place  to  place  over  an  ex- 
tended district  of  country  in  the  same  manner  as  other  true  epidemic 
diseases.  More  frequently,  however,  when  it  prevails  severely,  it  is 
limited  to  particular  communities,  and  is  more  properly  styled  endemic, 
than  epidemic.  At  the  present  time,  writers  are  inclined  to  describe  two 
forms  of  the  disease;  one,  styled  simple  or  catarrhal  dysentery,  and  the 
other  croupous  or  pseudo-membranous  dysentery,  sometimes  also  called 
diphtheric  dysentery.  This  division,  however,  is  one  that  can  not  be 
maintained  clinically  at  the  bed-side;  for  observation  has  abundaiitly 
shown,  that  cases  of  the  pseudo- membranous,  or  diphtheritic  form  of 
dysentery,  occur  frequently  interspersed  among  other  cases  of  a  strictlv 
catarrhal  character.  On  the  other  hand,  cases  of  simple  or  catarrhal 
dysentery  occur  very  frequently  intermingled  with  those  of  a  diphtheritic 
character,  especially  when  the  disease  is  prevailing  with  more  than 
ordinary  severity. 

All  forms  of  dysentery,  whether  sporadic  or  endemic,  prevail  most  in 
warm  climates,  especially  within  what  are  called  tropical  countries,  where 
the  summer  temperature  is  long  continued;  and  also  more  frequentlv  iu 
warm  seasons  of  the  year  in  temperate  climates.  Indeed,  throughout  the 
temperate  zone  of  the  earth,  dysentery  rarely  prevails,  except  during  the 
last  months  of  summer,  and  the  first  of  autumn.  In  the  northern  belt  of 
the  United  States,  its  prevalence  is  limited  almost  entirely  to  the  months 
of  July,  August,  September,  and  sometimes  extending  through  a  portion 
of  October.  Its  highest  average  prevalence  is  usually  in  the  month  of 
August.  The  order  in  which  the  intestinal  diseases  appear  in  our  coun- 
try, is,  usually,  fi.rst,  the  serous  diarrhoeas,  cholera  morbus,  and  cholera 
infantum,  connected  with  and  immediately  following  the  climax  of  sum- 
mer heat.  As  we  |)ass  this  climax,  we  begin  to  have  the  prevalence  of 
dysentery,  and  a  little  later,  the  autumnal  fevers  make  their  appearance, 
showing  that  there  is  a  relationship  in  the  order  of  the  prevalence  of  these 
diseases. 

These  facts  in  regard  to  the  climates  and  seasons  most  favorable  for  the 
prevalence  of  dysentery,  show  that  there  are  certain  predisposing  causes 
that  exert  a  strong  influence  over  the  production  of  the  disease;  such  as 
the  extreme  high  temperature  of  the  warm  climates  or  tropical  regions; 
the  warm  days  and  cool  nights  of  the  last  months  of  summer  and  early 
autumn  in  the  temperate  regions.  To  these,  which  are  evidently  strong 
predisposing  causes,  may  be  added,  also,  certain  other  changes,  such  as 
the  existence  of  over-crowding,  want  of  ventilation,  as  illustrated  iu  the 
denser  populated  portions  of  cities,  esj^ecially  among  the  inhabitants  of 
tenement  houses  and  manufacturing  establishments,  where  many  workmen 
are  congregated  in  small  dwellings,  also  still  more  in  work-houses  and 
prisons,  where  sanitary  regulations  have  been  overlooked,  and  in  the 
camps  of  armies. 

Dysentery,  in  the  endemic  or  epidemic  form,  appears  to  be  of  fre- 
quent occurrence  in  connection  with  the  movements  of  large  armies, 
in  almost  all  the  countries  of  the  tropical  and  temperate  regions  of  the 
earth.  Few  diseases  were  more  destructive  to  life  and  health  than  dys- 
entery in  connection  with  our  army  during  some  portions  of  the  war  for 
independence,  again  with  the  army  that  invaded  Mexico,  and  still  more 
in  the  armies  on  both  sides  in  the  recent  civil  war.  Another  influence 
which  seems  to  predispose  to  the  prevalence  of  dysentery  is  malaria,  or 
the  active  cause  of  periodical  fevers;  it  having  been  observed  in 
almost  all  cases,  that  dysentery  was  more  prevalent  in  those  decidedly 
malarious   districts  than  in   non-malarious  ones,  under  otherwise   similar 


HISTOEY.  553 

conditions  of  temperature  and  of  season.  Arid  it  has  also  been  noticed  that 
the  seasons  of  the  highest  prevalence  of  malaria  itself  were  usually  charac- 
terized by  an  increased  prevalence  of  dysentery.  This  fact,  however,  has 
been  noted  by  many  observers,  that  while  malarious  fevers  were  prevalent 
upon  the  low  lands  in  malarious  districts,  dysentery  was  often  observed 
to  be  decidedly  more  prevalent  on  the  neighboring  or  adjacent  elevations 
and  ranges  of  hills.  It  would  seem  that  age  also  exerted  some  influence 
as  a  predisposing  cause,  from  the  fact  that  much  the  larger  proportion  of 
the  cases  of  dysentery  are  met  with  in  adult  life.  It  is  true  that  cases 
occur  at  all  periods  of  life,  even  from  infancy  to  old  age;  but  a  far  larger 
proportion  of  them  are  met  with  between  the  ages  of  fifteen  and  forty, 
than  at  an  earlier  or  later  period.  And,  while  dysentery  undoubtedly 
prevails  most  as  an  endemic  disease,  recurring  with  different  degrees  of 
severity  in  different  years  in  malarious  districts,  and  in  densely  populated 
towns  and  cities  where  the  population  is  subject  more  or  less  to  the  causes 
which  favor  the  development  of  typhoid  and  typhus  fevers,  it  is  by  no 
means  restricted  to  those  localities.  Occasionally  it  has  prevailed,  and 
that,  too,  in  its  most  malignant  form,  in  hilly,  rugged  districts  of  councry, 
which  were  almost  entirely  free  from  malarious  influences,  and  among  3 
rural  population  as  much  as  among  those  occupying  towns  and  villages.  A 
few  such  instances  have  come  under  my  own  observation.  I  recollect  well 
when  the  disease  prevailed  with  great  severity,  destroying  many  lives 
through  a  wide  district  of  the  middle  and  southern  portions  of  New 
York;  grabracing  the  larger  parts  of  the  counties  of  Otsego,  Chenango, 
Courtland,  Broome,  Tioga  and  Steuben  in  a  single  season  during  the 
latter  part  of  summer  and  autumn;  it  assumed  as  malignant  a  character 
in  the  isolated  farm  houses  of  well-to-do  farmers  directly  upon  the  rugged 
hills,  as  in  any  other  portion  of  the  district. 

In  the  reports  from  the  various  committees  upon  epidemics,  and  some 
of  those  on  pract'cal  medicine  to  be  found  in  different  volumes  of  the 
"  Tratisactions  of  the  American  Medical  Association,"  especially  during 
the  first  fifteen  or  twenty  years  of  the  history  of  that  organization,  are 
allusions  to,  and  descriptions  of  many  epidemics  of  dysentery.  For  prac- 
tical and  clinical  purposes  I  may  include  the  various  cases  of  acute  dysen- 
tsry  in  three  groups:  one,  that  I  shall  designate  as  acute  sthenic,  or  active 
dysentery;  another  malarious,  or  periodical;  and  a  third  as  asthenic,  or 
typhoid.  Not  that  these  are  different  forms  of  disease  in  any  respect, 
but  simply  that  the  first  includes  those  cases  generally  of  a  sporadic 
character  though  sometimes  epidemic,  which  occur  in  otherwise  healthy 
districts  of  country,  and  in  populations  no:  debilitated  or  constitutionally 
influenced  by  any  other  general  causes.  While  the  second  group  in- 
cludes those  cases,  which  are  met  with  oftentimes  endemically  in  dis- 
tinctively malarious  districts  of  country;  and  the  third  group  embraces 
such  cases  of  dysentery  whether  sporadic  or  endemic,  as  occur  in  the 
midst  of  sanitary  influences  well  known  to  predispose  to  t\-phoid  con- 
ditions of  the  system.  These  groups  are  not  different  diseases,  but 
simply  the  same  disease;  essentially  an  acute  itiflimmation  in  a  particular 
portion  of  the  alimentary  canal;  but  occurring  under  different  modify- 
ing circumstances: — such  as  have  altered  more  or  less  the  condition  of 
the  blood,  the  secretions,  and  the  vital  properties   of  the  tissues. 

Syynptoras. — The  symptoms  of  acute,  active  or  sthenic  dysentery  are 
usually  well  marked  and  easily  recognized,  as  diagjiostic  of  this  disease. 
Some  cases  commence  abruptly  with  a  chill,  but  in  the  great  majority  of 
cases,  the  patient  feels,  from  one  to  three  days,  a  gradually  increasing 
disturbance  in  the  abdomen;  consistina:  of  rumbiinfj  of  srases,  increased 


554  ACUTE^  DYSENTEKY. 

peristaltic  motion  of  the  bowels,  occasionally  slight  griping  pains,  and 
from  one  to  three  or  four  intestinal  discharges  per  day.  During  this 
premonitory  stage  the  discharges  are  foetid  but  thinner  than  natural. 

In  most  instances,  at  the  end  of  from  one  to  three  days  of  the  premonitory 
disturbances  to  which  I  have  alluded,  the  discharges  become  more  frequent, 
smaller  in  quantity,  and  consisting  largely  of  mucus,  together  with  a  dis- 
position to  strain,  called  tenesmus,  while  each  discharge  is  usually  pre- 
ceded and  accompanied  by  much  more  severe  pains  across  the  abdomen, 
sometimes  called  tormina.  In  addition  to  these  frequent  paroxysms  pass- 
ing through  the  abdomen,  and  the  tenesmus  and  pressure  upon  the  rectum, 
accompanying  the  frequent  small  mucous  discharges,  there  is  usually  also  a 
dull  moderately  severe  pain  in  the  sacral  region  of  the  back,  not  infre- 
quently some  frontal  headache,  with  a  great  sense  of  weariness;  there  is 
dryness  of  the  mouth,  often  some  thirst,  a  whitish  coat  upon  the  tongue,  a 
slightly  reddened  appearance  of  the  lips,  moderate  acceleration  of  the  pulse, 
and  ail  increase  of  from  one  to  three  degrees  of  temperature  above  the 
normal  standard,  with  a  dryer  feeling  of  the  skin,  and  often  a  slightly 
flushed  appearance  of  the  face.  In  other  words,  with  the  supervention  of 
frequent,  painful,  scanty  mucous  discharges,  there  comes  a  moderate 
general  febrile  action.  The  urine,  also,  becomes  at  this  time  diminished 
in  quantity,  redder  than  natural,  and  not  infrequently  giving  rise  to 
some  burning  and  irritation  in  the  urethra  when  discharged.  Usually, 
within  twenty-four  hours  after  the  discharges  become  small  and  mucous, 
they  become,  also,  more  or  less  streaked  and  intermixed  with  blood,  and 
after  the  first  two  or  three  days  the  general  febrile  movement  increases 
moderately  in  severity,  the  tongue  and  lips  become  more  dry,  thirst  more 
decided,  the  pulse  is  increased  in  frequency,  until  it  often  reaches  ninety- 
five  to  a  hundred  beats  per  minute,  the  temperature  in  some  instances 
reaches  from  30°  to  40°  C.  (1 02°  to  104°  F.),  the  pains  preceding  and  accom- 
panying the  discliarges  become  extremely  sharp  and  severe,  while  there  is 
almost  constant  feeling  of  fullness  in  the  rectum.  The  patient  suffers  from 
distressing  tenesmus,  often  no  sooner  rising  from  the  vessel  and  returning 
to  bed  than  he  is  again  compelled  to  be  up  with  a  vain  effort  to  pass  more, 
when  perhaps  with  all  his  efforts,  the  matters  passed  will  be  no  more  than 
a  spoonful  of  simple  jelly-like  mucus,  intermixed  with  blood.  In  the 
severer  class  of  cases  the  stomach  often  becomes  irritable,  drinks  which 
the  patient  craves  very  frequently  are  rejected  by  vomiting,  and  in  a 
small  proportion  of  the  cases  the  vomiting  becomes  so  frequent  and 
urgent  as  to  seriously  interfere  with  the  administration  of  both  medi- 
cines and  nourishment. 

In  a  large  majority  of  cases,  however,  the  stomach  remains  quiet,  and 
usually  the  mind  free  from  disturbance  or  delirium.  In  cases  of  ordinary 
average  severity,  in  about  three  days  the  discharges  begin  to  change. 
The  mucus  presents  more  of  a  whitish  or  opaque  appearance,  and 
the  blood  is  more  intimately  intermixed  with  it.  The  quantity 
passed  each  time,  also,  is  larger,  while  the  passages  are  a  little  less  fre- 
quent. With  this  change  in  the  appearance  of  the  discharges  to  a  more 
rnuco-purulent  character,  the  skin  becomes  less  hot,  the  mouth  a  little 
less  dry,  and  if  there  has  been  a  coat  upon  the  tongue  it  begins  to  disap- 
pear, especially  along  the  edges,  and  the  patient  gets  longer  intervals  of 
rest,  between  the  paroxysms  of  pain  or  griping,  either  with  or  without 
the  intestinal  discharges.  In  those  cases  tending  toward  a  favorable  re- 
sult, the  changes  I  have  just  mentioned  become  more  and  more  promi- 
nent, until  about  the  fifth  or  sixth  day,  when  the  discharges  will  begin  to 
■lose  their  mucous,  or  muco-puruient  character,  and  to  present  more  of 


SYMPTOMS.  555 

an  intermixture  ot  orJinary  fa3ces.  The  urinary  secretion  which  had  pre- 
viously been  very  scanty,  and  often  passed  with  pain,  now  becomes  freer 
than  usual,  and  is  passed  with  ease.  The  temperature,  also,  will  be  found 
to  have  returned  nearly  to  the  natural  standard  and  the  mouth  to  have  be  ■ 
come  quite  free  from  dryness.  The  tenesmus  and  straining  at  stool  now 
rapidly  diminish  and  the  discharges  from  this  time  on  grow  less  and  less 
frequent,  until  by  the  end  of  the  week  from  their  beginning,  or  at  the 
longest,  the  middle  of  the  second  week,  there  will  be  no  longer  any- 
thing of  a  dysenteric  character. 

Those  cases  of  dysentery,  of  moderate  or  average  severity,  will  thus 
be  found  to  run  their  course  to  convalescence,  in  from  seven  to  nine  days; 
and  they  will  often  do  this  with  no  medication  whatever.  This  was 
proven  by  the  clinical  observations  of  Dr.  A.  Flint,  Sr.,  in  1875,  who  re- 
ported the  management  of  ten  cases  of  acute  dysentery  of  ordinary, 
•average  severity,  that  were  allowed  to  run  their  course,  wholly  independ- 
ent of  any  medication;  under,  of  course,  good  regulation  of  the  diet, 
drinks,  and  everything  of  a  sanitary  character.  These  ten  cases  were 
found  to  reach  a  spontaneous  termination  in  convalescence  in  different 
periods  of  time;  but  the  average  time  of  the  whole  number  was  from  eight 
to  nine  days.  While  it  is  true  that  the  milder  cases  of  dysentery,  whether  of 
sporadic  or  endemic  prevalence,  are  thus  inclined  to  terminate,  within 
from  seven  to  ten  days  on  an  average,  spontaneousiv,  it  is  equally 
true  that  the  severer  class  of  cases,  perhaps  occurring  at  the  same  seasons, 
intermingled  in  the  same  communities,  if  left  to  themselves,  will  run  a 
much  more  dangerous  course,  and  yield  a  large  ratio  of  deaths. 
AVhen  cases  of  this  class  are  left  to  their  own  course,  they  begin 
■with  the  same  symptoms  I  have  described  in  all  respects,  except  perhaps 
developing  more  suddenly  with  less  prodromic  stage,  and  wlien  developed, 
exhibiting  more  urgency  in  the  frequency  of  the  discharge,  and  a  greater 
degree  of  tenesmus  and  more  severe  griping  pains.  The  pulse  at  the  be- 
ginning is  more  accelerated  often  ranging  from  a  hundred  to  a  hundred 
and  twenty  per  minute,  the  temperature,  sometimes  even  in  bad  cases, 
remaining  low  or  only  a  little  above  the  normal  standard,  but  in  others 
rising  on  the  second  or  third  day  to  40°  or  40.5°  C.  (104°  or  105°  F.)  with 
the  skin  dry,  and  a  continuation  of  nausea,  depression,  dryness  of  the 
mouth  and  lips.  The  putient  feels  a  great  sense  of  prostration,  with 
much  distress  at  the  epigastrium,  and  generally  a  troublesome  inclination  to 
vomit.  These  more  severe  cases  present  the  same  succession  of  changes 
in  the  evacuations  as  I  have  alrendy  described. 

But  after  the  first  three  days,  the  quantity  of  muco-purulent  material 
becomes  increased,  presenting  more  of  a  yellowish  color,  and  the  blood  in- 
termingled With  it  is  of  a  darker  hue;  the  urine  at  the  same  time  becoming 
very  scanty,  is  often  almost  as  painful  in  its  passage  as  are  the  dysenteric 
discharges.  The  patient  suffers  all  the  symptoms  of  extreme  prostration, 
not  infrequently  the  extremities  become  cold  and  bluish,  the  mind  is  wan- 
dering, the  pulse  soft,  small,  almost  thready  at  the  wrist,  and  the  respirations 
are  irregular  and  sometimes  sighing.  Such  cases,  if  not  modified  by  treat- 
ment, are  very  liable  between  the  fifth  and  the  seventh  days  to  present 
evacuations  of  a  verj'  thin  dnrk  brown  or  reddish  brown  color,  emitting 
an  offensive  or  putrid  odor,  in  which  if  closely  examined,  may  be  found 
shreds  and  patches  of  the  mucous  membrane,  sometimes  from  one  to  two 
inches  in  length.  These  discharges  are  not  so  frequent  as  at  first,  but 
much  larger  in  quantity,  and  soon  become  involuntary,  or  at  least  par- 
tially so.  Occasionally  it  will  happen,  at  this  stage,  when  the  discharges 
have  become  almost  involuntary,  and  the  patient  greatly  prostrated,   that 


556  ACUTE    DYSENTERY. 

a  larger  intermixture  of  blood  will  appear;  or  a  true  hemorrhage;  followed 
very  speedily  by  oomDlete  collapse  and  death.  The  most  acute  and  rap- 
idly progressing  cases,  often  of  the  sthenic  variety  of  the  disease,  are 
those  reaching  a  fatal  termination  between  the  fifth  and  seventh  days; 
but  the  great  majority  of  cases  that  terminate  fatally,  do  not  do  so 
until  the  middle  or  latter  part  of  the  second  week,  and  in  some  instan- 
ces, not  until  the  end  of  the  third  week.  If  they  continue  be3'ond  this,  it 
is  usually  in  the  chronic  form,  on  account  of  the  extensive  ulcerations  left 
from  the  disintegration  and  sloughing  of  the  mucous  membrane;  and  al- 
though they  may  terminate  ultimately,  in  death,  yet  where  of  the  chronic 
form,  the  duration  may  be  many  weeks. 

The  symptoms  of  the  periodical,  or  malarious  form  of  dvsentery,  differ 
from  the  group  of  cases  I  have  just  described,  chiefly  in  two  particulars; 
namely:  in  the  mode  of  beginning,  and  periodicity.  Almost  all  of  this 
class  of  cases,  after  a  period  of  perhaps  one  or  two  days  of  moderate  loose- 
ness of  the  bowels  or  slight  diarrhoea,  begin  the  active  dysenteric  symp- 
toms abruptly  by  a  chill,  usually  of  Itrief  duration,  but  sufficient  to  be 
easily  recognized.  The  chill  is  ini mediately  followed  by  a  general  fever, 
usually  of  an  active  type,  and  directly  associated  with  all  the  local 
phenomena  of  severe  dysentery;  such  as  severe  pains  in  the  loins  and 
sacral  region,  sharp  cuttiria:  pains  through  the  abdomen,  frequent  desire  to 
evacuate  the  bowels,  the  character  of  the  evacuations  being  similar  to 
■what  I  have  previously  described,  and  the  temperature  almost  always 
higher  than  in  the  other  class  of  cases.  Indeed,  the  dysenteric  phenom- 
ena, and  the  general  fever  in  this  class  of  cases,  usually  present  a  very 
active  and  severe  gr  ide,  leading  the  practitioner,  if  he  first  comes  to  the 
case  in  the  paroxysm,  to  suppose  the  patient  has  a  very  severe  and  danger- 
ous attack.  But  this  intense  activity  in  the  symptoms  usually  continues 
from  five  to  twelve  hours,  when  it  begins  to  decline;  and,  in  a  short  time 
all  the  active  phenomena  have  ceased,  the  temperature  falls  nearly  to  the 
natural  standard,  and  in  many  instances  a  slight  moisture  appearing  upon 
the  surface,  the  patient  falls  into  a  quiet  sleep. 

This  remission  in  the  symptoms  continues  until  the  same  period  of 
time  in  the  twenty-four  hours  at  which  the  first  chill  occurred,  when  the 
symptoms  of  dysentery  and  fever  both  reappear, — usually,  however,  with- 
out a  marked  chill,  but  the  dysenteric  symptoms  and  the  general  fever  both 
present  as  much  severity  as  in  the  first  paroxysms,  and  continue  longer 
before  the  next  remission.  We  thus  have  a  true  periodical  or  exacerbat- 
ing type  of  dysentery.  If  appropriate  treatment  is  neglected,  each  return- 
ing paroxysm  reduces  the  patient's  strength,  and  usually  is  more  protracted 
than  the  previous  one,  until  at  the  end  of  five  or  six  days,  the  remissions 
are  much  less  distinct  than  at  first,  and  the  dysenteric  discharges  are  con- 
tinued but  not  with  an  equal  degree  of  activity  through  the  whole  twenty- 
four  hours.  In  a  majority  of  the  cases  the  coating  upon  the  tongue  becomes 
dry,  and  more  brown,  the  abdomen  tender  to  pressure,  the  pulse  soft,  com- 
pressible and  frequent.  The  urine  is  scanty.  The  mind  of  the  patient  often 
wanders  during  the  height  of  the  exacerbation,  but  is  clearer  during  the  rest 
of  the  time.  The  discharges  change  as  in  any  other  case  of  dysentery  from 
a  jelly-like  mucus,  streaked  with  blood,  to  a  muco-purulent  character,  and 
if  not  terminated  by  the  end  of  the  first  week,  almost  always  become  more 
copious  but  less  frequent,  and  when  reddish  brown  contain,  on  close  ex- 
amination, shreds  such  as  were  previously  mentioned,  indicating  disintegra- 
tion and  sloughingof  portions  of  the  mucous  membrane,  and  not  infrequent- 
ly, are  pretty  copiously  intermixed  with  dark  blood,  and  yield  a  decidedly  of- 
fensive or  putrid  odor.  When  such  cases  are  allowed  to  continue  two  weeks, 


SYMPTOMS.  557 

or  inoro,  they  end  in  entire  prostration,  involuntary  discharges,  collapse 
and  death.  In  this  class  of  cases,  there  appears  to  occur  more  or  less 
congestion  of  the  liver,  and  of  the  spleen,  indicated  by  an  increased  area  of 
dullness  on  percussion  over  the  hypochondriac  regions,  and  sometimes 
by  the  projection  of  the  edges  of  the  organs  below  the  margins  of  the 
ribs.  In  hot  climates  inflammation  of  the  interior  of  the  liver  is  very  apt 
to  occur,  terminating  in  suppuration  and  a  hepatic  abscess  ;  sometimes 
there  will  be  oidy  a  single  abscess,  but  more  frequently  a  number  of  them 
in  the  hepatic  structure.  It  is  comparatively  rare  that  a  hepatic  abscess 
forms  in  connection  with  dysentery  in  the  temperate  climates,  yet  cases 
do  occasionally  occur  in  this  and  all  other  countries.  Not  less  than  four  or 
five  cases  have  come  under  my  observation.  Three  of  those,  however, 
took  place  after  the  dysenteric  disease  had  assumed  a  chronic  form. 
The  symptoms  of  the  third  form  of  dysentery,  or  that  which  I  have  de- 
nominated asthenic  or  typhoid,  differ  from  both  of  the  others,  more  partic- 
ularly in  the  character  of  the  discharges,  and  in  the  grade  of  continued 
fever.  It  is  seldom  that  the  symptoms  are  ushered  in  by  a  chill,  but 
most  frequently  commence  with  thin  diarrhoeal  discharges,  not  more 
than  two  or  three  for  the  first  day,  but  increasing  the  second,  and  becom- 
ing more  decidedly  of  a  dysenteric  character,  that  is,  consisting  mostly  of 
a  bloody  serum,  instead  of  mucus,  streaked  with  blood.  In  these  cases 
the  discharges  will  usually  vary  in  quantity  from  sixty  culiic  centimeters 
to  two  hundred  and  sixty  (fl.  rii  to  ^viii).  The  discharges  are  accom- 
panied by  less  acute  and  distressing  pains  across  the  abdomen,  consid- 
erable tenesmus,  although  not  as  acute  and  seveie  as  in  the  more  active 
or  sthenic  grade  of  the  disease.  From  the  beginning  the  patient  has  a 
dull,  heavy  expression  of  countenance,  often  suffused  with  dark  redness, 
the  temperature  is  then  seldom  more  than  37.7°  to  39°  C.  (100°  to 
102°  F.);  the  pulse  is  soft,  easily  compressed,  in  some  cases  much  accel- 
erated in  frequency,  and  in  others  preternaturally  slow,  with  occasional 
intcrmittence. 

The  patients  of  this  class  are  much  less  restless  and  uneasy  than  those 
suffering  from  the  acute  form  of  dysentery.  The  discharges  are  seldom  as 
frequent,  but  being  larger  in  quantity,  and  an  intermixture  of  serum  aiid 
blood,  the  latter  usually  of  a  dark  color,  they  undergo  loss  of  strength 
more  rapidly  than  in  either  of  the  other  forms  of  the  disease.  In  the  most 
severe  cases  of  this  class,  such  as  I  met  with  often  during  the  cholera 
epidemics  from  1849  to  1854,  and  again  in  1866,  the  disehRrges  of  bloody 
serum  were  sufficiently  copious  and  frequent  to  prostrate  the  patient  al- 
most as  rapidly  as  the  regular  attacks  of  epidemic  cholera.  Alter  the 
first  twenty-four  hours  the  discharges  were  not  only  considerable  in  quan- 
tity, and  largely  intermixed  with  blood  of  a  dark  hue,  Vjut  there  were  many 
specks  or  flakes  of  a  whitish  color  floating  in  the  Vjloody  serum,  giving  to 
the  whole  mass  much  the  appearance,  in  some  instances,  of  the  Avater  in 
which  bloody  pieces  of  lean  meat  had  been  washed.  Some  of  these  cases, 
if  not  promptly  influenced  by  judicious  treatment,  failed  so  rapidly  as  to 
cause  entire  prostration,  involuntary  intestinal  discharges,  suppression  of 
urine,  cold  extremities,  dull,  drowsy  condition  of  mind,  and  finally  entire 
collapse  and  death  at  the  end  of  the  third,  or  during  the  fourth  day.  The 
larger  number  of  fatal  cases,  however,  terminated  between  the  fifth  and 
seventh  days.  This  is  a  much  more  fatal  form  of  dysentery  than  either 
of  the  o^her  varieties.  Still  it  varies  greatly  in  its  severity  in  different 
seasons  and  in  different  localities,  much  depending  upon  the  previous  tone 
and  health  of  the  individuals  attacked,  and  still  more  upon  the  sanitary 
surroundings  in  which  they  are  placed.     The   first  time   I   met  this   form 


^5$  DYSENTERY. 

of  dysentery  was  in  1849,  during  the  severe  epidemic  of  cholera 
that  prev^ailed  in  this  country  in  the  summer  of  that  year.  I  was 
then  a  resident  of  New  York  city.  The  cases  began  to  occur  about  the 
time  the  epidemic  of  cholera  reached  its  climax;  became  more  frequent 
as  the  epidemic  declined,  and  the  attacks  of  dysentery  continued  to  re- 
cur for  some  three  or  four  weeks  after  those  of  cholera  had  ceased. 

Moving  from  New  York  to  Chicago  in  the  latter  part  of  that  season,  I 
met  with  moderate  epidemics  of  cholera,  in  the  latter  city,  during  the 
summers  of  1850,  'ol,  '53,  and  a  very  severe  epidemic  in  '54.  Again,  a 
moderate  epidemic  prevailed  in  this  city  as  well  as  in  other  parts  of  the 
country  in  1866.  In  all  these  seasons,  I  saw  cases  of  this  typhoid  or  as- 
thenic type  of  dysentery,  more  strongly  marked  than  I  have  seen  at  any 
other  periods  of  time.  Yet  but  few  seasons  have  passed  during  the  whole 
of  my  residence  in  this  city  that  I  have  not  met  with  some  cases  of 
dysentery  that  presented  the  characteristics  of  this  particular  grade.  In 
most  of  the  seasons  they  have  been  limited  to  patients  who  were  occupy- 
ing badly  ventilated  rooms,  or  exposed  to  atmospheres  contaminated  by 
accumulations  of  animal  and  vegetable  matters  undergoing  decomposi- 
tion, as  in  unclean  alleys,  in  rear  houses,  or  in  places  in  which  they  were 
using  water  more  or  less  contaminated  with  organic  matter  derived  from 
percolation  through  the  surface  soil.  In  connection  with  armies,  dysen- 
tery is  not  infrequently  found  to  prevail  under  circumstances  in  which 
another  element  is  exerting  an  influetjce:  namely,  scorbutus  or  scurvy. 
During  the  civil  war  in  this  country,  there  were  some  instances  in  which 
portions  of  the  army  were  subject  to  a  decidedly  scorbutic  influence,  at 
the  same  time  they  were  occupying  a  malarious  region  and  also  sur- 
rounded by  more  or  less  of  the  causes  that  produce  typhoid  fever.  It  may 
be  said  that  the  causes  of  typhoid  fever,  malarious  fever,  and  scorbutus 
were  acting  coincidently.  Under  such  circumstances,  the  occurrence  of 
dysentery  proved  to  be  one  of  the  most  intractable  forms  of  acute  disease 
that  the  members  of  the  medical  staff  had  to  encounter.  Of  all  those 
who  were  invalided  and  sent  to  the  North  for  more  favorable  conditions 
of  recovery,  none  were  found  more  difficult  of  management  and  restora- 
tion to  health,  than  the  cases  of  chronic  dysentery  that  had  originated 
under  the  combination  of  influences  I  have  just  mentioned.  All  the 
forms  of  dysentery  I  have  described  are  liable  either  to  terminate  spon- 
taneously in  recovery  in  from  one  to  three  weeks,  or  to  proceed  to  a 
fatal  termination  within  the  same  limits  of  time,  or  to  become  moderated 
in  severity,  and  continue  in  a  chronic  form  for  an  indefitiite  period. 
Cases  of  dysentery  are  met  with  among  children  particularly,  every 
summer,  which  follow  attacks  of  cholera  morbus  and  serous  diarrhoea. 
Although  secondary  to  the  choleraic  attack,  yet  after  having  assumed  the 
characteristics  of  dysentery,  their  tendency  and  general  progress  are 
similar  to  those  I  have  already  described. 

Anatomical  Changes. — The  appearance  of  the  mucous  membrane  af- 
fected with  dysenteric  inflammation  varies  much  in  different  cases,  more 
particularly  on  account  of  the  differences  in  the  intensity  of  the  inflam- 
matory process.  In  all  cases  in  the  first  stage,  the  membrane  is  intensely 
injected  with  blood,  giving  it  various  shades  of  redness,  from  a  bright 
red  color  to  a  dark  brown,  and  when  it  has  proceeded  to  a  fatal  termina- 
tion, usually  causing  decided  softening  and  impairment  of  the  texture- 
In  those  cases  which  have  been  denominated  simple  or  catarrhal  inflam- 
mation, the  parts  of  the  membrane  affected  most  are  the  folds  and  parts 
containing  the  glandular  structures.  In  addition  to  the  various  shades 
of  deep  redness,  the  membrane  is  tumefied  or  swollen,  altered  in  various 


ANATOMICAL    CHANGES.  559 

der^reos  in  its  texture,  perhaps  always,  in  acute  cases,  in  the  direction  of 
softening;  the  submucous  tissue  much  infiltrated  with  liquor  sanguinis, 
containing  plenty  of  leuc(?cytes  or  white  corpuscles,  and  in  some  instances 
small  points  of  red  corpuscles,  or  slight  extravasations  of  blood.  In 
some  instances  these  changes  also  exist  in  the  muscular  coat,  but  in  a  less 
degree.  The  mucous  membrane  itself  contains  numerous  lymphoid  cells, 
pus  corpuscles  and  fibrinous  exudate,  not  only  filling  the  interstitial 
spaces  of  the  membrane,  but  obstructing  the  tubules  and  follicles  in  some 
places  to  such  an  extent  as  to  cause  necrosis  and  sloughing  of  the  super- 
ficial layers  of  the  structure;  thus  giving  to  the  more  intensely  inflamed 
portions  of  the  membrane  the  appearance  of  irregular  and  more  or  less 
extensive  ulcerations.  In  the  grade  of  inflammation  which  has  been 
called  diphtheritic,  the  disease  invades  the  tissue  more  deeply,  and  in- 
stead of  being  limited  largely  to  the  prominent  folds  of  the  mucous  mem- 
brane, it  permeates  as  extensively  the  base  of  these  folds  or  the  whole 
membrane  continuously,  and  causes  a  greater  degree  of  tumefaction  on 
account  of  the  more  copious  infiltration  into  the  submucous  tissue,  and 
in  some  instances  into  the  muscular  coat,  and  leads  to  a  larger  amount  of 
fibrinous  exudation  into  the  interstitial  spaces,  both  of  the  submucous 
tissue  and  of  the  mucous  membrane  proper.  Under  the  microscope,  you 
have  the  appearance  of  lymphoid  cells,  or  white  corpuscles  and  pus  glob- 
ules interspersed  with  more  or  less  of  tibrillated  fibrin.  These  substances 
fill  up  more  or  less  closely  the  interstitial  spaces,  and  in  some  places  crowd 
upon  the  tubules,  and  block  the  vessels  so  much  as  to  cause  more  exten- 
sive necrosis  and  sloughing  of  the  mucous  membrane  than  in  the  catar- 
rhal cases,  and  leave  det^p,  irregular  ulcerations  on  a  large  part  of  the  sur- 
face. 

Not  infrequently  in  those  portions  of  the  membrane  where  the  changes 
of  structure  have  been  greatest,  the  inflammatory  process  extends  through 
to  the  peritoneal  coat,  causing  its  outer  surface  to  be  injected  with  blood, 
sometimes  covered  with  fibrinous  ex\idation,  by  which  adhesions  are  formed 
between  coils  of  the  intestine.  Cases  have  occurred  in  which  the  ulcers 
have  extended  through  the  peritoneum,  permitting  more  or  less  of  the 
contents  of  the  intestine  to  escape,  and  yet  the  coincident  fibrinous  ad- 
hesions prevent  the  difi"asion  of  the  matter  into  the  general  cavity  of  the 
peritoneum  and  lead  to  a  circumscribed  abscess.  In  other  instances  the  ad- 
hesions not  limiting  the  diffusion  of  the  feecal  matter,  general  peritonitis, 
speedy  collapse,  and  death  has  followed.  While  in  nearly  all  cases  of 
acute  and  subacute  inflammation  of  the  colon  and  rectum  whether  of  the 
catarrhal,  croupous  or  diptheritic  grade,  the  membrane  undergoes  soften- 
ing disintegration,  or  sloughing  and  ulceration  to  a  greater  or  less  degree, 
in  the  chronic  form  of  the  disease,  the  submucous  tissue  becomes  infil- 
trated with  more  plastic  material  and  the  mucous  membrane  itself  be- 
comes more  or  less  indurated  and  thickened,  while  its  appearance  is  ren- 
dered very  unequal  and  ragged  with  ulcerations  varying  from  the  most 
superficial  to  those  penetrating  deeply  into  the  tissues.  Some  cases  of 
the  acute  form  of  dysentery  have  occurred,  in  which  in  limited  portions 
of  the  intestines  more  especially  in  the  sigmoid  flexure  and  upper  portion 
of  the  rectum,  deep  and  extensive  ulcers  have  formed  from  the  sloughing 
of  the  tissues,  and  yet  convalescence  has  followed,  and  tliese  deep  and 
large  ulcers  have  Ultimately  been  repaired  by  granulation  and  cicatriza- 
tion. But  the  cicatrices,  and  cicatricial  tissue  here,  as  in  most  other  struct- 
ures of  the  body  contract  after  the  cicatrices  have  been  completed;  and 
in  doing  so,  they  have  caused  permanent  alterations  in  the  caliber  of  the 
intestine,  by  projecting  like   bands  across   portions  of  its  diameter,  and 


06D  DYSEN^TEEY. 

sometimes  to  =o  f^reat  an  extent  as  to  constitute  strictures  that  seriously 
obstruct  the  passages  of  the  bowels.  Such  cases,  although  the  patients 
recover  for  a  time,  are  extremely  liable  to  be  followed,  sooner  or  later, 
by  the  setting  up  of  chronic  inflammation  above  these  strictured  portions, 
where  the  faeces  are  kept  lodged  an  undue  length  of  time,  and  always  to 
give  much  annoyance  in  the  procurement  of  regular  evacuations.  I  have 
a  patient  now  under  observation,  seriousl}-  annoyed  by  a  stricture  dimin- 
ishing the  caliber  of  the  intestine  more  than  one  half,  situated  just  at 
the  lower  portion  of  the  sigmoid  flexure,  which  resulted  from  a  severe 
attack  of  acute  dysentery  some  fifteen  years  since.  The  onlv  Avav  bv 
■which  she  can  be  rendered  comfortable  is  to  secure  just  that  degree  of 
relaxation  of  the  bowels,  by  which  the  fgeces  are  rendered  serai-fluid. 

iJiagnosis. — The  symptoms  which  I  have  described  as  characterizing 
the  different  stages  in  the  progress  of  acute  and  subacute  dysentery  are 
so  characteristic  in  their  nature  as  to  render  the  diagnosis  of  the  disease 
comparatively  easy.  From  inflammation  of  the  membrane  lining  the  small 
intestines,  it  is  distinguished  by  the  greater  amount  of  pain,  especially 
tenesmus,  and  the  more  decidedly  mucous  discharges,  almost  always  more 
or  less  intermixed  with  blood.  The  only  two  other  conditions  which 
might  possibly  be  mistaken  for  dysentery,  are  habitual  constipation  in 
which  the  sigmoid  flexure  and  portion  of  the  rectum  have  been  allowed 
to  become  filled  with  hardened  faeses,  causing  local  irritation  in  the 
rectum.  These  cases  are  to  be  differentiated  from  true  dj^sentery,  first 
by  carefully  inquiring  as  to  the  preceding  condition  of  the  patient;  which 
would  develop  the  fact  that  the  bowels  had  been  not  only  habitually 
costive,  but  probably  that  there  had  been  no  faecal  evacuations  for  sev- 
eral days  before  the  irritation  in  the  rectum  was  manifest;  and  secondly, 
by  direct  examination  of  the  rectum,  which  would  disclose  the  fact  that 
it  was  filled  with  impacted,  or  hardened  fgeces.  The  other  morbid  con- 
dition which  may  simulate  in  some  respects  d^^senteric  sj^mptoms  is  the 
presence  of  inflamed  hemorrhoids,  or  piles.  Dilatation  and  sacculation  of 
the  hemorrhoidal  veins  constituting  one  form  of  hemorrhoids,  not  infre- 
quently are  accompanied  by  suflScient  inflammatory  action,  more  espe- 
cially when  some  of  the  more  dilated  vessels  get  strangulated  by  being  re- 
tained in  the  sphincter,  after  a  passage  of  the  bowels,  to  give  rise  to  much 
of  the  same  kind  of  feeling  or  desire  to  frequently  evacuate  the  bowels, 
with  sense  of  fullness  or  pressure  in  the  rectum  as  exists  in  dysentery. 
But  such  cases  are  seldom  accompanied  by  any  discharge  of  mucus, 
neither  will  there  usually  be  any  general  febrile  symptoms  or  disturbance 
of  the  appetite  and  secretions.  But  a  more  immediate  means  of  differ- 
entiating this  class  of  cases  will  be  in  the  direct  examination  of  the  rec- 
tum, thereby  ascertaining  the  existence  of  the  hemorrhoidal  tumors. 

Progyxosts. — The  prognosis,  in  acute  and  subacute  dysentery,  will  vary 
much  from  the  great  differences  in  the  severity  of  the  disease  in  different 
seasons,  and  especially  in  the  different  periods  of  its  epidemic  prevalence. 
A  ver}'  large  proportion  of  all  the  cases  of  sporadic  dysentery  have  a 
tendency  to  recovery,  and  consequently  the  prognosis  is  generally  fa- 
vorable. In  much  the  larger  proportion  of  cases,  in  those  seasons  when  it 
may  be  said  to  have  an  endemic  or  even  an  epidemic  prevalence,  the  in- 
flammation causes  so  much  destruction  of  the  mucous  membrane  as  to 
prevent  recovery.  Such  cases  will  usually  reach  a  fatal  termination  in 
from  one  to  two  weeks.  There  are  some  seasons  in  which  dysentery  pre- 
vails in  so  malignant  a  form,  that  more  than  one  half  of  all  the  cases 
terminate  fatally;  but  such  epidemics  are  rare.  Within  my  own  experi- 
ence I  have  met  with  no  season  of  its  prevalence  in  which  the  mortality 


TREATMENT.  561 

exceeded  one  in  ten  or  twelve  of  the  whole  number  coming  under  obser- 
vation. And,  with  the  exception  of  two  or  three  seasons  of  unusually 
severe  prevalence,  the  mortality  has  not  reached  one  in  twenty-five  or 
thirty  cases.  Such  as  have  terminated  fatally  have  usually  been  of  the 
class"^  I  have  denominated  typhoid,  occurring  among  those  who  are  sub- 
jected to  unfavorable  sanitary  influences,  and  who  generally  neglect  to 
secure  proper  medical  attendance  until  the  disease  has  made  considerable 
advancement. 

I'reatment. — Much  diversity  of  opinion  seems  to  exist,  even  at  the 
present  day,  among  writers  of  eminence,  in  regard  to  the  best  mode  of 
treatment  in  acute  and  subacute  attacks  of  dysentery.  Many  claim  that 
the  treatment  should  be  almost  invariably  commenced  by  the  administra- 
tion of  saline  cathartics,  sufficient  to  cause  free  evacuations  from  the  bow- 
els; others  recommend  oleaginous  cathartics,  as  castor  oil.  The  advantages 
claimed  for  the  administration  of  either  saline  or  oleaginous  laxatives, 
especially  the  first  in  the  commencement  of  dysenteric  inflammation,  are, 
first,  to  remove  supposed  retained  faeces,  or  other  irritating  matters  in  the 
alimentary  canal,  and  second,  to  deplete  the  congested  vessels  by  the  in- 
creased effusion  caused  by  the  operation  of  the  saline  class  of  cathartics. 
Even  those  writers  who  readily  assent  to  the  fact  that  nineteen-twentieths 
of  all  the  cases  of  dysentery  begin  with  diarrhoea,  and  thereby  show  con- 
clusively that  the  alimentary  canal  contains  no  hard  faeces,  or  accumula- 
tions of  any  kind  other  than  the  ordinary  secretions,  nevertheless  assent 
to  the  general  direction  to  commence  treatment  by  a  saline  laxative,  for 
the  purpose  of  making  sure  that  the  contents  of  the  bowels  have  been 
properly  evacuated. 

Another,  perhaps  smaller  class  of  writers,  advocate  with  the  most  de- 
cided confidence  the  commencement  of  treatment  by  the  administration 
of  large  doses  of  ipecac;  claiming  that  the  administration  of  from  one  to 
three  grams  (gr.  xv  to  xlv)  of  ipecac  in  a  single  dose  in  the  early  stage 
of  the  disease,  and  the  same  repeated  twice  in  the  twenty-four  hours,  will 
produce  the  most  decided  amelioration  in  the  condition  of  the  patient, 
and  modify  favorably  the  subsequent  progress  of  the  disease.  It  is  con- 
ceded, that  in  most  cases,  the  first  dose  will  produce  free,  often  copious 
vomiting;  but  it  is  claimed  that  the  subsequent  doses  will  be  retained, 
and  from  one  to  three  such  doses  retained  will  be  sufficient  to  cause  free 
faecal  evacuations  from  the  bowels,  apparently  containing  a  liberal  quan- 
tity of  the  coloring  matter  of  bile,  with  little  or  no  pain  at  the  time  of  the 
evacuation.  These  bilious  stools  are  sufficiently  characteristic  to  receive 
the  designation  of  ipecac  stools  ;  and  in  some  instances  they  have  ap- 
peared to  be  followed  by  a  rapid  subsidence  of  all  the  phenomena  of  in- 
flammation, and  an  early  recovery  of  the  patient.  In  hot  climates  where 
dysentery  is  more  severe  and  more  liable  to  proceed  to  an  early  fatal 
termination,  and  at  its  outset  involves  a  higher  grade  of  inflammatory 
action,  there  are  not  wanting  those  who  regard  a  free  venesection  at  the 
commencement  of  the  disease,  as  of  much  value  in  moderating  its  further 
progress.  My  own  experience  in  regard  to  the  use  of  large  doses  of  ipecac 
has  not  been  uniformly  favorable.  On  the  contrary,  in  a  majority  of  the 
cases  in  which  I  have  exhibited  it,  the  {:  itients  have  not  only  been  vom- 
ited freely  by  the  first  dose  but  equally  so  by  the  second  and  even  by  the 
third.  And,  in  two  or  three  instances,  the  stomach  remained  so  irritable, 
as  to  reject  subsequently  almost  everything,  in  the  way  of  either  medicine, 
drink,  or  nourishment,  and  apparently  was  the  cause  of  an  early  and  un- 
due degree  of  prostration.  In  some  other  cases,  after  the  first  dose,  the 
medicine  was  retained,  and  in  from  twelve  to  eighteen  hours,  free  char- 

36 


562  DYSENTEEY. 

acteristic  evacuations  from  the  bowels  followed,  with  much  relief  to  the 
sensations  of  the  patient,  but  the  relief  was  not  permanent.  In  from  six 
to  twelve  hours  the  intestinal  discharges  began  again  to  recur,  and  grad- 
ually assumed  more  and  more  of  the  characteristic  mucous  and  bloody 
appearance;  and  in  twenty-four  hours  more,  all  the  symptoms  of  the  dys- 
enteric disease  were  re-established,  almost  as  actively  as  before  the  ad- 
ministration of  the  remedy.  On  the  other  hand,  in  a  few  cases,  the  ipecac 
treatment  has  been  followed  by  the  most  satisfactory  results.  In  one 
case  of  a  very  acute  and  severe  character,  in  which  twenty-four  hours  had 
passed  before  I  saw  the  patient,  the  symptoms  indicated  a  case  of  the  utmost 
gravity.  I  directed  thirteen  decigrams  (gr.  xx)  of  ipecac  to  be  mixed  with  a 
little  svrup  and  taken  at  once,  and  the  same  to  be  repeated  in  six  hours. 
At  my  next  visit  I  found  that  both  doses  had  been  retained,  no  vomiting 
had  occurred,  and  the  tenesmus  and  frequent  desire  for  evacuation  had 
almost  entirely  ceased.  I  then  ordered  smaller  doses  to  be  continued 
every  four  hours,  and  during  the  next  twelve  hours  three  or  four  copious 
yellowish  brown  faecal  evacuations  occurred,  after  which  there  was  no  re- 
turn of  the  dysenteric  discharges,  and  the  patient  reached  a  very  early 
convalescence.  Another  was  a  case  of  dysentery  following  confinement, 
sometimes  called  puerperal  dysentery.  In  this  instance  the  stomach  was 
excessively  irritable,  and  would  neither  retain  ipecac  nor  any  other  med- 
icine. On  account  of  this  extreme  irritability  of  the  stomach,  I  caused 
ipecac,  combined  with  a  few  drops  of  the  tincture  of  opium  to  be  admin- 
istered per  rectum.  Three  grams  (gr.  xlv)  of  ipecac,  and  two  cubic 
centimeters  (min.  xxx)  of  the  tincture  of  opium  in  one  hundred  cubic 
centimeters  (fl.  fiii)  of  milk-warm  water,  were  administered  as  an  enema, 
the  parts  being  supported  for  a  few  minutes  after  the  withdrawal  of  the 
syringe,  and  the  whole  was  retained,  producing  entire  relief  from  suffering 
and  causing  the  patient  in  one  hour  to  fall  into  a  comfortable  sleep.  In 
about  three  hours,  what  was  left  of  this  enema  passed  off,  and  was  soon  fol- 
lowed by  moderate  tenesmus,  and  some  cutting  pains  across  the  abdomen. 
Another  enema  of  the  same  material  was  immediately  used.  This  was 
followed  by  the  same  entire  relief,  which  was  of  longer  duration  than  after 
the  first.  After  this  no  symptoms  of  returning  dysenteric  irritation  oc- 
curred for  twelve  hours.  Then  another  enema,  containing  only  half  the 
quantity  of  ipecac  and  tincture  of  opium  was  administered.  I  have  no 
doubt  but  there  are  cases,  if  we  could  discriminate  them  properly,  in 
which  the  administration  of  ipecac  in  the  beginning  of  the  disease — and 
the  earlier  it  is  done  the  better — would  be  followed  by  a  speedy  and 
entire  arrest  of  all  the  symptoms.  But  my  own  experience  has  led  me 
to  believe  that  a  large  majority  of  the  cases,  as  we  meet  with  them  in 
ordinarv  general  practice,  can  not  be  treated  as  successfully  in  this  way 
as  by  other  means.  The  distressing  vomiting  that  often  follows  the  first 
administration  of  the  ipecac,  is  not  compensated  for  by  any  degree  of 
permanency  in  the  relief  obtained;  and  unless  the  temporary  relief  is 
followed  up  by  other  medicines  calculated  to  secure  a  continuance  of  the 
result,  in  nearly  all  the  cases  the  effects  of  the  remedy  will  be  temporary 
in  their  duration. 

And  my  observation  has  shown,  that  the  same  remedies,  which  are  nec- 
essary to  secure  and  perpetuate  the  beneficial  results  of  the  ipecac,  will 
in  most  csa-es  quite  as  efficiently  secure  all  those  results,  if  administered 
without  the  ipecac.  In  regard  to  the  administration  of  cathartics  of  any 
kind,  saline  or  otherwise  as  the  initial  step  in  the  treatment  of  acute  dys- 
entery, I  have  become  satisfied  by  a  very  long  and  abundant  experience, 


TREATMENT.  563 

that  the  rule  gi\^en  by  most  writers  is  altogether  too  broad:  and  leads  to 
tlie  use  of  evacuant  remedies  not  only  when  unnecessary  but  often  when 
decidedly  injurious  to  the  patients.  It  must  be  remembered,  that  a  large 
majority  of  the  cases  commence  with  diarrhoea,  and  that  there  is  no  evi- 
dence whatever  of  the  retention  in  the  bowels  of  a  single  ball  of  hardened 
faeces,  nor  any  other  morbid  material,  except  the  products  of  the  inflam- 
mation itself.  Simply  removing  these  products,  without  modifying  the  in- 
flammation, is  merely  a  work  of  supererogation,  as  the  patient's  own  efforts 
at  stool,  every  ten,  twenty,  or  thirty  minutes,  evacuate  them  quite  as  fast 
as  they  are  formed.  My  rule  has  been,  when  called  to  a  case  of  dj^sen- 
tery,  uniformly  to  make  a  careful  inquiry  as  to  the  character  and  extent 
of  the  ffecal  evacuations  at  the  commencement,  and  for  one  or  two  davs 
prior  to  the  beginning  of  the  disease.  Whenever  it  appears  from  such 
inquiry  that  there  may  be  retained  faeces,  either  in  the  middle  of  the  in- 
testinal canal  or  in  any  part  of  the  colon,  and  especially  if  on  making 
careful  examination  by  palpation  over  the  abdomen  there  is  any  indica- 
tion of  fullness,  that  is  not  gaseous  but  fgecal  in  any  part  of  the 
course  of  the  colon,  I  do  not  hesitate  to  commence  treatment  with 
a  sufficient  amount  of  saline  laxatives  to  cause  one,  two,  and  sometimes 
three  free  evacuations  from  the  bowels.  But  as  I  have  intimated,  these 
inquiries  result  in  at  least  forty-nine  cases  out  of  every  fifty,  in  furnish- 
ing full  and  satisfactory  evidence,  that  there  are  no  retained,  or  accumu- 
lated faeces  in  any  part  of  the  alimentary  canal.  Consequently  in  all  such 
cases  I  proceed  directly  to  the  administration  of  such  remedies  as  will 
most  certainly  allay  pain  and  diminish  the  extreme  morbid  excitability  of 
the  inflamed  structures,  until  the  intestines  are  put  entirely  at  rest.  I 
usually  combine  the  anodyne,  which  is  required  for  this  purpose,  with 
such  alteratives  as  will  be  likely  to  moderately  excite  the  various  natural 
secretions  of  the  system;  more  especially  those  of  the  kidneys,  skin, 
and  other  important  glandular  structures.  If  it  be  within  the  first 
twenty-four  hours  after  the  commencement  of  the  attack,  and  the  skin  is 
dry,  the  temperature  somewhat  elevated,  the  desire  for  evacuations  fre- 
quent, the  urine  scanty,  I  have  generally  prescribed  a  powder  composed 
of  pulverized  opium  one  decigram  (gr.  iss)  nitrate  of  potassium  three 
decigrams  (gr.  v)  and  mild  chloride  of  mercury  six  centigrams 
(gr.  i),  to  be  taken  every  two  hours  until  the  pains  and  tenesmus  are 
relieved,  and  the  patient  inclined  to  sleep. 

In  those  instances  which  are  occasionally  met  with,  in  which  the  gen- 
eral febrile  actirn  is  more  active,  giving  a  temperature  of  39°  or  40°  C. 
(103°  or  104.5°  F.),  with  a  coating  upon  the  tongue,  and  much  thirst,  I 
have  given  between  these  powders  a  mixture  of  nitrous  ether  and  cam- 
phorated tincture  of  opium  each  forty-five  cubic  centimeters,  (fl.  fiss)  and 
tincture  of  veratrum  viride  four  cubic  centimeters  (fl.  3i),  in  doses  of  four 
cubic  centimeters  (fl.  3i)  diluted  with  a  little  water.  Under  these  influ- 
ences the  patient  usually  begins  to  feel  some  degree  of  relief  within  the 
first  six  or  eight  hours,  which  is  gradually  increased  with  each  renewed 
administration  of  the  medicines,  until  before  the  end  of  the  first  twenty- 
four  hours,  there  will  be  an  entire  suspension  of  all  the  more  severe  symp- 
toms, some  moisture  upon  the  skin,  and  the  patient  will  be  inclined  to 
sleep.  When  this  is  the  case  I  leave  out  the  mild  chloride  of  mercury 
from  the  powders,  and  extend  the  interval  between  the  time  of  their  ad- 
ministration to  four  hours  instead  of  two,  and  continue  the  liquid  prescrip- 
tion as  before,  between  the  doses  of  the  powders,  and  in  this  way  allow 
an  interval  of  twelve  or  eighteen  hours  to  elapse.  If  during  that  time 
the  bowels  have  remained  quiet,  without  further  discharges,  I  suspend  the 


564  DYSENTERY. 

use  of  the  powders  altogether,  and  give  an  enema  of  warm  water  to  be 
administered  in  suflficient  quantity  to  fill  up  the  rectum  well,  for  the 
purpose  of  provoking  moderate  evacuations  from  the  bowels.  In  the  great 
majority  of  instances  this  will  be  followed  within  half  an  hour  by  an  evac- 
uation, that  is  semi-fluid,  feecal,  and  usually  tinged  a  yellow  or  greenish 
color,  such  as  is  popularly  called  a  bilious  stool.  In  almost  all  instances 
this  will  be  followed  in  one  or  two  hours  by  another  evacuation  of  a  sim- 
ilar character.  This  will  be  accompanied  by  a  sense  of  relief  to  the  pa- 
tient, and  if  the  administration  of  medicine  is  now  allowed  to  remain  sus- 
pended, in  most  instances  another  discharge  will  follow  in  less  than  an 
hour,  containing  a  little  mucus,  and  accompanied  by  slight  griping  pains 
across  the  bowels.  If  not  interfered  with  the  passages  will  continue 
to  increase  in  frequency,  and  by  the  end  of  twenty-four  hours  from  the 
time  of  procuring  the  first  stools  the  patient  will  be  sufi'ering  from  a  return 
of  all  the  dysenteric  symptoms,  but  a  little  less  severe  than  at  first. 

This  result,  however,  can  be  prevented  usually,  and  should  be,  by  care- 
fully providing  the  patient  with  some  anodyne  medicine  to  be  t':iken 
immediately  after  the  second  evacuation  from  the  bowels.  One  of  the 
best  medicines  for  this  purpose  is  a  combination  of  the  aromatic  sulphuric 
acid,  sulphate  of  magnesia,  and  tincture  of  opium  mixed  with  water  in  the 
proportion  of  four  cubic  centimeters  (fl.  3')  of  each  of  these  ingredients 
to  thirty  cubic  centimeters  (fl.  ji)  of  water;  of  which  four  cubic  centi- 
meters (fl.  3i)  should  be  administered,  diluted  with  sweetened  water, 
immediately  after  the  second  fascal  evacuation  of  the  bowels.  The  same 
may  be  repeated  after  every  evacuation  until  the  bow^^ls  hav^e  again  be- 
come entirely  quiet.  In  a  great  majority  of  instances,  two  or  three  doses 
will  so  far  control  further  evacuations,  that  the  patient  will  be  very  com- 
fortable, and  the  discharges  will  not  occur  oftener  than  once  in  from  three  to 
four  hours.  And  in  three  or  four  days  they  will  have  assumed  an  entirely 
healthy  fascal  character,  and  there  will  not  be  more  than  one  or  two  in  the 
day;  in  other  words,  the  patient  will  have  reached  the  commencement  of 
convalescence.  It  is  seldom  that  the  veratrum  viride,  which  was  placed 
with  the  nitrous  ether  and  camphorated  tincture  of  opium  in  the  liquid 
prescription  is  needed  more  than  the  first  forty-eight  hours.  While  in  a 
large  majority  of  the  cases  of  ordinary  sporadic  dysenterj^,  the  remedies 
which  I  have  thus  far  indicated,  when  they  are  used  as  recommended, 
will  be  sufficient  to  guide  the  patient  to  an  early  convalescence,  you  will 
meet  with  many  cases,  especially  in  seasons  when  the  disease  is  prevailing 
in  the  more  severe  or  endemic  form,  in  which  the  inflammatory  action 
will  be  more  persistent.  In  such  cases  the  discharges  soon  assume  a  more 
distinctly  muco-purulent  character,  mixed  with  blood,  and  accompanied 
by  some  tenesmus  and  the  continuance  of  a  low  grade  of  febrile  action. 

Under  such  circumstances  I  have  found  no  remedy  equal  in  value  to 
the  emulsion,  containing  oil  of  turpentine,  oil  of  wintergreen  and  tincture 
of  opium  rubbed  together  thoroughly  with  gum  arable,  sugar  and  water, 
the  formula  for  which  I  have  given  you  when  speaking  of  the  treatment 
of  the  advanced  stage  of  typhoid  fever,  and  more  recently  in  the  same 
condition  of  inflammation  in  the  mucous  membrane  of  the  ileum  (see  p.  53;*) 
Four  cubic  centimeters  (fl.  3i)  of  this  emulsion  given  every  two,  three  or 
four  hours  to  an  adult  according  to  the  freqviency  of  the  evacuations,  will, 
in  a  large  majority  of  even  the  more  severe  cases,  produce  a  very  speedy 
and  decidedly  beneficial  effect  by  steadily  lessening  the  frequency  of  the 
discharges,  diminishing  the  amount  of  blood  in  them,  and  generally 
causing  their  entire  arrest  in  from  three  to  four  days.  The  doses  should 
be  given  frequently  at  first,  and  the  interval  lengthened  in  proportion  as 


TREATMENT.  566 

the  discharges  diminish,  thereby  limiting  the  latter  to  one  or  two  in  the 
twenty- four  hours,  until  they  become  natural  in  quality,  rather  than  en- 
tirely suppressed.  If  the  discharge  of  urine  is  painful,  as  is  often  the  case 
in  this  disease,  it  may  be  much  lessened  by  giving  between  each  of  the 
doses  of  the  emulsion  four  cubic  centimeters  (fl.  3i)  of  an  equal  mixture 
of  the  liquor  ammonii  acetatis  and  nitrous  ether.  If  the  pulse  is  decid- 
edly weak,  fifteen  minims  of  the  tincture  of  digitalis  may  be  added  to 
each  dose  of  the  liquor  ammonii  acetatis  mixture  with  much  benefit.  In 
children  and  sometimes  in  adults,  I  have  found  that  the  emulsion  con- 
taining turpentine  proved  more  or  less  offensive  to  the  stomach,  and  after 
taking  a  few  doses  was  rejected  by  vomiting.  In  other  instances  when 
it  has  not  been  rejected,  after  its  continuance  at  frequent  intervals  for 
three  or  four  days,  it  has  added  to  the  irritation  of  the  neck  of  the  blad- 
der, and  induced  symptoms  of  strangury.  When  either  of  these  circum- 
stances occur  it  should  be  discontinued,  and  in  its  place  I  give  a  gelatine 
capsule  containing  carbolic  acid,  pulverized  ipecac  and  pulverized  opium, 
in  such  proportions  that  each  capsule  will  contain  sixteen  milligrams 
(gr.  :j)  of  the  carbolic  acid,  twelve  centigrams  (gr.  ii)  of  the  ipecac, 
and  six  centigrams  (gr.  i)  of  the  opium.  A  pill  or  capsule  containing 
these  ingredients  may  be  given  to  an  adult  every  two,  three  or  four  hours 
until  the  discharges  are  arrested,  and  then  given  at  intervals  sufficient  to 
hold  them  in  check  until  the  inflammatory  action  has  subsided,  and  the 
discharges  returned  to  a  more  natural  character.  In  children,  the  ordi- 
nary carbolic  acid  mixture  may  be  given  (see  formula  p.  138)  in  doses, 
to  a  child  five  years  of  age  for  instance,  of  twenty  or  thirty  minims  every 
three  or  four  hours,  and  instead  of  having  any  tendency  to  nauseate  the 
stomach,  it  allays  nausea  when  it  already  exists,  and  sel,  om  fails  to  im- 
prove the  discharges,  both  in  their  frequency  and  their  quality.  If,  under 
the  influence  of  these  or  any  other  remedies  which  may  be  administered, 
the  dysenteric  disease  manifests  a  tendency  to  continue  and  assume  a 
chronic  form,  one  of  the  best  remedies  that  can  be  found  is  the  nitrate 
of  silver  in  combination  with  pulverized  opium  and  extract  of  hyoscya- 
mus  in  the  form  of  a  pill;  in  the  proportion  of  two  centigrams  (gr.  ■^) 
of  the  nitrate  of  silver,  and  six  centigrams  (ar.  i)  each,  of  the  extract 
of  hyoscyamus  and  pulverized  opium,  in  each  pill.  As  the  activity  of 
the  symptoms  has  already  abated,  and  the  disease  assumed  a  more  chronic 
form,  it  will  be  sufficient  to  give  one  of  these  pills  once  in  from  four  to 
six  hours. 

If,  when  given  at  these  intervals,  they  do  not  exert  the  necessary 
restraining  influence  over  the  frequency  of  the  discharges,  they  may  be 
aided  by  giving  moderately  full  doses  of  the  turpentine  and  laudanum 
emulsion  previously  alluded  to,  each  night  and  morning.  You  will 
notice  that  I  have  omitted  from  the  list  of  remedies  recommended  for 
the  management  of  acute  and  subacute  dysentery  all  the  more  active 
class  of  ordinary  astringents,  such  as  gallic  acid,  representing  the 
various  vegetable  astringents,  and  acetate  of  lead,  sulphate  of  alumin- 
ium, etc.,  representing  the  mineral  astringents.  I  have  done  this  pur- 
posely, because  my  own  clinical  experience  has  satisfied  me  that  they 
can  seldom  be  used  in  these  forms  of  the  disease  without  checking 
other  secretions,  at  the  same  time  that  they  temporarily  lessen  the  exu- 
dations from  the  mucous  membrane  of  the  colon  and  rectum;  and  con- 
sequently that  their  effects  as  a  whole  are  not  beneficial  to  the  patient. 
In  giving  the  clinical  history  of  dysentery,  I  mentioned  a  class  of  cases 
liable  to  occur  in  malarious  districts,  that  are  modified  in  their  progress 
by  the  coincident  action  of  malaria  upon  the  system,  especially  at  seasons 


0(i6  DYSENTERY. 

of  the  year  when  that  ai^eiit  is  mainly  exerting  an  influence  upon  the 
community.  The  only  decided  dift'ereiice,  however,  in  the  management  of 
that  class  of  cases,  from  the  ordinary  active  form  of  dysentery,  consists  in 
the  early  and  efficient  administration  of  quinine,  or  some  other  reliable 
antiperiodic,  in  addition  to  the  ordinary  remedies  addressed  to  the  local 
inflammatory  disease.  The  best  antiperiodic  for  this  purpose  is  undoubt- 
edly the  sulphate  of  quinine,  and  the  most  favorable  time  for  its  admin- 
istration is  at  that  part  of  the  twenty-four  hours  corresponding  with  the 
remission  in  the  febrile  paroxysms.  And  during  such  remission  it  is  de- 
sirable to  administer  the  quinine  in  such  doses,  that  from  twelve  to 
twenty  grains  shall  be  given  during  each  of  the  first  two  or  three  days. 
Subsequently  it  is  seldom  necessary  to  give  more  than  from  six  to  eight 
grains  in  the  twenty-four  hours  until  convalescence  is  established.  By 
simply  supplementing  the  ordinary  treatment,  as  I  have  given  in  detail, 
with  the  use  of  quinine,  or  any  efficient  substitute  of  an  antiperiodic  nature, 
you  will  be  able  to  control  nearly  all  the  cases  of  dysentery  in  malarious 
districts  that  come  under  supervision  at  an  early  period  of  their  progress. 

A  third  variety  of  dysenteiy,  or  distinct  class  of  cases,  was  described  as 
occurring  under  circumstances  and  sanitary  influences  such  as  favor  the 
development  of  typhoid  conditions  oi  the  system  and  giving  to  the  dys- 
entery a  distinctly  asthenic  grade  of  action,  from  the  beirinning.  In 
these  cases,  as  I  have  already  stated,  the  discharges  are  more  of  a  bloody 
serum  in  the  early  stage,  than  a  jelly-like  mucus.  The  pulse  is  softer, 
weaker  from  the  beginning,  and  the  whole  aspect  of  the  patient  is  that  of 
a  depressed  and  typhoid  condition.  Some  of  these  cases  tend  very  rap- 
idly to  extreme  exhaustion  and  early  collapse.  Consequently  they  require 
to  be  met  promptly  with  appropriate  remedies.  This  is  particularly  the 
case  during  the  seasons  when  the  disease  assumes  an  epidemic  character. 

When  called  to  this  class  of  patients,  if  I  find  the  discharges  quite 
large  in  quantity,  decidedly  serous,  tinged  with  dark  blood  and  recurring 
as  often  as  every  half  hour,  with  a  soft  compressible  pulse,  dingy  and 
depressed  appearance  of  the  countenance  I  usually  commence  treat- 
ment by  giving  a  powder  consisting  of  acetate  of  lead  thirteen  centi- 
grams (gr.  ii),  pulverized  opium  six  centigrams  (gr.  i.)  and  calo- 
mel three  centigrams  (gr.  ^),  every  four  hours,  and  four  cubic  centi- 
meters of  the  same  solution  of  aromatic  sulphuric  acid,  sulphate  of  mag- 
nesia, and  tincture  of  opium  that  I  have  previously  mentioned,  half  way 
between  the  powders;  causing  them  to  alternate  two  hours  apart — some- 
times oidy  an  hour  and  a  half  apart.  At  the  same  time  I  direct  an  ene- 
ma to  be  given  immediately  after  every  evacuation  from  the  bowels, 
containing  six  decigrams  (gr.  x)  of  acetate  of  lead  and  three  centi- 
grams (gr.  -A-)  acetate  of  morphia,  dissolved  in  two  ounces  of  cold 
water.  I  mean  literally  that  I  give  this  enema  immediately  after  each 
evacuation  from  the  bowels. 

If  the  patient  is  allowed  to  wait  ten  or  fifteen  minutes  after  an  evacua- 
tion, before  the  enema  is  administered,  time  enough  will  have 
elapsed  to  have  caused  more  or  less  accumulation  of  the  bloody  serum 
in  the  rectum,  together  with  the  abiLty  of  the  muscular  coat  of  the  intes- 
tine again  to  take  on  peristaltic  or  expulsive  action,  and  the  enema,  if 
then  given  will  be  promptly  forced  back.  But  if  the  materials  are  ready, 
and  the  enema  is  administered  as  soon  as  the  patient  has  finished  his  evac- 
uation, and  returned  to  a  recumbent  position,  and  as  the  pipe  of  the 
syringe  is  withdrawn,  the  anus  is  supported  for  a  few  minutes,  by  pressing 
the  nates  together  or  supporting  it  with  a  napkin,  it  will  very  frequently 
be  retained  long  enough  to  exert  a  very  important  influence,  in  aiding  to 


TREATMENT.  .    567 

suppress  this  class  of  discharges.  I  have  kiiowa  some  very  severe  cases 
of  this  disease  to  be  controlled,  by  the  combined  influence  of  medi- 
cines given  by  the  mouth  and  rectum,  so  promptly  that  the  patients 
were  placed  at  the  end  of  the  first  twenty-four  hours  in  a  comparatively  safe 
condition.  If  these  means  succeed  in  actually  arresting  the  disciiarges,  it  is 
desirable  that  the  doses  be  simply  given  at  longer  intervals,  so  as  to  main- 
tain the  effect  until  the  bowels  have  remained  quiet  for  at  least  twenty- 
four  hours.  If  no  evacuations  occur  during  that  period  of  time,  all  reme- 
dies containing  anodynes  may  be  suspended,  and  the  patient  allowed  to 
take  small  quantities  of  properly  prepared  wheat  flour  and  milk  gruel  at 
intervals  of  half  an  hour  or  an  hour,  with  perhaps  a  tablespoonful  of 
strong  tea  or  coffee,  either  with  or  after  the  doses  of  the  gruel,  until 
eighteen  hours  more  have  passed,  during  which  in  a  very  large  proportion 
of  the  cases,  evacuations  will  have  returned.  Not  as  at  first,  however, 
but  more  of  a  semi-fluid,  or  ftecal  character,  though  sometimes  a  little 
tinged  with  blood;  and  the  first  one  or  two  unaccompanied  by  pain.  If 
such  evacuations  occur  spontaneously,  immediately  after  the  second  move- 
ment of  the  bowels,  the  solution  of  aromatic  sulphuric  acid,  sulphate  of 
magnesia  and  tincture  of  opium  should  be  resumed,  and  the  doses  should 
be  repeated  now  after  every  evacuation;  or  if  no  further  evacuations 
occur,  once  in  about  four  hours,  for  two  or  three  days.  If  the  urinary 
secretion  has  been  scanty,  it  will  be  profitable  to  give  the  patient  between 
the  doses  of  the  last  named  medicine,  either  a  teaspoonful  of  the  nitrous 
ether  diluted  with  water,  or  an  equal  quantity  of  the  nitrous  ether  and 
liquor  ammonii  acetatis.  If  the  pulse  be  quite  weak  and  soft,  it  will  be 
proper  to  add  from  ten  to  fifteen  minims  of  the  tincture  of  digitalis,  to 
each  of  the  doses  of  the  diuretic.  I  have  seen  many  of  the  cases,  of  what 
are  termed  typhoid  dysentery,  as  promptly  arrested  by  this  method  of 
treatment  as  the  ordinary  cases  are,  by  the  treatment  recommended  for 
them. 

But  when  cases  are  not  brought  under  treatment  until  the  disease  has 
progressed  one  or  two  days,  or  if  the  remedies  as  used,  fail  to  control  the 
progress  of  the  discharges,  and  the  patient  becomes  more  decidedly  ex- 
hausted, as  indicated  by  a  very  soft,  weak  pulse,  cold  and  leaden  hue  of 
the  extremities,  sunken  eyes,  torpid  or  wandering  condition  of  the  mind, 
partial  loss  of  control  over  the  sphincters,  so  that  the  bed  is  frequently 
soiled  before  the  patient  can  give  warning  of  the  desire  to  evacuate  the 
bowels,  I  have  found  no  remedy  or  combination  of  remedies,  that  has 
been  equally  valuable  with  that  of  strychnia,  nitric  acid,  and  tincture  of 
opium;  a  convenient  formula  consisting  of  strychnia,  six  centigrams 
(gr.  i),  nitric  acid,  four  cubic  centimeters  (fl.  3i),  tincture  of  opium  fifteen 
cubic  centimeters  (fl.  3iv)  simple  syrup  and  water  a  hundred  and  twenty 
cubic  centimeters  (siv).  Of  this,  four  cubic  centimeters  (fl.  3i)  diluted 
with  additional  water,  may  be  given  at  first  every  two  hours.  And  at 
the  same  time  injections  may  be  given  either  of  the  acetate  of  lead 
and  morphia,  as  previously  recommended,  or  gallic  acid  and  tincture  of 
opium,  and  repeated  under  the  same  regulations  as  mentioned  before. 
In  addition  to  the  medicines,  these  cases  should  also  be  sustained  by  giv- 
ing at  least  twice  between  each  of  the  doses  of  the  strychnia  solution  one 
or  two  tablespoonfuls  of  the  flour  and  milk  gruel,  with  equal  quantities  of 
the  tea  or  coffee,  or  their  active  principles,  caffeine  or  theine.  Where  it 
can  be  had,  the  caffeine  is  perhaps  preferable  to  either  an  infusion  of 
coffee  or  tea.  But  an  ordinary  strong  cup  of  coffee  with  a  little  milk  and 
sugar  will  usually  answer  a  good  purpose  by  being  taken  with  the  gruel, 
thus  furnishing  small  quantities  of  nourishment   in   the  most   convenient 


568     .  CHRONIC   DYSENTERY. 

condition  for  absorption,  while  the  tea  or  coffee  shall  act  as  a  true  nerve 
excitant.  You  thereby  counteract  the  tendency  to  stupor  and  drow- 
siness, and  thus  maintain  or  assist  in  maintaining  the  general  functions 
of  nutrition  and  innervation.  The  strychnia  also  is  given  with  a  view 
of  exerting  a  prompt  and  strong  influence  in  sustaining  the  sensibility 
and  action  of  the  nervous  centers;  for  it  is  through  failure  of  these,  and 
the  consequent  failure  of  the  capillary  circulation,  accompanied  by  gen- 
eral suppression  of  secretions,  with  relaxation  of  the  sphincters,  that  the 
patient  is  hastened  directly  into  collapse  and  death.  I  have  derived  the 
most  satisfactory  results  from  the  use  of  the  combination  of  strychnia, 
mineral  acids  and  opium,  in  the  treatment  of  this  class  of  cases;  and  have 
seen  many  recoveries  from  conditions  that  were  supposed  to  be    hopeless. 

Of  course  as  the  discharges  become  less  frequent  and  copious,  and  less 
bloody  under  the  influence  of  the  enemas  and  the  strychnia  and  opiate  so- 
lutions combined,  the  frequency  of  the  doses  of  the  latter  should  be  dimin- 
ished, but  only  in  proportion  as  the  discharges  become  less  frequent,  aiming 
always  to  limit  them  to  one  or  two  in  the  twenty-four  hours  until  they 
become  natural.  I  have  seen  nothing  but  disastrous  results  from  the  use 
of  cathartics  in  this  class  of  cases  of  dysentery.  In  a  few  instances  I 
have  derived  very  decided  advantage  from  the  use,  in  the  first  stage,  of 
pretty  full  doses  of  ipecac  and  morphine  in  the  form  of  enema; 
thirteen  decigrams  (gr.  xx)  of  the  ipecac  and  three  centigrams  (gr. -g^) 
morphine  in  sixty  cubic  centimeters  (^ii)  of  water,  may  be  passed  into  the 
rectum  immediately  after  each  evacuation  until  the  latter  ceases  to  recur. 
If  from  any  cause,  cases  of  an  asthenic  or  typhoid  type  of  dysentery  are 
only  partially  controlled  during  the  active  stage  of  the  disease,  and 
manifest  a  tendency  to  assume  the  chronic  form  after  the  general  fever 
has  subsided,  and  the  discharges  continue  at  the  rate  of  from  three  to  six 
in  the  twenty-four  hours,  being  less  of  the  bloody  serous  character,  but 
containing  more  evidence  of  a  muco-purulent  material,  they  will  generally 
be  found  to  diminish  steadily  until  convalescence  is  established,  by  giving 
them  the  ordinary  turpentine  and  laudanum  emulsion,  alternated  with 
the  strychnia  and  nitric  acid  solution;  each  prescription  may  be  given 
once  in  six  hours,  making  them  alternate  three  hours  apart.  Particular 
attention  throughout  all  stages  of  this  variety  of  dysentery  should  be  given 
to  the  SLipport  of  the  patient  by  judicious  nourishment. 

Chronic  Dysentery. — When  inflammation  of  the  mucous  membrane  of 
the  colon  and  rectum  has  assumed  a  decided  chronic  form,  whether  as 
the  sequel  of  an  acute  attack,  or  as  a  primary  disease,  there  is  usually  no 
general  febrile  action,  or  increased  heat,  little  or  no  tendency  to  coatino- 
upon  the  tongue,  or  much  dryness  in  the  mouth,  and  but  little  interfer- 
ence with  secretions,  either  from  the  skin  or  kidneys.  But  the  patient 
is  troubled  with  paroxysms  of  griping  and  commotion  in  the  bowels,  fol- 
lowed by  tenesmus  of  a  moderate  character,  and  either  muco-purulent  or 
sero-purulent  discharges,  varying  in  frequency  from  two  to  six  or  more  in 
the  twenty-four  hours;  not  infrequently  the  patient  being  able  to  be  up 
and  dressed,  and  sometimes  going  out  almost  every  day.  The  evacua- 
tions in  such  cases  are  almost  always  more  numerous  and  urgent,  on  the 
patient's  first  rising  from  the  bed  in  the  morning,  or  rhe  tendency  is  mani- 
fested for  one  or  two  evacuations,  soon  after  taking  food  at  each  meal- 
time. Sometimes  the  amount  evacuated  each  time  is  considerable,  con- 
sisting of  thin  reddish  brown,  slightly  faecal  material,  more  or  less  offen- 
sive in  its  odor,  and  at  other  times  persistently  maintaining  the  character 
of  small  muco-purulent  discharges,  streaked  here  and  there  with  blood. 
Examination  under  the  microscope  will,  in  almost  all  these  cases,  detect 


ANATOMICAL    CHANGES.  569 

an  abundance  of  pus,  detached  epithelium,  not  infrequently  shreds  of 
necrosed  or  detached  portions  of  the  mucous  membrane.  The  patient 
pretty  steadily  emaciates  and  loses  strength,  until  after  many  months, 
and  sometimes  two  or  three  years  of  suffering,  he  reaches  the  stage  of 
fatal  exhaustion.  The  final  failure  is  preceded  in  many  instances  by 
more  or  less  oedema  of  the  extremities,  apthous  ulcerations  of  the  mouth 
and  fauces,  scanty,  and  sometimes  albuminous  urine,  and  occasionally, 
though  rarely  in  our  climate,  the  supervention  of  suppurative  inflammation 
in  the  liver,  giving  rise  to  hepatic  abscesses.  The  anatomical  changes 
which  are  found  in  cases  of  chronic  dysentery,  may  be  found  copiously 
and  admirably  illustrated  in  one  of  the  volumes  giving  the  medical  his- 
tory of  the  late  civil  war.  Indeed,  I  would  refer  you  to  these  volumes,  in 
which  there  is  a  large  amount  of  very  valuable  matter  pertaining  espe- 
cially to  the  anatomical  changes,  and  the  great  variety  of  results  that  are 
liable  to  occur  in  the  progress,  not  only  of  the  different  grades  of  dysen- 
tery, but  of  all  the  inflammatory  affections  of  the  alimentary  canal,  partic- 
ularly as  they  are  modified  by  camp  life  in  connection  with  armies,  and 
an  exposure  both  of  the  causes  of  periodical  fevers  on  the  one  hand,  and 
of  typhoid  fevers  and  scorbutus    upon  the   other. 

The  most  important  anatomical  changes  are  the  thickening  and  indura- 
tion of  the  folds  of  the  mucous  membrane  in  whatever  part  of  the  colon  or 
rectum  the  disease  has  existed;  these  folds  being  in  many  cases  so  thick- 
ened from  the  infiltration  and  induration  of  the  sub-mucous  connective 
tissue  as  to  give  them  the  appearance  of  ridges,  and  sometimes  of 
polypoid  projections  into  the  caliber  of  the  intestine. 

The  epithelial  layer  of  the  membrane,  over  much  of  the  inflamed 
surface,  is  either  removed  or  much  disturbed.  In  some  places  the  whole 
depth  of  the  mucous  membrane  is  destroyed  by  necrosis  or  sloughing, 
leaving  ulcerations  of  considerable  extent,  with  irregular  edges,  and 
separated  often  one  from  another  by  thin,  narrow  strips  of  tumefied,  or 
dark  red  tissue,  causing  the  intestine  when  laid  open,  either  in  the  rec- 
tum, sigmoid  flexure,  or  at  the  angles  above,  to  appear  like  a  dark  red  and 
extremely  ragged  or  irregular  surface,  resting  upon  a  thickened  and 
hardened  sub-mucous  tissue  as  a  base.  Now  and  then  a  case  will  be 
met  with  in  which  these  ulcerations  have  penetrated  so  deeply  into  the 
tissue  that  their  base  rests  upon  the  peritoneal  covering,  and  even  occa- 
sionally penetrates  this  membrane,  inducing  the  ordinary  consequences  of 
intestinal  perforations,  namely:  general  acute  peritonitis  and  death. 

l^rognosis. — The  prognosis  in  purely  chronic  dysentery  should  always 
be  given  with  caution;  for  though  there  are  many  of  the  milder  class  of 
cases,  in  which  the  anatomical  changes  to  which  I  have  alluded  are  of 
limited  extent,  and  patients  under  judicious  treatment,  both  in  regard  to 
hygienic  measures  and  medicine,  will  recover,  yet  in  other  cases  where 
these  changes  are  very  extensive,  occupying  a  large  part  of  the  surface 
of  the  colon,  they  will  be  found  entirely  incurable.  All  remedies,  how- 
ever varied  and  judiciously  applied,  prove  only  palliative  in  their  eifects, 
and  the  disease  proceeds  until  the  patients  are  ultimately  reduced  to  a 
fatal  degree  of  exhaustion.  In  their  management,  the  regulation  of  the 
diet  and  drinks  is  a  matter  of  very  great  importance.  The  principle 
should  be  here  fts  in  all  cases  of  dysentery  and  diarrhoea,  to  have  the 
patient  use  such  articles  of  nourishment,  and  in  such  forms  as  are  capable 
of  being  most  perfectly  absorbed  and  converted  into  nutritive  material 
and  taken  up  by  the  vessels  of  the  stomach  and  first  part  of  the  aliment- 
ary canal,  leaving  the  smallest  possible  amount  of  faecal  residue  to  pass 
over  the  diseased  surfaces,  whether  in  the  ileum,  colon  or  rectum.     As  I 


570  CHRONIC    DYSENTERY. 

have  had  occasion  several  times  to  remark,  the  material  which  answers 
this  purpose  perhaps  better  tlian  any  other,  and  at  the  same  time  pos- 
sesses all  the  ingredients  necessary  for  supplying  the  human  system  is 
milk,  either  alone  or  mixed  with  a  small  proportion  of  lime-water,  or  still 
better,  with  a  small  proportion  of  wheat  flour,  in  the  form  of  a  thin 
homogeneous  flour  and  milk  gruel.  While  this  constitutes  the  best  basis 
for  nutrition  that  has  been  devised,  to  prevent  the  patient  from  becomirjg 
disgusted  with  its  constant  use,  it  may  be  alternated  with  more  or  less  of 
the  various  animal  broths,  such  as  beef  tea,  chicken  broth,  mutton  broth, 
all  of  which,  when  used,  should  be  seasoned  with  salt  to  suit  the  patient's 
taste.  Sometimes  it  will  be  well  to  give  the  patient  the  albumen  of  egg, 
separated  from  the  yolk,  and  simply  intermixed  or  suspended  in  water, 
administered  in  small  quantities. 

The  patient  should  avoid  taking  all  such  vegetables  as  consist  mostly 
of  starch,  like  potatoes,  very  tender  bits  of  meat  being  much  more  likely 
to  be  digested  and  well  borne  than  potatoes,  beets,  or  even  most  varieties 
of  bread.  As  a  rule  it  is  better  that  the  patient  take  nourishment  in  very 
limited  quantities,  and  at  such  stated  intervals  as  will  give  a  reasonable 
amount  of  support  in  every  twenty-four  hours,  experience  having  fully 
shown  that  when  the  secretion  of  gastric  juice  is  lessened  by  wasting 
disease,  if  any  form  of  nourishment  is  taken  in  considerable  quantities,  a 
portion  of  it  is  very  liable  to  undergo  fermentation,  and  create  more  or 
less  disturbance,  before  the  whole  of  it  can  be  taken  up  by  the  absorbents. 
Whereas,  if  the  same  material  is  taken  in  smaller  quantities  and  at  such 
intervals  as  will  allow  what  is  taken  at  one  time  to  have  been  fully  absorbed 
before  the  next  quantity  is  taken,  the  patient  will  avoid  the  retention 
of  any  long  enough  to  undergo  fermentation,  and  yet  he  gets  the  amount 
necessary  in  the  twenty-four  hours.  In  regard  to  the  remedial  agents  to 
be  used  in  the  treatment  of  chronic  forms  of  dysentery,  I  can  give  you 
no  better  direction  than  to  use  the  same  , formulae  that  I  have  already 
given  for  the  treatment  of  the  advanced  stages  of  the  acute  form  of  the 
disease,  simply  adjusting  the  doses,  and  the  time  of  their  administration, 
in  such  a  way  that  they  shall  so  far  control  the  discharges  as  to  keep 
them  as  near  one  in  the  twenty-four  hours  as  may  be  possible,  until  the 
injured  portions  of  the  inflamed  membrane  can  undergo  the  process  of 
reparation  and  cicatrization.  The  patient  should  persistently  use  some 
combination  which  possesses  the  qualities  of  a  soothing  or  anodyne  agent, 
with  that  which  will  increase  the  tone  or  contractility  of  the  vessels  of  the 
inflamed  part,  thereby  constantly  repressing  the  excess  of  blood  in  the 
tissue,  and  lessening  also  the  morbid  susceptibility,  until  a  renewal  of 
nutrition,  granulation  and  cicatrization  is  induced  in  the  ulcerated  parts. 
At  the  same  time  the  capillary  vessels  and  circulatory  organs  will  be 
aided  in  removing  from  the  thickened  and  indurated  structures  any 
adventitious  material  that  may  have  been  added  to  them  by  either 
exudation,  cell  proliferation  or  any  other  mode  of  thickening  and  hyper- 
trophy of  the  connective  tissue.  In  my  own  experience,  though  trying  a 
large  variety  of  remedies  as  they  have  been  suggested  frOm  time  to  time, 
I  have  found  none  to  succeed  better  in  the- treatment  of  the  different 
grades  of  chronic  dysentery,  than  either  the  turpentine,  oil  of '  winter- 
green,  and  laudanum  emulsion;  carbolic  acid,  ipecac  and  opium  pills  or 
capsules;  or  nitrate  of  silver,  hyoscyainus  and  opium  in  the  form  of  pills, 
all  of  which  I  have  already  mentioned  in  speaking  of  the  treatment  of 
the  more  acute  form  of  the  disease.  It  is  impossible  to  give  a  rule  by 
which  you  can  judge,  in  any  given  case  which  of  these  formulae  will  be 
productive  of  the  greater  amount  of  good.     Observation  has  fully  satis- 


TREATMENT.  571 

fied  me  that  direct  clinical  trial  is  the  only  test.  I  have  found  a  con- 
siderable majority  of  the  cases  of  ciironic  dysentery  to  be  benefited  in  a 
greater  degree  and  for  a  longer  period  of  time  by  talcing  four  cubic  centi- 
meters (tl.  3i)  of  the  turpentine  and  laudanum  emulsion  from  three  to 
four  times  in  the  twenty-four  hours,  than  from  either  of  the  other  com- 
binations alone.  Next  to  this  I  have  placed  the  combination  of  carbolic 
acid,  ipecac  and  opium;  and  as  the  third  in  rank  in  its  applicability  to 
these  cases,  the  nitrate  of  silver  and  opium.  But  there  are  very  many  of 
this  class  of  patients  who  are  obliged  to  have  treatment  for  a  long  period 
of  time.  Many  of  them  will  progress  favorably  under  the  influence  of  one 
of  these  combinations  for  one  or  two  weeks,  when  they  will  cea<e  to  make 
further  improvement.  If  you  persist  in  giving  the  same  remedies  they 
"will  begin  to  retrograde,  the  discharges  become  again  very  frequent,  and 
the  patient  of  course  very  much  reduced. 

But  if,  as  soon  as  the  patient,  who  has  been  improving  up  to  a  given 
time,  ceases  to  make  further  progress  in  that  direction,  you  immediately 
substitute  one  of  the  other  preparations,  the  new  impression  will  very 
generally  carry  the  improvement  still  further,  and  the  patient  will  make  a 
steady  but  slow  progress  in  the  direction  of  recovery  for  a  time,  and 
ao'ain  begin  to  show  indications  of  receding.  This  is  an  indication  that 
the  medicine  should  be  again  changed  either  to  the  first  formula  or  to  the 
third  one.  By  thus  changing  from  one  to  the  other  at  suitable  times, 
always  continuing  to  use  o  le  persistently  as  long  as  the  improvement 
continues,  and  by  substituting  another  which  will  give  a  little  different 
impression,  and  yet  have  the  same  general  end  in  view,  you  will  succeed 
'.n  greatly  improving  patients,  that  without  such  a  succession  of  remedies 
would  have  ceased  to  improve  and  proceeded  to  an  early  fatal  termina- 
tion. An  item  of  much  importance  in  the  treatment  of  these  chronic 
cases  of  disease  is  the  securing  for  the  patient  good  air,  cleanly  and 
healthy  surroundings,  almost  entire  rest  during  a  part  of  each  day  as 
well  as  at  night  in  a  recumbent  position,  and  a  steady,  persistent  regu- 
lation of  the  diet  on  the  principles  that  I  have  indicated.  If  all  these 
circumstances  can  be  made  to  co-operate,  some  one  of  the  formulae 
that  I  have  mentioned  will  almost  always  be  found  greatly  to  mit  - 
gate  the  suffering  of  the  patient,  and  to  prolong  his  life,  if  it  does  not 
cause  positive  reparation  of  the  injured  structures  and  lead  to  recovery. 
In  addition,  however,  to  the  list  of  remedies  I  have  already  mentioned, 
in  some  cases  where  the  patients  have  become  much  anaemic,  I  have 
found  a  powder,  composed  of  the  sub-nitrate  of  bismuth,  from  three  to  five 
decigrams  (gr.  v  to  viii),  sub-carbonate  of  iron  from  one  to  two  deci- 
grams (gr.  iss  to  iii)  and  pulverized  opium  six  centigrams  (gr.  i) 
given  from  three  to  four  times  a  day  to  produce  very  decided  ameliora- 
tion of  the  symptoms,  and  in  a  few  instances  apparently  turn  the  scale  in 
favor  of  permanent  improvement  and  ultimate  recovery.  In  a  few  in- 
stances, also,  of  somewhat  similar  character,  I  have  used  bromine  rendered 
soluble  with  the  bromide  of  potassium  in  the  proportion  of  eight  minims 
of  the  bromine,  four  grams  (3i)  of  the  bromide  of  potassium,  in  one  hundred 
and  eighty  cubic  centimeters  (§vi)  of  water;  of  which  from  four  to  six 
cubic  centimeters  (3i  to  3iss)  may  be  given,  further  diluted  with  sugar 
and  water,  every  four,  six  or  eight  hours,  according  to  the  effect  desired. 

In  some  cases  of  long  standing,  where  the  patients  had  become  ex- 
hausted, the  stomach  irritable,  the  mucous  membrane  of  the  mouth  and 
fauces  apthous  and  tender,  1  have  rendered  the  patients  much  more  comfort- 
able in  all  respects,  by  giving  frequent  doses  of  an  emulsion  made  in  the 
same  manner  as  the  turpentine  and  laudanum  emulsion,  only  substituting 


572  PEEITONEAL    EKTEEITIS. 

the  same  amount  of  pulverized  gum-benzoin  for  the  oil  of  turpentine.  The 
gum-benzoin  thus  rubbed  up  with  sugar  and  tincture  of  opium  will  not  dis- 
solve in  the  mixture,  but  remains  suspended  only,  of  which  some  will  fall 
to  the  bottom  while  standing,  and  consequently  the  mixture  should  be  well 
shaken  up  whenever  it  is  poured  out.  But  it  is  devoid  of  any  qualities  cal- 
culated to  offend  the  stomach,  and  has  sometimes  produced  very  pleasant 
and  ameliorating  effects.  Etmay  be  given  in  the  same  doses,  and  with  the 
same  frequency  as  the  ordinary  turpentine  and  laudanum  emulsion.  I 
have  now  spoken  of  the  strictly  inflammatory  affections,  acute  and 
chronic,  which  are  met  with  in  ordinary  practice,  in  the  different  portions 
of  the  interior  of  the  alimentary  canal,  from  the  mouth  to  the  anus.  There 
remain  of  the  digestive  apparatus,  the  exterior  or  peritoneal  covering  of 
the  intestinal  canal,  and  the  important  glandular  structures  in  the  mesen- 
tery, the  liver,  spleen,  and  pancreas  yet  to  be  considered. 


LECTURE    LV. 


Peritonitis— Peritoneal   Enteritis — Their  Causes,  Clinical  History,   Anatomical  Changes,  Diag- 
nosis, Progaosis  and  Treatm.nt. 

GENTLEMEN:  The  peritoneum,  like  the  pleura  and  pericardium,  is  a 
complete  sac,  composed  of  serous  membraiie,  lining  the  interior  of  the 
abdominal  cavity  and  reflected  over  the  mesenteric  glands  and  intestines, 
including  the  upper  portion  of  the  pelvic  viscera,  and  the  exterior  of  the 
liver,  spleen,  and  in  a  less  direct  marnier,  the  kidneys  and  pancreas.  Like 
the  other  serous  membranes  it  is  composed  largely  of  conneccive  tissue, 
a  layer  of  lymph  ducts,  a  vascular  net-work,  an  abundance  of  lymphoid 
cells  and  canas,  with  a  free  surface  of  polygonal  cells,  or  what  is  usually 
called  endothelium.  The  membrane  thus  composed  possesses  a  high 
degree  of  absorbing  power,  taking  up  readily  almost  any  substance  in  a 
fluid  form,  that  is  placed  in  contact  with  its  surface.  Consequently  it 
imbibes  actively  septic  matters,  which  may  be  formed  in  adjacent  tissues 
and  organs,  or  that  may  be  derived  from  perforation  and  escape  of  the 
contents  of  the  intestines,  stomach  or  other  hollow  viscera,  with  which  it 
is  connected.  It  is  subject  to  attacks  of  inflammation  of  all  grades  of 
severity  or  activity  from  the  most  acute  and  rapidly  progressive,  to  the 
most  slow  and  chronic  form  of  disease.  It  is  subject  to  acute  attacks 
that  rapidly  involve  a  large  portion  or  all  of  the  membrane,  and  in  other 
instances  it  may  be  circumscribed  or  limited  to  a  very  small  part  of  it. 
The  latter  cases  are  what  are  called  circumscribed  peritonitis,  and  usually 
result  from  the  extension  of  inflammation  to  the  peritoneum  from  viscera 
pfeviously  inflamed,  to  which  the  peritoneum  is  attached — or  from  per- 
forations that  allow  the  escape  of  irritating  material,  and  the  establish- 
ment of  a  primary  local  inflammation  of  the  membrane  surrounding  the 
perforation.  The  chronic  form  of  inflammation  may  occur  idiopathically, 
or  it  may  be  the  sequel  of  an  acute,  or  subacute  attack.  And  like  the 
acute  grade  of  the  disease  it  may  be  either  general,  involving  the  whole 
membrane,  or  it  may  be  limited  to  a  small  portion  of  it.  For  practical 
purposes,  it  is  convenient  to  consider  inflammations  of  the  peritoneum 
under  three  heads: — acute  diffuse  peritonitis,  acute  and  subacute  circum- 
scribed peritonitis,  and  chronic  peritonitis. 


SYMPTOMS.  573 

Acute  General  Peritonitis. — As  an  idiopathic  affection  arising  from 
ordinary  atmospheric  causes,  acute  inflammation  of  the  peritoneum  is  of 
rare  occurrence.  Cases,  are,  however,  occasionally  met  with  arising  from 
sudden  and  severe  exposure  to  cold  and  wet,  excessive  exercise  and  from 
mechanical  injuries.  But  far  the  larger  proportion  of  cases  originate  sec- 
ondarily during  the  progress  of  inflammation  in  organs,  with  which  the 
peritoneum  is  in  contact.  I  have  already  had  occasion  to  mention  that 
in  mucous-enteritis,  coUitis  and  gastritis,  the  inflammation  not  infrequently 
extended  during  its  progress  to  the  peritoneum,  and  sometimes  spread 
dift'usely  over  the  surface  of  this  membrane;  particularly  Wiis  this  men- 
tioned as  frequently  occurring  in  connection  with  typhlitis  and  peri- 
typhlitis. It  is  also  liable  to  occur  as  the  result  of  all  forms  of  severe  in- 
testinal obstruction,  whether  from  irritation  of  the  circular  flbers  of  the 
muscular  coat,  inducing  contraction  of  the  intestine  of  a  tonic  and  per- 
sistent character,  from  concretions  and  tumors,  or  from  positive  intussus- 
ception. But  among  the  more  frequent  causes  capable  of  developing 
rapid  and  fatal  peritonitis,  are  intestinal  perforations  either  durino-  the 
latter  stages  of  typhoid  and  typhus  fevers,  or  during  the  progress  of 
chronic  gastric  ulcers,  or  perforaiions  of  the  vermiform  process,  or  of  the 
gall  bladder  and  escape  of  bile,  and  sometimes  though  rarely  of  a  rupture 
of  the  ureter,  or  of  the  pelvis  of  the  kidney,  or  from  suppuration  in  one 
or  more  of  the  mesenteric  glands,  the  abscess  maturing  and  perforating 
the  peritoneum,  and  allowing  the  escape  of  pus.  Similar  residts  some- 
times take  place  also  in  abscesses  of  the  liver,  perforating  the  membrane 
covering  that  organ  and  allownng  pus  to  escape  into  the  cavity  of  the 
peritoneum.  Cases  of  general  peritonitis  have  also  occurred  from  the 
escape  of  injections  directed  into  the  uterine  cavity,  through  the  Fallo- 
pian tubes  into  the  cavity  of  the  peritoneum.  Acute  general  peritonitis 
also  arises  not  infrequently  in  the  progress  of  metritis,  and  sometimes 
from  pelvic  cellulitis,  and  almost  always  accompanies  that  severe  form  of 
disease  called  puerperal  fever,  or  puerperal  peritonitis.  But  as  puerperal 
fever  proper  is  a  disease  arising  from  a  specific  cause  in  connection  with 
child-bed,  and  is  fully  considered  in  nearly  ail  works  upon  midwifery  and 
diseases  of  women,  we  shall  not  include  it  in  our  further  discussion  of 
this  subject. 

fSi/mptofns. — Acute,  general  peritonitis  usually  commences  abrupth', 
and  in  the  larger  proportion  of  cases  is  accompanied  in  its  beginning  bv 
a  more  or  less  distinct  chill.  Coincident  with  the  occurrence  of  the  chill, 
which  is  usually  of  brief  duration,  there  is  a  sense  of  soreness  and  tension 
in  the  abdomen,  with  frequent,  sharp  lancinating  pains,  with  more  or  less 
sense  of  heat  or  burning  in  the  interval  between  the  sharp  pains.  As  the 
sensation  of  chilliness  or  the  cold  stage  passes  by,  the  cutaneous  surface 
generally  becomes  dry,  and  increased  in  temperature  from  two  to  four 
degrees  above  the  normal.  The  pulse  becomes  rapidly  increased  in  fre- 
quency, usually  numbering  from  one  hundred  to  one  hundred  and  ten 
per  minute,  before  the  end  of  the  first  twenty-four  hours.  It  is  usually 
rather  soft,  compressible,  as  well  as  frequent,  though  sometimes  it  is  tense 
and  firm  under  the  finger.  The  respirations  are  short  and  increased  in 
frequency,  being  suppressed  in  some  measure  by  the  voluntary  efforts  of 
the  patient,  on  account  of  the  increase  of  pain  caused  by  full  inspirations. 
As  the  febrile  stage  is  developed,  the  pains  in  the  abdomen  become  more 
severe,  the  tenderness  to  pressure  very  acute,  and  all  motions  of  the  body 
in  turning  or  moving  in  any  direction  increase  the  pains  in  a  marked  de- 
gree. The  respirations  are  stifled  on  account  of  the  descent  of  the  dia- 
phragm crowding   upon  the  abdominal  viscera,  causing  much  increase  of 


574  PERITONITIS. 

pain.  The  bowels  are  almost  always  constipated  from  the  time  of  the  super- 
vention of  the  inflammation  or  tenderness,  there  being  no  disposition  to 
further  intestinal  discharges.  Some  instances  have  been  observed,  indeed 
two  have  recently  come  under  my  own  observation,  in  which  immediately 
preceding  the  supervention  of  chilliness,  and  commencement  of  symptoms 
of  local  inflammation,  the  bowels  had  been  evacuated  freely  two  or  three 
times.  In  the  later  stages  of  the  disease,  however,  the  inflammatory  ac- 
tion extends  into  the  coats  of  the  intestines  sufficiently  to  induce,  in  many 
of  the  cases,  more  or  less  active  diarrhoea.  The  stomach,  in  the  diffuse 
acute  peritonitis  very  generally  becomes  more  or  less  irritable,  and  vomit- 
ing in  many  of  the  cases  is  a  very  troublesome  and  distressing  symptom. 
The  contraction  of  the  abdominal  muscles  in  the  act  of  vomiting  causes 
very  great  increase  of  pain  and  soreness,  and  sometimes  apparently  adds 
much  to  ttie  prostration  of  the  patient.  The  urinary  secretion  is  usually 
much  diminished  in  quantity  from  the  beginning  of  the  disease,  and  red- 
der than  natural,  very  generally  voided  with  little  difficulty,  but  some- 
times with  decided  pain  or  scaldino-.  There  is  usually  much  thirst  ;  a 
very  anxious  expression  of  countenance,  at  first  a  white  coat  upon  the 
tongue,  turning  more  or  less  brown  and  dry  as  the  case  progresses  ;  there 
is  much  thirst  and  desire  for  cold  drinks,  and  yet  vomiting  is  often  pro- 
voked by  the  use  of  the  smallest  quantity  of  liquids.  The  matters  ejected 
by  vomiting  are  at  first  simply  the  contents  of  the  stomach,  but  subsequently 
mixed  more  or  less  with  a  mucous  or  serous  fluid,  usually  colored  deeply, 
with  the  coloring  matter  of  bile,  altered  by  the  action  of  the  acids  of  the 
gastric  secretion  to  a  green  hue.  If  the  case  progresses  unfavorably,  in 
from  three  to  four  days  the  matters  ejected  by  vomiting  become  greatly 
increased  in  quantity,  of  a  dark  brown  color,  and  are  ejected  more  by  a 
regurgitation,  than  the  ordinary  process  of  vomiting.  Occasionally  there 
will  be  indications  of  blood  in  the  matters  ejected. 

And  if  diarrhoea  supervenes  in  the  advanced  stage,  the  discharges  are 
usually  of  a  dark  brown  color,  oiFensive  in  odor,  and  also  sometimes  inter- 
mixed with  blood.  As  the  fatal  result  draws  near,  the  urinary  secretion 
is  often  suppressed  entirely,  the  pulse  becomes  extremely  rapid  and  feeble, 
the  extremities  cold  and  bluish,  eyes  sunken,  expression  of  countenance 
haigard,  the  mind  inclined  to  be  drowsy  and  dull,  and  occasionally,  wan- 
dering, or  muttering  with  a  low  form  of  delirium.  In  connection  with 
these  symptoms  the  discharges  become  involuntary,  the  sphincters  re- 
laxed, the  chin  dropped,  the  respirations  shorter  and  shorter,  until  life 
ceases.  Death  is  said  to  take  place  from  asthenia  or  exhaustion.  In  the 
most  acute  form  of  the  disease,  diffuse  peritonitis  frequently  passes 
through  its  successive  stages  and  terminates  fatally  in  from  three  to  five 
days.  Perhaps  the  average  duration  of  acute  cases  is  from  five  to  seven 
days.  In  addition  to  the  symptoms  that  I  have  already  mentioned,  ab- 
dominal distension  or  tympanitis  is  a  prominent  and  important  one.  It 
usually  commences  early  after  the  beginning  of  the  disease,  and  often- 
times is  extreme — the  abdomen  being  distended  to  such  an  extent  with 
the  arrest  of  gases  in  the  intestines,  that  the  distension  is  not  only  pain- 
ful to  the  patient,  Ijut  it  crowds  the  liver,  stomach  and  diaphragm  up- 
wards to  such  an  extent  as  to  greatly  lessen  the  capacity  of  the  chest,  and 
consequently  to  render  the  aeration,  or  oxygenation  and  decarbonization 
of  the  blood  very  deficient.  This  diminution  of  the  capacity  of  the  chest 
for  air,  and  the  consequent  failure  of  the  natural  function  of  respiration, 
greatly  increa-es  the  rapidity  of  failure  in  the  strength  of  the  pulse, 
developing  cold  extremities,  blueness  of  the  lips  and  ends  of  the  fingers, 
early  somnolency,  suppression  of  urine,  and  death.     More  or  less  of  abdom- 


ANATOMICAL    CHANGES.  575 

inal  distension,  and  acute  tenderness  to  pressure, — the  tenderness  and 
pam  on  pressure  being  increased  in  proportion  to  the  depth  of  the  pres- 
sure,— are  symptoms  that  are  perhaps  more  distinctive  of  this  form  of  in- 
flammation than  any  other  that  we  have  enumerated.  While  the  great 
majority  of  cases  of  acute  diffuse  peritonitis  commence  in  the  manner  I 
have  indicated,  by  chilliness  and  an  abrupt  development  of  inflammatory 
action  or  symptomatic  fever,  there  are  a  few  cases  in  which  the  disease 
develops  gradually,  and  without  marked  chill.  The  patient  complains 
of  a  progressively  increased  sense  of  soreness  and  pain,  aggravated  by 
pressure  and  motion  of  the  body,  as  in  walking  or  upon  turning  from  one 
side  to  the  other,  for  two,  three  or  even  four  days  before  sufficient  general 
f.;brile  movement  and  feeling  of  sickness  supervene  to  seriously  attract 
the  attention  of  the  patient.  But  when  once  developed  it  pursues  the 
same  general  course  that  we  have  already  described.  Again,  cases  have 
been  met  with,  though  very  rarely,  in  which  the  symptoms  of  the  disease 
were  entirely  masked  or  latent  ;  there  being  neither  any  considerable 
amount  of  pain  locally  in  the  abdomen,  tenderness,  nor  any  apparent  gen- 
eral fever  ;  and  yet  the  patient  became  rapidly  and  fatally  exhausted. 

When  the  disease  arises  from  a  local  cause,  such  as  perforation  of  some 
of  the  hollow  viscera  in  connection  with  the  peritoneum,  or  from  exten- 
sion of  inflammation  from  other  parts,  there  is  less  liability  to  chilliness 
at  the  time  the  peritoneal  inflammation  commences,  and  the  local  symp- 
toms are  usually  at  first  circumscribed — that  is,  the  pain  is  seemingly 
limited  at  the  outset  to  the  neighborhood  or  locality,  where  the  perfo- 
ration of  the  peritoneum  or  inflamed  vlscus  exists;  but  the  extension  may 
b.3  so  rapid  as  to  cause  diffusion  of  the  inflammation  over  the  whole  mem- 
brane, within  a  few  hours  after  it  has  established  itself  at  the  original 
point  of  attack. 

Anatomical  Changes. — The  anatomical  changes  which  take  place  during 
the  progress  of  acute,  diffuse  peritonitis  are  the  same  in  kind  that  occur 
in  acute  pleuritis  and  pericarditis.  There  is  intense  injection  of  the 
vessels  of  the  membrane,  causing  a  deep  red  color,  sometimes  bordering 
upon  a  brown;  at  other  times  a  greenish  hue,  with  more  or  less  tumpfaction 
or  apparently  increased  thickening  of  the  membrane,  and  accumulation  or 
exudation  of  fibrinous  material,  lymphoid  cells,  white  corpuscles,  and 
inore  or  less  serum  in  the  interstitial  spaces  of  the  membrane,  and  sub- 
jacent connective  tissue.  At  the  same  time  there  is  more  or  less  exuda- 
tion upon  the  surface  of  the  membrane,  ii!  some  instances  of  a  plastic  or 
fibrinous  character  organized  into  white  layers  of  adventitious  tissue  ad- 
hering to  the  surface  and  sometimes  causing  coils  of  intestines  lying  in 
contact  to  be  more  or  less  adherent  to  each  other,  and  to  the  in- 
flimed  surface.  More  frequently  in  addition  to  a  moderate  amount 
of  this  semi-plastic  exudation,  there  is  also  an  exudation  of  serous  fluid, 
containing  more  or  less  of^pus  corpuscles,  shreds  of  a  fibrinous  material, 
and  sometimes  enough  of  the  red  corpuscles  of  the  blood  to  give  it  a  red- 
dish appearance.  In  other  instances  instead  of  either  a  plastic  or  serous 
exudation,  the  accumulation  upon  the  surface  of  the  membrane  is  almost 
entirely  purulent.  Perhaps  the  great  majority  of  cases  that  terminate 
fatally  present  all  three  of  these  inflammatory  results  coincidently; — 
namely,  fibrinous  exudation  forming  layers  upon  the  surface  of  the  in- 
flamed membrane,  with  a  pretty  abundant  serous  effusion  freely  inter- 
mingled with  pus  corpuscles,  so  as  to  constitute  a  sero-purulent  accumu- 
lation. When  the  inflammation  causes  only  a  serous  exudation,  it  may 
pursue  the  same  course  as  any  serous  exudation  into  the  pleura  or  peri- 
cardium, namely,  absorption  and  consequent  recovery  of  the  patient, 
without  leaving  any  unpleasant  sequelcB. 


576  PERIT02TITIS. 

In  those  cases,  however,  in  which  the  accumulation  in  the  cavity  of  the 
peritoneum  is  purulent,  complete  absorption  will  not  take  place,  and  in 
the  great  majority  of  cases  it  will  cause  a  fatal  termination.  In  a  few  in- 
stances, however,  even  of  purulent  accumulations,  the  serous  part  of  the 
pus  has  been  removed  by  absorption,  leaving  a  white  or  yellowish  white 
cheesy  mass,  which  has  appeared  capable  of  remaining  in  that  condition 
without  further  change  for  a  considerable  length  of  time.  In  a  few  instances 
in  which  post-mortems  have  shown  the  absorption  of  the  serous  part  pf 
these  sero-parulent  effusions,  there  has  been  left  a  substance  closely  anal- 
ogous to  colloid  material.  Where  there  has  been  plastic  exudation,  and 
yet  the  inflammatory  action  subsides  without  fatal  prostration,  a  slow  dis- 
integration of  the  partially  organized  fibrine  has  taken  place  until  it  has 
entirely  disappeared.  But  much  more  frequently  it  only  partially  dis- 
appears by  this  process,  and  the  remainder  becoming  more  highly  organized 
remains  as  new  tissue  and  causes  either  permanent  thickening  of  the  peri- 
toneal membrane,  or  more  frequently  permanent  bonds  of  union  between  ' 
what  would  otherwise  be  free  surfaces, — attaching  coils  of  intestine  to 
each  other,  thereby  embarrassing  the  natural  peristaltic  motion,  and 
often  inducing  colic,  and  other  troublesome  intestinal  derangements. 
Sometimes  these  bands  of  false  tissue  contract  in  the  process  of  time 
so  as  to  form  constrictions  and  troublesome  obstructions  of  the  bowels, 
and  occasionally  give  rise  to  an  entanglement  of  loops  of  intestine 
in  such  a  way  as  to  produce  complete  strangulation  and  death  of  the 
patient  at  some  remote  period  of  time  from  their  original  formation. 

Diagnosis. — The  diagnosis  of  acute  peritonitis  is  not  difficult.  The 
acute  tenderness  of  the  abdomen  to  pressure,  the  pain  being  increased  in 
proportion  to  the  depth  of  the  pressure,  directly  associated  with  increased 
rapidity  of  pulse,  increased  temperature,  acute  lancinating  pains  greatly 
aggravated  by  any  motion  of  the  body,  certainly  distinguish  the  disease, 
even  in  its  early  stage,  from  almost  any  other  morbid  condition  that  can 
be  named.  And  the  distinguishing  features,  both  general  and  local, 
become  more  prominent  as  the  disease  progresses.  There  are  some  cases, 
however,  of  hypera3sthesia  or  morbid  spnsitiveness  from  a  peculiar  con- 
dition of  the  nervous  system,  in  which  there  is  an  apparent  extreme  sen- 
sitiveness of  the  tissue  over  the  abdomen,  and  which  might  at  first  be 
mistaken  as  evidence  of  peritonitis.  But  in  all  classes  of  cases  of  myalgia, 
neuralgia  or  hyperassthesia,  the  tenderness  has  this  distinctive  character: 
that  it  is  superficial,  and  the  patient  gives  some  evidence  of  pain  and 
shrinks  from  slight  touches  upon  the  surface,  as  much  as  he  does  from 
steady  firm  pressure.  And  in  almost  all  such  cases,  if  the  palm  of  the 
hand  is  placed  upon  the  abdomen  and  steady  continuous  pressure  made, 
it  is  fou.id  that  the  patient  complains  no  more  than  he  did  from  the 
slightest  touch  of  the  fingers  upon  the  surface.  The  reverse  of  this,  how- 
ever, is  true  of  peritonitis.  In  all  forms  of  inflammation  of  the  peri- 
toneum, very  slight  pressure  upon  the  surface  creates  but  little  uncom- 
fortable sensations,  while  the  more  firm  and  deep  the  pressure  the  more 
acute  the  pain  the  patient  suffers.  Another  characteristic  of  peritonitis 
which  aids  in  maintaining  the  diagnosis  is  the  rigidity  of  the  abdominal 
muscles. 

This  is  more  particularly  noticeable  in  the  recti  muscles  before  the  ab- 
domen has  become  too  greatly  distended  by  tympanitis.  If  you  thus  give 
due  attention  to  the  character  of  the  tenderness,  and  the  effects  of  deep 
pressure  as  distinguished  from  mere  superficial  touches,  the  condition  of 
rigidity  or  non-rigidity  of  the  abdominal  muscles,  and  remember  that  in 
connection  with  th's,  in  the  inflammation  of  the  peritoneum,  there  is  more 


.  PKOGNOsis.  577 

or  less  general  constitutional  disturbance,  such  as  pyrexia,  unusual  ra- 
pidity of  pulse,  a  correspondingly  short,  stifled  and  frequent  respiration 
and  occurrence  of  pain  on  any  attempt  at  such  motion  of  the  body  as  will 
disturb  the  abdominal  cavity,  you  will  not  be  liable  to  confound  acute 
peritonitis  with  any  other  variety  of  disease. 

Prognosis. — The  prognosis  in  acute  diffuse  peritonitis  should  always  be 
given  with  caution.  If  the  disease  is  recent  and  from  exposure  to  cold  or 
wet,  or  from  ordinary  accidents  in  previously  healthy  conditions  of  the 
system,  under  judicious  management  a  large  majority  of  cases  will  re- 
cover. So,  too,  when  it  originates  simply  from  extension  of  the  inflarh- 
mation  from  other  organs  with  which  the  peritoneum  is  in  contact,  there 
is  a  strong  probability  that  the  case  will  terminate  favorably,  provided 
the  primary  disease  can  be  controlled;  as  the  same  means  which  have 
answered  for  its  control,  will  be  sufficient  also  to  limit  and  finally  over- 
come the  peritonitis.  Cases  to  which  I  have  alluded  as  favorable  in  their 
prognosis  are  usually  accompanied  only  by  plastic  or  sero-plastic  exuda- 
tions. But  when  the  disease  occurs  as  the  result  of  perforations  of  the 
intestines,  or  any  of  the  hollow  viscera  or  parts  connected  with  the  per- 
itoneal membrane,  or  from  absorption  of  septic  or  poisonous  material  from 
disease  or  suppurative  processes  in  any  of  the  viscera,  or  in  the  advanced 
stage  of  renal  disease  and  dropsical  effusions,  the  prognosis  is  extremely 
unfavorable.  In  nearly  all  such  cases  the  inflammatory  products  assume 
early  the  form  of  pus.  And  whenever  accumulations,  taking  place  in  the 
peritoneal  cavity,  are  purulent,  the  patients  become  early  exhausted  and 
very  rarely  recover.  Still  there  are  some  instances  in  which  the  inflam- 
mation supervenes  from  direct  perforation  and  escape  of  material  from  the 
intestines  or  from  some  of  the  hollow  organs  in  connection  with  it,  and 
yet  exudation  thrown  out  rapidly  around  the  point  of  opening  causes  so 
early  an  adhesion  to  the  parts  lying  in  contact  as  to  set  bounds  to  the 
further  escape  of  material  through  the  perforation,  and  also  to  prevent 
whatever  suppuration  takes  place  from  becoming  diffused  through  the 
whole  of  the  peritoneal  surface.  Thus  the  inflammation  is  purely  circum- 
scribed, and  the  exudative  material  is  limited  to  the  small  space  in 
immediate  connection  with  the  original  opening.  Such  cases  have  occa- 
sionally ended  favorably.  Sometimes  by  the  reabsorption  of  the  accumu- 
lated products  of  the  inflammation,  more  frequently  by  enlarging  the 
opening  and  permitting  their  escape  into  the  intestine  and  discharge 
through  the  alimentary  canal,  or  by  the  formation  of  a  circumscribed 
accumulation  of  pus  capable  of  being  early  recognized  hy  palpation,  and 
removed  either  by  aspiration  or  by  free  incision  through  the  abdominal 
walls.     Such  instances,  however,  are  comparatively  rare. 

When  around  a  circum.scribed  inflammation,  plastic  material  has  been 
thrown  out,  adhesions  have  been  formed,  and  at  the  same  time  serous 
effusions  have  occurred  from  the  inflamed  surface,  these  effusions,  in- 
stead of  being  allowed  to  enter  into  the  general  cavity  of  the  peritoneum, 
are  limited  by  the  adhesions  to  a  part  of  the  cavity,  and  thus  constitute 
what  has  been  called  an  encysted  ascites.  This  is  capable  of  reabsorption 
like  any  other  serous  fluid,  allowing  the  patient  ultimately  to  recover,  or 
if  reabsorption  does  not  occur,  and  the  parts  become  distended  sufficiently 
to  reveal  the  true  nature  of  the  case,  paracentesis  in  the  ordinary  manner, 
or  aspiration  may  cause  its  removal,  and  contribute  to  the  patient's  ulti- 
mate recovery.  The  danger,  however,  from  aspiration,  or  incisions,  and 
from  the  use  of  the  ordinary  trochar  in  such  a  circumscribed  accumulation 
is  in  the  liability  of  having  the  instruments  perforate  some  portion  of  the 
37 


578  PERITONITIS. 

intestines.  Tiiis  must  be  kept  in  mind  as  an  important  item  where  such 
operations  may  be  deemed  advisable. 

Treatment. — When  acute  or  subacute  peritonitis  occurs  from  acci- 
dental or  atmospheric  causes  in  previously  healthy  conditions  of  the  sys- 
tem and  the  physician  is  called  early,  advantage  may  very  generally 
be  derived  from  a  moderate  local  bleeding  by  leeches.  It  is  seldom  that 
venesection  will  be  required,  though  in  some  instances  where  the  pulse  is 
full  and  firm  under  the  fingers,  the  symptoms  have  supervened  rapidly, 
and  the  abdomen  become  extremely  tender  with  great  pain,  it  may  be  ad- 
missible to  practice  one  free  venesection  at  a  very  early  period  in  the  prog- 
ress of  the  disease.  I  hardly  remember  a  case  presenting  these  features 
sufficiently  to  justify  or  require  the  use  of  the  lancet,  but  when  called 
early  I  have  derived  very  much  advantage  from  pretty  free  application  of 
leeches,  allowing  the  blood  to  flow  after  the  leeches  have  fallen  off,  en- 
couraging it  by  the  application  of  cloths  dipped  in  warm  water,  and  subse- 
quently keeping  the  abdomen  covered  with   warm    narcotic  fomentations. 

The  leading  object  of  the  treatment  is  to  directly  arrest  the  inflamma- 
tory process,  less  by  diminishing  the  vascular  fullness  than  by  overcoming 
the  morbid  excitability  of  the  inflamed  structure  by  the  use  of  anodynes  and 
sedatives.  Not  only  do  anodynes  here  act  in  the  direction  of  overcom- 
ing the  morbid  excitability  of  the  inflamed  structure,  but  they  are  most 
efficient  agents  for  putting  the  inflamed  parts  at  rest,  a  condition  very  es- 
sential in  the  treatment  of  all  inflammatory  processes.  Motion  of  the 
iparts  and  peristaltic  motion  of  the  bowels  especially,  greatly  increases  the 
pain  and  the  intensity  of  the  inflammatory  process.  Hence  to  put  the 
bowels  entirely  at  rest  and  keep  them  so,  until  the  inflammation  has 
abated,  is  one  of  the  essential  features  of  judicious  treatment.  And  one 
■of  the  most  common  errors  that  is  committed  consists  in  the  early  admin- 
istration of  evacuants  which  tend  directly  to  increase  the  peristaltic  motion 
under  the  delusive  idea,  that  it  is  essential  to  empty  the  alimentary  canal. 
This  causes  patients  also  to  be  disturbed  in  getting  up  and  moving  for 
the  evacuations,  thereby  greatly  aggravating  their  condition  instead 
■of  affording  relief.  In  the  cases  to  which  I  have  just  alluded,  where 
the  patient  is  not  previously  in  a  depraved  condition  of  health  by  prior 
disease,  or  constitutional  impairments,  I  have  preferred  the  administration 
to  adults,  during  the  first  twenty-four  or  thirty-six  hours  of  full  doses  of 
opium  in  connection  with  small  doses  of  mercurials;  more  particularly  of 
the  mild  chloride  or  calomel.  From  two  to  three  centigrams  (gr.  -J  to  ^) 
of  the  sulphate  of  morphia,  and  six  centigrams  (gr.  i)  of  calomel  in 
the  form  of  a  powder,  with  a  little  white  sugar,  may  be  given  every  two, 
three  or  four  hours  according  to  its  effects,  beginning  with  a  shorter  time 
tiil  the  patient  has  been  brought  sufficiently  under  the  influence  of  the 
medicine  to  be  free  from  pain  and  decidedly  inclined  to  sleep.  If  the  ad- 
ministration of  these  powders  is  commenced  in  direct  connection  with  the 
application  of  leeches,  and  later  is  followed  by  narcotic  fomentations  as  I 
have  indicated,  there  are  many  cases  in  which  the  first  three  doses  will 
cause  almost  entire  relief  of  the  pain  and  restlessness  of  the  patient,  and 
induce  the  beginnings  of  sleep.  As  soon  as  this  effect  is  produced  the 
interval  between  the  doses  should  be  increased,  first  to  three  hours,  then 
to  four  hours,  and  kept  only  at  such  intervals  as  will  serve  simply  to  per- 
petuate the  restful  condition  of  the  patient  without  inducing  profound 
stupor.  The  result  will  usually  be  that  in  from  twenty-four  to  forty-eight 
hours,  under  sufficient  narcotic  influence  to  produce  the  degree  of  rest  I 
have  indicated,  the  pulse  will  become  slower,  the  temperature  reduced,  the 


TREATMENT.  579 

skin  covereci  with  a  warm  moist  perspiration,  and  the  local  pains  and  ten- 
derness gi'eatly  diminished.  When  these  results  have  been  obtained  do 
not  immediately  risk  a  reversal  of  the  favorable  aspect  of  the  case  by  at 
once  resorting  to  cathartics,  but  allow  the  bowels  still  to  remain  at  rest 
leaving  out  calomel,  and  continuing  the  opiate  preparation  alone  at  just 
such  Intervals  as  will  keep  the  patient  in  a  comfortable  condition  of  rest. 
At  the  same  time  that  calomel  is  omitted,  give  in  addition  to  the  an- 
o^lyne  in  the  interval  between  the  doses  of  it,  some  diuretic.  For  this 
purpose  we  have  nothing  better  than  an  equal  mixture  of  the  liquor  ammonii 
acetatis  and  nitrous  ether,  four  to  eight  cubic  centimeters  of  which  may  be 
given,  diluted  with  a  little  water,  between  each  of  the  doses  of  the  anodyne, 
if  the  case  progresses  favorably  as  most  of  them  will,  of  the  kind  I  have 
now  under  consideration,  by  the  end  of  the  third  day  the  tenderness  will 
have  almost  entirely  disappeared  from  the  abdomen,  there  will  be  little  or 
no  tvmpanitis,  the  pulse  will  have  returned  nearly  to  its  natural  standard 
and  with  the  exception,  in  some  instances,  of  a  mild  degree  of  secondary 
nausea  from  the  effects  of  the  anodynes,  the  patient  will  bf^  entirely  com- 
fortable. Where  six  centigrams  (gr.  i)  of  calomel  have  been  given  in 
connection  with  the  first  five  or  six  doses  of  the  anodyne,  the  bowels  will 
now  in  many  of  the  cases  begin  to  move  spontaneously,  not  with  pain  but 
with  entire  ease;  the  discharges  being  usually  semi-fluid,  or  only  moder- 
ately consistent,  and  pretty  copious,  and  where  they  occur  not  more  than 
two  or  three  times,  they  need  not  be  interfered  with.  But  if  the  number 
of  the  discharges  increase,  become  more  thin,  and  are  accompanied  with 
some  pain  in  the  abdomen,  measures  should  be  taken  immediately  to 
arrest  their  further  occurrence,  and  put  the  intestines  more  perfectly  at 
rest. 

This  may  often  be  done  by  renewing  a  little  more  frequently  the  doses 
of  morphine,  or  still  better,  so  far  as  my  experience  goes,  by  giving  in 
place  of  the  morphine  what  I  have  frequently  mentioned  to  you  as  the 
ordinary  turpentine  and  laudanum  emulsion,  in  doses  of  four  cubic  centi- 
meters (fl.  3i)  after  each  evacuation  until  they  have  entirely  ceased. 
After  the  bowels  have  been  freely  moved,  either  spontaneously  or  by 
warm  water  enemas  thrown  into  the  rectum,  if  there  appears  to  be  no  ten- 
dency for  loose  discharges  and  pain  to  continue,  full  convalescence 
ensues,  and  the  patient  requires  little  other  treatment  than  rest,  and 
a  very  mild  unstiraulating  diet,  taken  in  small  quantities  for  three  or 
four  days.  At  the  end  of  that  time,  if  no  renewal  of  symptoms  occur,  he 
may  be  allowed  to  rise  from  the  bed,  and  occasionally  to  take  exercise. 
But  the  convalescent  in  all  such  cases  should  be  carefully  guarded 
against  all  excesses  both  in  exercise,  as  walking,  or  motions  that  jar  the 
abdomen,  and  in  indulgence  in  promiscuous  diet.  But  where  cases  are 
not  seen  quite  as  early  as  I  have  indicated  and  the  disease  has  made 
more  progress  before  coming  under  observation,  it  may  not  be  judicious 
to  apply  leeches  or  practice  any  local  bleeding.  But  the  warm  narcotic 
fomentations  may  be  applied  over  the  whole  abdomen,  and  opiates  may  be 
administered,  each  of  the  first  three  or  four  doses  being  combined  with 
six  centigrams  (gr.  i)  of  calomel.  The  anodyne  should  be  given  in  suffi- 
cient doses  with  sufficient  frequency  to  bring  the  patient  fairly  under  its 
sedative  influence  and  place  him  at  rest  as  early  as  practicable  without  lead- 
ing to  profound  narcotism.  The  combination  of  liquor  ammonii  acetatis 
and  nitrous  ether  to  encourage  continued  action  of  the  skin  and  kid- 
neys may,  if  retained  by  the  stomach,  be  given  between  the  doses  of  the 
anodyne.  And  to  prevent  the  stomach  from  becoming  irritable  and 
the  supervention  of  troublesome  vomiting,  the  patient  should  be  encour- 


580  PERiTONiirs. 

aged  to  take  only  bits  of  ice  to  satisfy  thirst  and  a  single  spoonful  at  the 
time  of  bland  nourishment  such  as  lime  water  and  milk,  or  some  one 
of  the  animal  broths.  After  the  first  twenty-four  hours  of  the  treatment, 
the  calomel  which  had  been  incorporated  with  the  first  four  or  five  doses 
of  the  anodyne  should  be  omitted.  The  anodyne  and  the  diaphoretic 
may  be  continued,  and  if  the  tympanitis  increases,  the  abdomen  may 
be  frequently  painted  over  either  with  a  liniment  of  camphorated  soap 
and  iodine  in  such  proportion  as  to  render  it  decidedly  stimulating  to 
the  surface,  or  there  may  be  applied  freely  over  the  surface  a  mixture  of 
olive  oil  and  oil  of  turpentine,  the  latter  being  in  such  proportion  as  will 
produce  an  active  irritation.  These  applications  may  be  repeated 
once  in  three  or  four  hours,  and  in  the  intervals  the  narcotic  fomentatioi  s 
may  be  kept  over  the  abdomen.  These,  however,  must  be  made  light, 
for  anything  heavy  especially  thick  poultices  over  the  tender  abdomen 
usually  increase  the  suffering  of  the  patient  more  than  they  do  good.  If 
these  measures  succeed  in  arresting  the  further  progress  of  the  disease, 
the  patient  may  remain  at  rest  two  or  three  days  during  which  the  pulse 
will  become  slower,  the  temperature  diminish  and  all  the  phenomena 
of  inflammation  disappear. 

If  now  spontaneous  evacuations  do  not  occur,  steps  may  be  taken 
to  cautiously  induce  movement  of  the  bowels  by  enemas  as  I  have 
already  described.  But  the  administration  of  cathartics  is  entirely  in- 
judicious, on  account  of  the  danger  of  renewing  the  pain  in  the  abdomen 
and  of  causing  the  return  of  all  the  phenomena  of  the  peritoneal  inflam- 
mation. And  sometimes  the  operation  proceeds  to  such  a  degree  of  pro- 
fuseness  as  to  hasten  the  patient  into  an  early  collapse.  Consequently 
unless  evacuations  spontaneously  occur  it  is  far  better  to  wait,  for  a  whole 
week,  than  it  is  to  resort  to  anything  more  than  mild  enemas  until  con- 
valescence is  well  established.  My  experience  has  been,  that  in  a  large 
proportion  of  cases  spontaneous  evacuations  occurred  before  the  end  of 
the  third  or  fourth  day.  It  is  much  more  frequently  necessary  to  in- 
stitute measures  for  limiting  and  ultimately  arresting  these  spontaneous 
evacuations  than  it  is  to  give  cathartic  medicines  of  any  kind.  One  of 
the  embarrassments  that  you  will  meet  with  in  the  treatment  of  acute 
peritonitis,  is  the  excess  of  irritability  of  the  stomach.  And  for  the  first 
two  or  three  days  you  will  frequently  find  it  impracticable  to  adminis- 
ter a  sufficient  amount  of  anodyne  by  the  stomach  to  obtain  the 
quieting  efi"ects  that  you  desire.  In  such  instances  hypodermic  injections 
of  morphine  should  be  resorted  to,  allowing  the  stomach  to  remain  entirely 
at  rest.  Always  use  hypodermic  injections,  however,  in  safe  doses,  and 
lake  the  trouble  of  repeating  them  rather  than  risk  doses  so  large  as  to 
produce  excessive  narcotism,  especially  when  the  abdominal  distension 
may  be,  at  the  same  time,  so  great  as  to  have  limited  the  respiratory  func- 
tion and  consequently  the  oxygenation  of  the  blood.  In  such  conditions 
the  subcutaneous  injection,  of  even  ordinary  doses  of  inorphine  have  been 
known  to  speedily  produce  so  profound  a  narcotism  as  to  prove  fatal 
within  a  few  hours.  And  yet  the  judicious  use  of  subcutaneous  injections 
in  some  of  these  cases  becomes  necessary  and  highly  valuable.  It  is  true 
that  in  some  they  may  be  avoided  by  the  use  of  anodyne  enemas.  But 
these  are  less  likely  to  be  retained,  are  slower  in  producing  their  effects,  and 
in  other  respects  less  reliable  than  the  use  of  the  remedy  subcutaneously. 
It  is  a  frequent  practice  to  apply  blisters  extensively  over  the  abdomen 
in  peritonitis,  at  that  stage  when  effusion  is  liable  to  commence,  or  what 
is  called  the  second  stage  of  the  disease.     I  have  sometimes  seen  decided 


CHRONIC    PERITONITIS.  581 

advantage  apparently  derived  from  their  use;  but  in  the  great  ma- 
jority of  cases  it  is  sufficient  to  apply  the  stimulating  embrocations 
and  liniments  that  I  have  already  mentioned.  If  the  acute  stage 
passes  by  and  partial  convalescence  supervenes,  leaving  the  abdomen 
enlarged  from  the  accumulation  of  serous  effusions,  as  sometimes  happens, 
it  may  become  desirable  to  apply  a  succession  of  small  blisters  over  the 
abdomen  in  connection  with  the  internal  use  of  suitable  doses  of  the 
iodide  of  potassium  sometimes  combined  with  digitalis.  The  use  of 
iodide  of  potassium  in  combination  with  digitalis  internally,  and  moderate 
counter-irritation  externally,  will  also  constitute  the  best  remedies  when 
the  inflammation  assumes  a  chronic  form.  If  the  amount  of  fluid  in  the 
peritoneal  cavity  is  large  and  there  is  manifest  but  little  disposition  to 
diminish  under  the  use  of  these  remedies  it  may  be  removed  by  the  aspirator 
or  bv  the  ordinary  method  of  paracentesis  abdominis,  and  its  reaccumulation 
retarded  if  not  entirely  prevented  by  a  continuance  of  the  remedies  I 
have  already  named,  after  the  withdrawal  of  the  fluid.  If  in  the  progress 
of  the  treatment  of  acute  peritonitis  the  remedies  I  have  indicated  fail  to 
arrest  the  disease,  and  the  pulse  becomes  extremely  rapid  and  feeble,  the 
extremities  cold  and  blue,  the  respirations  short  and  frequent,  the  mind 
dull  and  wandering,  the  abdomen  more  or  less  distended,  there  is  little 
prosDect  that  the  patient  will  recover,  under  any  kind  of  treatment  what- 
ever. Opiates  under  such  circumstances  must  be  given  more  cautiously; 
and  in  conjunction  with  their  moderate  continuance,  the  patient  mav 
derive  some  benefit  from  the  use  of  such  dift'usible  stimulants  as  car- 
bonate of  ammonia,  camphor,  caffeine  and  theine;  and  digitalis  as  a  tonic 
to  sustain  the  heart's  action.  Stimulating  embrocations  over  the  abdomen 
may  also  be  continued,  and  a  vigilant  administration  of  nourishment. 
Tablespoonful  doses  of  wheat  flour  and  milk  gruel,  beef  tea,  or  other  an- 
imal broths,  and  the  frequent  administration  of  one  or  two  spoonfuls  of 
warm  tea  or  coffee  such  as  is  usually  taken  upon  the  table,  will  constitute 
the  best  means  of  support. 

It  is  almost  the  universal  practice  in  these  cases  to  resort  to  the  free 
use  of  alcoholic  remedies,  under  the  idea  that  these  will  aid  in  sustaining 
the  vital  forces  and  in  preventing  fatal  exhaustion.  I  have  never  seen  an 
instance,  however,  in  which  I  could  perceive  the  slightest  beneficial  effect 
from  their  use.  In  the  cases  of  limited,  or  circumscribed  peritonitis, 
if  the  inflammatory  symptoms  abate  and  yet  leave  accumulations,  either 
of  a  serous  or  purulent  character,  the  first  will  generally  disappear  by 
absorption  under  the  influence  of  the  measures  I  have  indicated.  If  not,  it 
can  be  removed  by  aspiration.  In  those  cases  where  the  accumulations 
are  purulent  aspiration  may  be  resorted  to,  and  if  the  pus  is  found  to  be 
too  thick  to  pass  the  aspirator  needle  successfully  and  freely,  larger 
openings  may  be  made,  the  pus  discharged,  and  the  subsequent  antiseptic 
treatment  judiciously  carried  out  with  some  prospect  of  success.  Yet 
many  such  cases  will  ultimately  fail  under  continued  suppuration  and 
die  from  exhaustion.  What  I  have  now  stated  in  regard  to  the  varieties 
of  acute  general  or  diffuse  peritonitis,  has  included  so  much  concerning 
the  circumscribed  form  of  the  disease;  and  the  management  of  this  class 
of  cases  is  so  directly  parallel  in  kind  with  that  of  the  more  diffuse,  as  to 
make  a  separate  consideration  unnecessary. 

Chronic  Peritonitis. — Chronic  inflammation  of  the  peritoneum  may  be 
the  sequel  of  an  acute  or  subacute  attack,  or  it  may  originate  independ- 
ently of  an\-  preceding  acute  stage.  A  large  proportion  of  the  acute 
attacks  accompanied  by  suppurative  action  and  accumulation  of  pus  or 
pus  mixed  with  serum  in  the  cavity  of  the  peritoneum,  degenerate  into  the 


582  CHEONIC    PERITONITIS. 

chronic  form, and  although  often  continuing  a  considerable  length  of  time, 
ultimately  terminate  fatally.  Many  of  those  that  I  have  mentioned  as  cir- 
cumscribed inflammations  of  the  peritoneum  also  terminate  in  subsidence  of 
the  general  febrile  symptoms,  while  the  membrane  will  remain  more  or  less 
thickened,  with  increased  vascularity,  some  degree  of  tenderness  and  an  in- 
creased accumulation  of  the  inflammatory  products  so  as  to  constitute,  strict- 
ly speaking,  a  chronic  form  of  the  disease.  Occasionally  cases  may  be  met 
with,  in  which  chronic  inflammation  is  developed  in  the  peritoneum,  or  in 
some  portion  of  it,  as  the  result  of  mechanical  violence,  induced  by  falls  or 
blows,  but  more  frequently  by  far  the  cases  of  chronic  inflammation  of  this 
membrane  originate  not  from  any  acute  attacks,  but  are  from  the  beginning 
of  that  low  grade  called  chronic,  and  having  for  their  causes  either  the  efi"u- 
sion  of  serous  fluid  into  the  cavity  of  the  peritoneum  from  obstructions  to 
the  portal  circulation,  as  in  diseases  of  the  liver,  or  in  connection  with  gen- 
eral dropsy  as  in  renal  disease;  the  inflammatory  action  being-  secondary 
to  the  dropsical  accumulations  in  such  instances.  Or  they  may  originate 
from  tuberculous  deposits  more  frequently  in  that  part  of  the  mesentery 
covering  the  omentum,  meso-co!on  and  the  exterior  of  the  liver  and 
spleen.  In  a  very  large  proportion  of  the  cases  of  general  milliary  tuber- 
culosis, more  or  less  deposits  take  place  in  the  portions  of  the  peritoneal 
membrane  just  mentioned,  sometimes  without  exciting  sufficient  inflam- 
matory action  to  attract  attention,  and  in  others  being  accompanied  with 
a  slow,  insidious  development  of  inflammation,  exudation  and  effusion, 
sufficient  to  fill  up  the  peritoneal  cavity.  In  some  patients  of  scofu'ous 
constitution,  especially  in  early  childhood  the  mesenteric  glands  become 
involved  in  hypertrophy  and  casaous  degeneration  in  the  same  manner  as 
the  lymphatic  glands  in  the  neck  or  in  the  arm  pits,  and  during  their  prog- 
ress especially  in  the  stage  of  softening,  sufficient  inflammatory  action 
is  set  up  to  involve  the  peritoneum,  entering  into  the  formation  of  that 
part  of  the  mesentery,  in  which  the  glands  are  located.  Bat  this  form  of 
disease  was  sufficiently  described  when  speaking  of  the  various  conditions 
of  scrofula  in  its  local  developments  througUout  the  whole  system. 
Another  cause  of  chronic  peritoneal  inflammation  is  the  formation  of 
cancerous  nodules  in  the  omentum  and  involving  the  peritoneum  in  their 
progress,  if  not  primarily  originating  in  that  membrane.  Some  of  the 
cases  of  scirrhus  of  the  pylorus,  involve  also  more  or  less  inflammation  of 
the  adjacent  peritoneum,  and  the  same  is  true  when  scirrhus  exists  in  the 
liver,  or  in  the  spleen,  near  enough  to  the  surface  to  involve  the  perito- 
neum covering  them. 

Syrnptoins. — When  chronic  peritonitis  follows  as  the  sequel  of  the 
acute  form  of  the  disease  its  symptoms  consist  chiefly  of  distension  of  the 
abdomen  from  accumulations  of  more  or  less  serous  or  sero-purulent  fluid 
accompanied  by  thickening  of  portions  of  the  membrane  and  tenderness 
to  pressure,  particularly  in  circumscribed  places.  The  pulse  is  moderately 
accelerated,  the  respiration  usually  shorter  and  quicker  than  natural, 
owing  more  to  the  mechanical  impediment  to  the  descent  of  the  diaphragm 
than  to  any  other  cause.  The  skin  is  dry,  and  the  temperature  generally 
elevated  two  or  three  degrees  in  the  afternoon  and  evening,  while  in  the 
morning  it  falls  to  the  natural  standard.  There  is  progressive  loss  of  tlesh 
and  strength,  impairment  of  appetite,  scantiness  of  urine  and  a  variable 
condition  of  the  bowels,  thev  being  sometimes  costive,  and  at  others  too 
loose,  and  in  many  cases,  constipation  and  diarrhoea  alternate  with  each 
other  at  frequent  intervals.  Under  direct  examination  of  the  abdomen  in 
such  cases,  in  addition  to  tenderness  on  firm  pressure,  there  is  in  most  of  the 


SYMPTOMS.  583 

cases,  a  feeling  of  inequality  in  diflPerent  portions  of  the  abdomen,  some 
places  being  harder  and  more  prominent,  apparently  from  the  thickness  of 
portions  of  the  peritoneal  membrane  lining  the  abdominal  walls.  Also 
more  or  less  dullness  on  percussion  and  usually  plain  fluctuation,  indicat- 
ing the  existence  of  fluid. 

The  dullness  on  percussion  and  the  fluctuation  by  palpation  is  most 
evident  in  the  most  dependent  parts  of  the  abdominal  cavity,  according 
to  the  position  of  the  patient.  In  lying  upon  the  back  there  will  be  fre- 
quently well  marked  tympanitic  resonance  in  the  epigastrium  and  portions 
of  the  umbilical  region,  while  the  hypochondrium  and  lumbar  regions  are 
entirely  dull,  and  afford  plain  fluctuation.  After  the  disease  has  as- 
sumed a  strictl}'-  chronic  form,  there  are  not  usually  severe  pains,  and  yet 
most  cases  will  be  characterized  by  moderate  lancinating  pains  at  inter- 
vals, especially  when  the  patient  has  attempted  to  exercise  or  to  make 
any  considerable  movements  of  the  body.  There  is  also  a  sense  of  in- 
creased heat  in  the  abdomen  in  the  majority  of  cases.  Frequently  there 
is  sympathetic  disturbance  of  the  system,  imperfect  digestion  of  food, 
occasional  vomiting,  particularly  in  association  with  the  appearance  of 
diarrhoea  in  the  advanced  stage  of  the  disease.  When  the  chronic  peri- 
tonitis has  resulted  as  a  secondary  affection  in  the  progress  of  either  renal 
or  hepatic  diseases,  inducing  a  dropsical  condition  of  the  system,  the 
evidences  of  the  peritoneal  inflammation  are  often  very  obscure — the 
prior  disease  having  already  debilitated  the  patient,  altered  the  condition 
of  the  blood,  and  induced  in  the  renal  cases  general  dropsy,  and  in  the 
hepatic,  more  or  less  circumscribed  accumulations  in  the  peritoneal  cavity; 
all  the  symptoms  are  very  apt  to  be  referred  to  the  original  disease,  and 
yet  close  inquiry  will  show,  that  whenever  the  peritoneal  membrane 
actually  takes  on  inflammatory  action,  there  is  an  increase  of  febrile  move- 
ments, accelerating  the  pulse  beyond  what  it  had  been  in  connection 
with  the  previous  disease,  causing  more  or  less  increased  sense  of  sore- 
ness, and  sometimes  sharp  pains  throughout  different  places  in  the  ab- 
domen, with  tenderness  to  pressure,  especially  in  particular  regions  of  the 
abdominal  cavity,  and  more  rapid  distension  of  its  walls  from  the 
accumulations  of  fluid  within.  The  patient  almost  always  finds  great 
difficulty  in  turning  from  one  side  to  another,  without  feeling  a  sore  pain 
run  deeply  through  the  abdomen,  and  attempts  to  walk  also  generally 
give  rise  to  feelings  of  sore  pain  from  the  concussion.  In  most  such  cases, 
the  effusion  into  the  cavity  becomes  so  great  in  a  few  weeks,  or  months, 
that  the  diaphragm  with  the  liver  and  spleen  are  crowded  strongly  up- 
ward, trespassing  upon  the  capacity  of  the  chest,  and  so  far  interfering 
with  the  expansion  of  the  lungs  in  inspiration  as  to  cause  great  incon- 
venience to  the  patient,  from  shortness  of  breath,  sense  of  suffocation  or 
oppression,  and  often  a  relaxation  of  the  skin  with  cold  perspiration,  blue- 
ness  of  the  lips,  coldness  of  the  extremities,  inability  to  recline  in  the  hor- 
izontal position,  or  to  assume  any  except  one  nearly  upright.  In  such  cases 
usually  the  appetite  is  lost,  the  urine  becomes  nearly  suppressed,  and 
unless  relief  is  obtained  by  removing  the  accumulated  fluid,  universal 
dropsical  infiltration  takes  place  into  the  tissues,  causing  general  oedema 
and  an  early  death.  In  other  instances  before  this  extreme  interference 
with  the  capacity  of  the  chest  and  the  respiratory  function,  the  patient 
becomes  very  much  emaciated,  apthous  ulcerations  appear  in  the  mouth 
and  fauces,  all  food  becomes  distressing  to  the  stomach,  or  is  rejected  by 
vomiting,  a  wasting  diarrhoea  supervenes,  and  he  dies  from  asthenia, 
rather  than  from  interference  with  the  respiratory  process.  When 
chronic  peritonitis   arises  from  tubercular   deposits   in  the  mesentery  or 


584  CHEONIC    PERITONITIS. 

or  meso- colon,  or  any  of  the  parts  connected  with  the  peritoneum,  the  early 
symptoms  are  often  exceedingly  obscure.  Patients  most  generally,  for  a 
considerable  length  of  time,  complain  only  of  irregular  pains  in  the  ab- 
domen, sometimes  only  momentary  and  sharp,  at  other  times  rather  dull, 
or  simply  of  a  sense  of  soreness  whenever  from  attempts  at  any  sudden 
movements  of  the  body  the  abdomen  is  jarred,  coupled  with  a  progressive 
loss  of  flesh,  a  sense  of  weakness,  a  quick  rather  small  and  compressible 
pulse,  a  slight  elevation  of  temperature  during  the  middle  and  latter  part 
of  the  da}',  accompanied  by  more  or  less  dryness  in  the  mouth  and  fauces, 
less  than  the  natural  secretion  of  urine,  a  fickle  or  variable  appetite, 
an  equally  variable  condition  of  the  bowels,  ijeing  sometimes  consti- 
pated and  sometimes  the  reverse,  and  after  from  one  to  three  months 
of  these  equivocal  moderate  symptoms  the  abdomen  is  found  to 
be  enlarging.  In  most  instances  percussion  and  palpation  will 
readily  determine  that  such  enlargement  is  owing  mainly  to  an  ac- 
cumulation of  fluid.  Sometimes,  though  rarel}-,  the  tubercular  form  of  the 
disease  will  be  accompanied  by  sufficient  enlargement  of  some  of  the 
mesenteric  glands,  or  by  sufficient  accumulation  of  tubercular  masses 
with  thickening  of  the  membrane  lining  the  abdominal  walls,  or  of 
the  omentum  superficially,  to  be  felt  as  hard  bodies  through  the  walls  of 
the  abdomen.  And  while  detecting  by  manipulation  or  palpation  the  ex- 
istence of  such  bodies  there  is  also  readily  revealed  more  or  less  fluctua- 
tion of  fluid  and  dullness  over  the  more  dependent  parts  of  the  abdominal 
cavity.  But  many  of  the  cases  are  not  accompanied  by  either  sufficient 
accumulations  of  tuberculous  deposits  or  enlargement  of  the  glands  in  the 
abdomen  to  present  any  tumor  that  can  be  detected  by  an  external  ex- 
amination. It  is  true  in  a  very  large  proportion  of  these  cases  tubercular 
deposits  are  not  limited  to  parts  in  the  abdomen,  but  exist  at  the  same 
time  in  the  pulmonary  tissue,  or  in  the  liver,  or  both.  When  the  lungs 
are  involved,  physical  exploration  will  usually  detect  their  existence,  if 
the  physician's  attention  is  turned  in  that  direction.  And  finding  actual 
tubercular  deposit  in  the  lungs  or  any  other  portions  of  the  system,  at 
once  would  render  it  highly  probable  if  not  certain  that  the  abdominal 
symptoms  to  which  I  have  alluded,  also  originated  from  tubercular  de- 
posits in  connection  with  the  peritoneal  membrane  as  already  described. 
And  even  in  cases  where  theie  is  no  appreciable  deposit  in  the  lungs,  if 
the  patient  is  in  the  early  part  of  life,  and  possesses  a  strong  hereditary 
tendency  to  scrofulosis  or  tuberculosis  as  indicated  by  family  history  and 
symptoms,  and  the  symptoms  referable  to  the  abdomen  that  I  have  de- 
scribed exist,  it  would  justify  the  inference  that  they  originated  from 
tubercular  deposits.  When  it  has  advanced  far  enough  to  occasion  any 
considerable  amount  of  serous  or  sero-purulent  accumulations,  then  all  the 
physical  signs  that  were  described  in  speaking  of  accumulations  from  the 
more  acute  form  of  the  disease,  equally  characterize  these  cases. 

That  chronic  peritonitis  does  occur  from  the  localization  of  the  tuber- 
cular deposits  in  the  peritoneum  and  other  parts  in  the  abdomen,  I  have 
seen  sufficient  clinical  proof.  During  the  present  college  term  there  has 
been  a  patient  in  the  hospital  for  a  number  of  weeks,  a  lad}'  about  thirty- 
five  years  of  age,  who  was  admitted  with  the  impression  that  she  had  an 
ovarian  tumor,  and  evidently  entertaining  the  hope  that  it  might  be  re- 
moved by  the  ordinary  operation  of  ovariotomy.  Having  my  attention 
directed  to  the  case  on  account  of  some  cough  and  expectoration  of  a  suspi- 
cious character,  I  found  on  careful  physical  exploration,  plain  evidences 
of  extensive  tubercular  deposit  in  the  upper  and  middle  portions  of  both 
lungs,  and  one  or  two  points  commencing  the  second  stage  of  their  prog- 


SYMPTOMS.  585 

rass.  And  it  was  evident  from  the  examination  of  the  abdomen,  that 
the  distension  there  was  occasioned  not  by  ovarian  cysts,  but  by  actual 
accumulation  in  the  peritoneal  cavity,  although  at  two  or  thr^e  places 
deep  pressure  would  apparently  bring  the  points  of  the  fingers  in  contact 
with  hard  bodies.  In  the  progress  of  this  case  the  patient  became  much 
oppressed  in  breathing  both  from  the  fullness  of  the  abdomen,  which 
impeded  the  descent  of  the  diaphragm,  and  from  the  disease  in  the 
lungs  themselves.  The  abdomen  presented  well  marked  fluctuation.  I 
thc)ught  to  give  temporary  relief  to  the  patient  by  evacuating  the  fluid 
contents  of  the  peritoneum  by  the  ordinary  operation  of  paracentesis-ab- 
dominis.  1  introduced  a  good-sized  trochar  withdrawing  the  styllet  but  no 
fluid  flowed.  And  yet  the  impression  as  it  entered  the  abdominal  cavity 
was  perfectly  characteristic  of  entering  a  fluid,  and  at  the  point  of 
its  introduction  no  solid  body  could  be  detected.  Introducing  an 
ordinary  probe  through  a  canula  no  resistance  was  found  at  the  en- 
trance of  the  canula,  and  on  twirling  it  a  little  there  came  out  a  small 
quantity  of  a  gelatinous  mass  or  semi-fluid  substance  thicker  and  more 
gelatinous  than  the  albumen  of  the  egg.  By  continued  manipulation,  and 
pressure  upon  the  abdomen  and  especially  aided  by  the  sudden  pressure 
produced  by  the  coughing  of  the  patient,  several  ounces  of  this  gelatinous 
material  were  withdrawn,  which  caused  a  considerable  lessening  of  the 
previous  tenseness  of  the  abdominal  walls.  On  withdrawing  the  styllet  and 
canula,  the  cough  continued  and  forced  more  of  this  material  through  the 
opening  for  the  next  hour — making  perhaps  in  all  that  was  withdrawn  eight 
or  ten  ounces.  This,  however,  was  only  a  very  small  proportion  of  the  quan- 
tity contained  within.  No  inflammatory  action  followed  withdrawal  of  this. 
The  lungs  were  so  much  involved,  that  it  was  improper  to  give  the  patient 
any  encouragement  about  ultimate  recovery  by  any  operative  procedure, 
she  therefore  returned  to  her  friends.  This  illustrated  what  sometimes 
develops  in  these  cases  of  chronic  peritonitis,  namely:  filling  up  of  the 
abdomen  more  or  less  with  a  fluid  mass  so  nearly  of  a  gelatinous  or 
thick  consistence  as  to  be  incapable  of  removal  through  ordinary  proc- 
esses, either  by  the  aspirator,  or  tapping  with  the  trochar.  In  another 
instance  of  a  girl  fourteen  years  of  age,  the  tubercular  disease  involved 
both  peritoneum  and  mesenteric  glanJs.  Some  of  the  latter  after  the  ab- 
domen had  become  much  distended  by  sero-purulent  fluid,  containing 
flocculi  or  masses  of  fibrinous  material  which  had  separated  from  a  portion 
of  the  colon  to  which  they  had  been  adherent,  continued  to  suppurate 
until  perforation  of  the  walls  of  the  intestines  took  place,  and  thus  dis- 
charged the  contents  of  the  abdomen  through  the  bowels;  afi"ording  for  a 
time  a  sensible  degree  of  diminution  in  its  size.  The  hectic,  emaciation, 
and  other  symptoms  continuing,  in  a  few  months  the  patient  was  worn  out, 
when  the  post-mortem  revealed  what  I  have  just  described;  namely, 
granular  tubercles  covering  the  surface  of  the  peritoneum,  throughout  the 
whole  of  the  omental  part,of  the  meso-colon,  and  nearly  the  whole  mass  of 
mesenteric  glands  in  diff"erent  stages  of  enlargement  and  degeneration. 
Some  being  actually  converted  into  purulent  abscesses,  and  one  larger 
gland,  which  had  constituted  an  abscess,  was  collapsed,  presenting  more 
the  appearance  of  a  sac,  the  inner  surface  constituting  the  walls  of  the 
abscess,  communicated  still  with  the  upper  portion  of  the  sigmoid  flexure 
of  the  colon. 

When  chronic  peritonitis  arises  from  the  existence  of  malignant 
or  cancerous  disease  within  the  abdominal  cavity,  the  symptoms  so 
far  as  they  depend  upon  peritoneal  inflammation,  do  not  differ  materi- 
ally from  those  I  have  just    described    as    occurring   in    connection    with 


5S6  CHRONIC    PERITONITIS. 

tubercular  deposits.  There  is  the  same  obscure  beginnings,  ending 
after  a  while  in  the  accumulation  of  fluid,  more  rapid  distension  of  the 
abdomen,  accompanied  by  well  marked  fluctuation,  and  usually  before 
the  walls  of  the  abdomen  become  too  tense,  or  the  accumulated  fluid 
too  large  in  amount,  the  existence  of  a  cancerous  tumor,  can  be  more  cr 
less  readily  felt  through  the  abdominal  walls.  Some  writers  have  claimed 
that  cancerous  disease  does  not  originate,  or  commence  primarily,  in  any 
part  of  a  serous  membrane;  particularly  those  who  adopt  the  theory  that 
all  cancers  originate  in  the  epithelial  structures;  serous  membranes  hav- 
ing no  proper  epithelium,  but  only  a  layer  of  polygonal  cells  or  endothe- 
lium. The  evidence,  however,  favors  the  doctrine  that  sometimes,  though 
rarely,  cancerous  developments  do  occur  in  the  endothelial  cells  them- 
selves; constituting  properly  an  endothelioma,  instead  of  an  epithelioma. 
The  distinction,  however,  is  of  little  or  no  practical  importance,  as  the 
results  would  be  the  same.  The  diagnosis  between  chronic  peritonitis 
associated  with  tuberculosis  from  that  associated  with  carcinoma  or  any 
variety  of  cancer  depends  not  so  much  upon  the  symptoms  belonging  to 
the  diseased  peritoneum,  as  to  those  which  belong  to  the  primary  afi"ec- 
tion.  The  distinctions  are  precisely  those  existing  between  the  cancerous 
cachexia,  with  more  isolated  an;l  harder  tumors  where  tumors  can  be 
detected,  and  the  tuberculous  diathesis  with  the  evidence  of  tubercular 
deposit  generally  distributed  throughout  many  of  the  structures,  instead 
of  being  limited  to  some  one  region,  or  to  some  one  hard  tumor. 

Still  another  form  of  chronic  inflanunation  of  the  peritoneum  has  been 
described  as  a  hemorrhagic  varietv.  This  appears  to  be  a  rare  affection 
occurring  in  the  peritoneum,  corresponding  in  its  anatomical  characters 
closely  with  what  is  called  pachymeningitis  in  the  serous  membranes  of  the 
brain.  There  is  first  dilatation  of  the  vessels  in  little  patches  on  the 
peritoneum,  then  ruptures  occur,  and  the  escape  of  small  quantities  of 
blood,  followed  by  sufficient  inflammatory  action,  usually  to  throw  out  a 
layer  of  false  membrane,  limiting  the  difi"usion  of  blood  and  constituting 
a  strictly  circumscribed  inflammation,  which  is  often  accompanied  by  very 
obscure  sjnnptoms,  and  from  which  the  patient  apparently  recovers  in  a 
little  time.  And  the  same  recurs  again  and  again  at  different  intervals 
until  finally  a  sufficient  portion  of  the  membrane  becomes  involved  to 
induce  serous  effusion,  and  all  the  phenomena  of  abdominal  dropsical 
accumulations.  When  the  water  is  withdrawn  it  is  very  generally  found 
tinged  with  blood,  or  contains  an  appreciable  number  of  red  corpuscles, 
and  as  its  tendency  is  to  reaccumulate,  the  patient  becomes  gradually 
exhausted,  either  from  the  extent  of  the  accumulation,  or  the  pressure  of 
it  upon  the  'thoracic  cavity  and  other  important  organs.  If  it  is  with- 
drawn b}'-  tapping  or  aspiration  to  avoid  the  distressing  effects  of  over- 
distension, the  withdrawal  of  the  nutritive  elements  of  the  blood  from 
continued  exudation  into  the  peritoneal  cavity  will  lead  ultimately  to 
general  exhaustion,  impairment  of  function,  universal  dropsical  infiltra- 
tions and  death. 

Prognosis. — From  the  description  I  have  given  of  the  various  forms  of 
chronic  inflnmrnation  of  the  peritoneum,  you  will  perceive  that  many  cases 
tend  to  an  ultimate  fatal  termination.  It  may  be  said  that  all  the  cases 
arising  from  tuberculosis,  cancers,  renal  and  hepatic  diseases  are  incurable. 
Their  progress  may  be  retarded,  temporary  relief  may  often  be  obtained 
by  removal  o'.  the  accumulated  fluid  in  the  abdominal  cavity  either  by 
as^piration  or  tapping;  but  the  diseases  which  have  given  rise  to  the  peri- 
toneal trouble,  being  themselves  incuraljle,  there  is  an  inevitable  tendency 
to  a  fatal  termination.     Tne  same  miy  be  said  of  such  cases   as  originate 


PROGNOSIS.  587 

in  connection  with  either  g-eneral  dropsy  from  cardiac  and  renal  disease 
or  from  direct  obstruction  of  the  portal  circulation  by  cirrhosis  or  other 
structural  diseases  of  the  Irver.  But  in  cases  which  have  originated  from 
moderate  subacute  and  acute  attacks  in  which  no  suppuration  has  oc- 
curred, but  simply  thickening,  and  continued  congestion  of  the  peritoneal 
membrane,  accompanied  by  more  or  less  serous  effusion  into  the  abdominal 
cavity,  frequently  accompanied  by  a  moderate  degree  of  plastic  exudation 
whlcii  form  patches  of  organized  membrane,  and  sometimes  constitute 
bands  of  adhesion  between  different  coils  of  intestine,  or  between  the 
surfaces  of  the  peritoneum  lying  in  contact  with  each  other,  there  is  a 
possibility  of  the  patient's  recovery,  by  the  use  of  such  remedies  as  usual- 
ly favor  a  disintegration  and  removal  of  inflammatory  products,  and  a 
careful  support  of  the  nutrition  of  the  patient.  The  inflammatory  prod- 
ucts existing  in  the  case  may  be  removed  by  absorption,  nutrition  re- 
maining active,  no  new  accumulations  take  place,  and  the  patient  remains 
well.  Quite  as  frequently,  however,  even  in  these  cases,  the  patient  does 
not  make  a  permanent  recovery. 

Remedies  for  a  time  lessen  the  amount  of  serous  accumulation,  render 
the  patient  much  more  comfortable,  but  on  the  recurrence  of  every  excess 
of  exercise,  exposure,  or  accident  that  is  calculated  to  disturb  the  abdom- 
inal cavity  the  symptoms  are  renewed,  new  accumulations  take  place 
until  the  peritoneal  membrane  becomes  permanently  indurated;  consti- 
tuting substantially  a  sclerosis  or  hypertrophy  of  the  connective  tissue  en- 
tering into  it — in  which  condition  a  continuance  of  the  process  of  exudation 
sufficient  to  renew  the  serous  accumulations  within  a  few  weeks  has  oc- 
curred, every  time  they  are  evacuated  either  by  aspiration  or  tapping. 
And  yet  such  patients  will  occasionally  live  for  many  years.  I  have  one 
still  in  the  wards  of  the  hospital;  a  woman  about  forty,  or  between  forty 
and  forty-five  years  of  age,  who  was  admitted  to  the  hospital  about 
sixteen  years  since.  At  the  time  of  her  admission,  the  abdomen 
was  enormously  distended  by  a  serous  accumulation.  It  had  been 
allowed  to  go  on  increasing  until  the  umbilical  region  had  given  way, 
and  a  large  umbilical,  hernial  protrusion  had  taken  place.  The  patient 
was  not  much  emaciated;  had  little  or  no  general  febrile  symptoms  or  in- 
creased heat,  but  was  suffering  extremely  from  the  crowding  of  the  dia- 
phragm upwards,  and  from  the  great  weight  of  the  abdomen.  Being  unable 
to  get  a  very  accurate  history  of  the  case,  and  the  dropsy  being  entirely  cir- 
cumscribed or  limited  to  the  abdominal  cavity,  with  no  cedematous  infiltra- 
tion into  the  feet,  ankles  or  any  other  part,  I  was  lead  to  suppose  that  it 
originated  from  some  disease  of  the  liver;  most  likely  the  early  stage  of 
cirrhosis.  But  for  temporary  relief,  I  introduced  an  ordinary  trochar 
through  the  abdominal  walls,  withdrew  the  styllet  and  drew  off  through 
the  canula  two  large  wooden  pails  full  of  a  very  heavy  thick  or  serous 
fluid  only  slightly  turbid.  When  the  abdomen  was  empty  I  could  detect 
no  evidence  of  any  tumor  in  any  part  of  it,  certainly  no  evidence  of  en- 
laro-ement  of  the  liver  or  spleen,  neither  was  there  indication  of  any  cori- 
siderabie  contraction  of  the  liver  as  in  cirrhosis.  There  was  slight 
tenderness  on  deep  pressure,  as  by  pressing  toward  the  back  parts  of  the 
abdomen  against  the  meso-colon,  but  it  was  by  no  means  strongly  marked. 
The  reaccumulation  of  fluid  was  slow,  but  at  the  end  of  six  months,  it 
had  again  become  sufiicient  to  be  very  troublesome  to  the  patient,  and 
again  we  resorted  to  tapping.  She  has  remained  in  the  hospital 
requiring  to  be  tapped  pretty  regularly  twice  a  year,  the  shortest  interval 
being  five  months,  the  longest  seven  between  the  tappings,  until  she  has 
now  had  thirty-four  tappings,   during  a  period  of  sixteen   or  seventeen 


588  CHRONIC   PEEITONITIS. 

years.  The  only  changes  that  have  taken  place  are  a  little  increased 
paleness,  from  diminution  of  the  red  corpuscles  of  the  blood,  and  progress- 
ively increased  dryness  and  harshness  of  the  cutaneous  surface,  the  urine 
is  almost  constantly  scant,  and  there  has  been  a  steadily  increased  thick- 
ening of  the  membrane  lining  the  abdominal  walls  and  of  the  parts 
constituting  the  mesentery,  as  readily  determined  by  examinations 
each  time  after  the  withdrawal  of  the  fluid.  And  yet  the  patient  is 
now  in  sufficient  health  to  render  it  probable  that  she  will  yet  require 
several  more  tappings  before  reaching  a  fatal  degree  of  exhaustion.  In 
onl}^  one  instance  was  fluid  withdrawn  tinged  with  blood,  and  that  was 
occasioned  by  the  patient's  having  a  fall,  which  caused  a  severe  contusion 
of  the  distended  abdomen  about  two  weeks  before  tapping.  It  would 
seem  in  this  case  that  the  patient  had  been  attacked  primarily  with  a 
moderate  chronic  peritoneal  inflammation,  more  particularly  of  that  part 
of  it  which  enters  into  the  formation  of  the  mesentery  and  meso-colon 
which  has  resulted  in  thickening  and  hypertrophy  of  the  membrane,  and 
a  persistent  exudatdon  of  serum.  But  in  no  part  of  her  long  stay  in  the 
hospital  has  she  exhibited  any  marked  febrile  symptoms  or  any  other  in- 
dications of  disease  of  an  inflammatory  character. 

Treatment. — Having  mentioned  the  chief  diagnostic  symptoms  of  the 
different  stages  and  varieties  of  chronic  peritonitis,  I  shall  pass  directly  to 
the  treatment.  This,  in  almost  all  the  cases,  must  be  palliative.  When 
the  disease  has  originated  without  connection  with  any  general  constitu- 
tional diathesis  or  local  developments  of  a  tuberculous  or  cancerous  Tiature, 
benefit  may  often  be  derived  from  the  internal  administration  of  diuretics 
in  connection  with  iodine  alterants;  more  especially  a  combination 
of  iodide  of  potassium  with  digitalis.  If  the  patient  suffers  pain 
or  much  soreness,  conium  or  hyoscyamus  or  belladonna  may  be  added 
to  the  iodide  and  digitalis;  and  long  continued  moderate  counter-irritation 
may  be  kept  up  over  the  surface  of  the  abdomen.  Occasionally  in  these 
cases  temporary  exacerbations  indicating  increase  of  local  inflammation 
in  some  particular  portions  of  the  abdomen  will  occur,  and  I  have  seen 
the  application  of  a  blister  under  such  circumstances  productive  apparently 
of  decided  good  effects.  But  more  generally  instead  of  blistering,  which 
to  be  effectual  must  be  repeated,  thereby  incurring  the  risk  of  having  the 
oantharides  irritate  the  neck  of  the  bladder,  it  is  better  to  rely  upon  such 
applications  as  will  produce  decided  stimulation  of  the  surface  without 
actually  vesicating.  A  liniment  composed  of  two  or  three  parts  of  cam- 
phorated soap  liniment,  and  one  of  the  tincture  of  iodine  may  be  used,  by 
applying  it  over  the  whole  abdominal  surface  morning  and  evening. 
When  the  inflammation  is  more  circumscribed  or  limited  to  some  particular 
part  of  the  abdomen,  and  is  not  complicated  with  any  constitutional  dia- 
thesis, advantage  may  be  derived  from  the  use  for  a  limited  time,  before 
the  application  of  soap  and  iodine  liniment,  of  a  mercurial  preparation, 
particularly  of  the  oloate  of  mercury.  But  this  must  be  used  with  suffi- 
cient caution  not  to  allow  the  amount  absorbed  to  produce  constitutional 
effects  or  soreness  of  the  mouth.  It  will  be  more  advantageous  to  use  it 
only  for  a  few  days  first,  and  then  follow  it  with  iodine  diluted  with 
camphorated  soap  liniment.  By  thus  using  diuretics,  mild  alterants  and 
anodynes  internally  with  counter-irritation  of  a  moderate  character  exter- 
nally, and  persisting  in  thjir  use  for  a  considerable  length  of  time,  the 
progress  of  some  cases  may  be  arrested,  the  effusion  that  had  taken 
place  reabsorbed,  and  recovery  produced.  Where  this  does  not  result, 
the  sam3  treatment  will  retard  the  progress  and  alleviate  the  symptoms 


HEPATITIS.  589 

of  the  patient,  and  perhaps  postpone  the  time  when  further  measures  must 
be  adopted  to  relieve  the  abdominal  distension.  Wiien,  however,  the 
latter  occurs  to  such  an  extent  as  to  seriously  embarrass  other  functions, 
and  is  not  readily  reduced  by  such  measures  as  I  have  indicated,  instead 
of  resorting,  as  is  sometimes  done  to  hydragogue  cathartics,  and  thereby 
impairing  the  digestive  organs,  and  yet  getting  only  a  temporary  and 
moderate  degree  of  relief  from  the  serous  accumulation  in  the  abdomen, 
it  is  better  to  proceed  to  aspirate  where  the  fluid  is  found  to  be  only  serous, 
and  repeat  the  aspiration  just  as  often  as  the  abdomen  becomes  sufficiently 
distended  to  crowd  upon  the  diaphragm.  It  is  not  well  to  repeat  it  ofrener; 
indeed  the  aspirations  or  tappings  should  not  be  made  as  long  as  the 
patient  can  be  comfortable,  or  can  maintain  the  respiratory  function  with- 
out serious  embarrassment,  because  every  removal  of  two,  three,  or  four 
gallons  of  serous  fluid  allows  the  exudation  to  proceed  more  rapidly,  and 
in  consequence  more  rapidly  exhausts  the  blood  of  its  albumen  as  well  as 
saline  and  watery  elements,  and  correspondingly  reduces  the  patient. 

When  by  aspiration  it  is  found  that  the  fluid  in  the  abdominal  cavity 
is  pus,  there  is  little  hope,  even  of  obtaining  much  temporary  relief,  or 
materially  retarding  the  progress  of  the  case.  And  the  question  whether 
the  patient  shall  be  rendered  as  comfortable  as  possible  by  palliatives,  and 
the  disease  allowed  to  progress  without  any  operative  procedure,  or 
whether  the  pus  shall  be  removed  by  tapping  with  a  large  trochar,  to 
which  a  Davidson's  syringe  is  attached,  and  the  abdominal  cavity  washed 
out  cautiously,  with  artiseptic  washes,  and  have  drainage  established  as 
in  cases  of  suppurative  pleuritis,  should  be  fairly  considered  by  the  prac- 
titioner, and  his  decision  should  rest  much  upon  the  disposition  of  the  pa- 
tient, coupled  with  the  degree  of  actual  impairment  of  respiration  and 
discomfort  arising  therefrom.  Many  of  the  patients  become  extremely 
anxious  when  suffering  from  dyspnoea,  inability  to  lie  down,  and  are  worn 
out  by  the  limited  amount  of  rest  they  get,  and  should  be  afforded  some 
relief,  even  if  it  be  of  a  very  temporary  character.  Under  such  circum- 
stances the  withdrawal  of  the  pus  by  either  of  the  methods  I  have  indi- 
cated would  be  justifiable  and  proper.  I  have  purposely  in  this  lecture 
said  nothing  in  regard  to  the  diagnosis,  or  differentiation,  of  ascites  de- 
pendent upon  the  different  forms  of  peritoneal  inflammation,  from  the  ova- 
rian cysts  and  other  abdominal  tumors,  for  the  reason  that  the  symptoms 
and  measures  relied  upon  for  such  diagnosis  are  given  in  more  detail,  and 
can  be  better  appreciated  when  discussing  the  diseases  from  which  the 
peritoneal  inflammation  is  to  be  distinguished,  than  before  such  diseases 
have  been  brous-ht  under  review. 


LECTURE    LVI. 


Hepatitis— Its  Varieties,  Clinical  History,  Anatomical  Changes,  Diagnosis,  Prognosis  and  Treat- 
ment. 

(GENTLEMEN:  True  inflammatory  affections  of  the  liver  are  less  fre- 
J  quent  in  temperate  and  cold  climates  than  the  same  forms  of  disease 
affecting  different  portions  of  the  alimentary  canal.  In  warm  climates 
the    liver  is    much   more    frequently   involved   in  inflammation.     When 


590  HEPATITIS. 

affected,  the  inflammation  maybe  limited  to  the  parenchyma  and  secreting 
cells  mainly,  or  it  may  be  restricted  more  to  the  connective  tissue,  espe- 
cially that  part  of  the  connective  tissue  belongina^  to  the  capsule  of  Glis- 
son,  and  its  ramifications  through  the  organ.  The  whole  organ  may  be 
invaded,  or  fche  disease  may  be  limited  to  particular  portions  of  it — as  to 
the  convex  surface,  or  to  the  right  or  left  lobes  separately.  The  inflam- 
matiion  may  vary  in  its  grade  o*^  activity  from  the  most  violent  and  rapidly 
progressive  to  the  slightest  and  most  chronic  form  of  inflammatory  action. 
For  convenience,  we  shall  consider  the  inflammations  under  the  general 
divisions  of  acute  and  chronic.  In  giving  tiie  clinical  history  I  shall  con- 
sider the  acute  cases  under  the  heads  of,  simple  parenchymatous  inflam- 
mation, circumscribed  suppurative  inflammation,  and  acute  yellow 
atrophy.  The  chronic  forms  of  inflammation  I  will  consider  under  the 
names  of  chronic  parenchymatous  inflammation,  which  is  most  generalfy 
the  sequel  of  acute  attacks,  and  chronic  interstitial  inflammation  more 
frequently  originating,  without  being  preceded  by  acute  disease,  and 
leading  to  such  changes  as  are  generally  designated  under  the  head  of  scle- 
rosis or  cirrhosis. 

Simple,  Parencliytnatous  Hepatitis. — As  I  have  stated,  most  of  the 
cases  that  have  been  met  with  in  practice,  and  described  by  writers,  of 
this  form  of  inflammation,  occur  in  hot  climates.  OccasionaJly  they  are 
met  with  in  all  climates,  and  especially  during  the  warm  seasons  of  the 
year  in  malarious  districts.  Very  rarely  instances  occur  as  tfhe  result  of 
sudden  exposure  to  cold  and  wet,  during  warm  seasons  of  the  year, 
where  no  malarious  influences  exist. 

Symptoms. — The  symptoms  which  characterize  an  attack  of  simple  par- 
enchymatous hepatitis  vary  much  with  the  severity  of  the  attack.  In  cases 
of  moderate  severity,  the  disease  supervenes  suddenly,  with  some  degree 
of  chilliness,  which  is  of  brief  duration,  however,  and  accompanied  by  a 
sense  of  heaviness  and  pain  in  the  right  hypochondriac  region.  The  char- 
acter of  the  pain  will  vary  according  to  the  part  of  the  liver  most  involved. 
If  the  disease  is  confined  strictly  to  t'he  parenchyma  of  the  organ,  the  pain 
will  usually  be  of  a  steady,  dull,  heavy  character,  generally  increased  by 
taking  a  full  inspiration,  or  by  any  motion  by  which  the  diaphragm  is  de- 
pressed, and  the  side  put  upon  the  stretch.  It  is  also  accompanied  by 
more  or  less  direct  tenderness  both  to  pressure  over  the  region  affected, 
and  particularly  to  percussion.  The  pain  is  also  usually  increased  by 
turning  upon  the  left  side  in  the  recumbent  position,  associated  with  a 
sense  of  dragging,  or  weight,  and  oftentimes  also  by  a  sense  of  nausea, 
and  inclination  to  vomit.  If  the  inflammation  extends  to  the  convex  sur- 
face of  the  liver,  involving  the  peritoneal  covering,  the  pain  will  be  much 
more  acute,  often  resembling  the  sharp,  lancinating  pains  of  pleurisy, 
and  aggravated  in  the  same  manner  by  the  respiratory  movements.  In 
such  cases  also  the  pain  sometimes  extends  backward  under  the  right 
scapula  and  upward  to  the  shoulder.  The  breathing  is  usually  shorter, 
being  stifled  to  avoid  the  sharp  pains.  The  pulse  is  frequent,  moderately 
full  and  firm  under  the  finger,  the  skin  dry,  the  face  moderately  flushed, 
the  temperature  of  the  body  increased  two  or  three  degrees  above  the 
natural  standard.  Generally  there  is  a  thin  whitish  coat  upon  the  tongue, 
more  or  less  dryness  of  the  mouth,  frequently  a  heavy,  dull  pain  through 
the  forehead  and  temples,  accompanied  by  dizziness  upon  taking  the  up- 
right position;  and  after  the  first  two  days  very  generally  some  degree  of 
yellovvness  of  tlie  conjunctiva  of  the  eye;  a  deep  brownish  red  oolor  of  the 
urine,  which  is  less  in  quantity  than  natural,  and  in  most  instances  a 
moderate  constipation  of  the  bowels. 


SYMPTOMS.  591 

If  the  right  hvpoclionclrium  is  examined  by  auscultation  and  percussion, 
the  first  will  develop  respiratory  sour.ds  tiiroughout  the  whole  depth  of 
the  chest  above  the  diaphragm  as  usual,  while  the  latter  will  indicate  an 
increased  area  of  dullness  over  the  space  occupied  by  the  liver,  associated 
directly  with  decided  tenderness  to  the  blows  inflicted  in  the  act  of  per- 
cussion. In  most  cases  the  enlargement  of  the  liver  will  be  such  that  its 
edge  may  be  felt  below  the  margin  of  the  ribs,  toward  the  right,  and  often 
it  will  extend  further  thau  usual  into  the  epigastric  region  to  the  left.  In 
most  acute  cases  there  is  much  disturbance  of  the  functions  of  the  stomach 
indicated  by  loss  of  appetite,  frequent  nausea  and  sometimes  vomiting, 
especially  when  drink  is  taken  in  considerable  quantities.  The  matter 
vomited  at  first  may  be  freely  intermixed  with  the  coloring  matter  of  bile, 
but  at  a  later  period  is  generally  only  the  secretion  of  the  stomach  and 
the  materials  that  have  been  taken  as  ingesta.  In  such  cases  as  are 
occasionally  met  with  in  connection  with  attacks  of  malarious  fever,  and 
as  I  have  seen,  the  result  of  direct  exposure  to  wet  and  cold,  the  symp- 
toms I  have  described  have  usually  increased  moderately  in  severity, 
during  the  first  three  or  four  days.  But  if  modified  by  appropriate  treat- 
ment, they  usually  pass  their  climax,  with  the  close  of  the  third 
day  and  begin  to  abate.  The  pain  diminishes,  the  general  febrile  symp- 
toms also  diminish  gradually,  the  tongue  becomes  more  clean,  the  sense 
of  fullness  and  weight  in  the  right  hypochondrium  lessens  from  day  to  dav, 
till  at  the  end  of  from  seven  to  ten  days,  convalescence  has  been  estab- 
lished, and  all  the  spmptoms,  both  of  enlargement  of  the  liver,  and  of 
functional  disturbance  have  ceased.  In  a  few  instances,  where  the  treat- 
ment had  been  neglected  during  the  early  stage,  the  disease  has  run  a 
more  protracted  course;  causing  a  much  greater  degree  of  enlargement 
of  the  liver,  more  general  prostration  of  the  patient,  the  pulse  at  the  end 
of  a  week  ranging  from  110  to  120  beats  per  minute,  being  smaller  and  more 
easily  compressed.  The  skin  and  eyes  become  deeply  yellow,  the  coat- 
ing upon  the  tongue  more  brown  and  dry  in  the  middle;  the  bowels  more 
or  less  constipated,  the  urinary  secretion  decidedly  scanty  and  very  deeply 
tinged  with  the  coloring  matter  of  bile.  In  two  or  three  cases,  such  as  I 
have  now  referred  to,  the  acute  stage  of  the  disease  gradually  declined,  with 
an  amelioration  of  the  more  active  symptoms,  such  as  fever,  pain  in  the  side, 
and  quick  pulse,  and  yet  the  liver  remained  much  enlarged,  jutting  from 
one  to  two  inches  below  the  margin  of  the  ribs,  through  the  whole  extent 
of  the  hypochondriac  region;  it  was  moderately  tender  to  percussion,  and 
there  was  a  continuance  of  the  sense  of  weight,  heaviness  and  more  or  less 
pain,  on  taking  deep  inspirations,  or  on  any  free  motion  of  the  affected 
side.  These  were  cases  in  which  the  acute  form  of  disease  terminated  in 
the  establishment  of  a  well  marked  chronic  inflammation,  accompanied  by 
enlargement  and  induration  of  the  substance  of  the  liver.  In  three  of  the 
cases  coming  under  ray  own  observation,  the  hepatic  enlargement  and 
induration  continued  from  two  to  three  months,  subsiding  very  slowlv, 
but  ending  in  the  ultimate  recovery  of  the  patient.  In  the  fourth  case, 
after  having  continued  in  the  chronic  form,  with  much  enlargement  of 
the  liver  for  nearly  three  months,  suppuration  took  place,  indicated  by 
the  occurrence  of  irregular  chills,  copious  sweats,  increased  rapidity  of 
pulse  and  emaciation,  and  a  well  marked  increased  swelling  in  the  right 
portion  of  the  hypochondriac  region  corresponding  with  the  convex  por- 
tion of  the  right  lobe  of  the  liver.  In  this  case  a  large  abscess  approached 
the  surface  near  enough  to  give  distinct  fluctuation  between  the  eighth  and 
ninth  ribs  a  little  forward  of  their  angles.  Although  the  abscess  was 
opened  and  discharged  its  contents,  leading  to  a  temporary  improvement 


592  HEPATITIS. 

of  the  patient,  the  subsequent  occurrence  of  hectic  symptoms  and  pro- 
gressive emaciation  terminated  the  case  fatally  at  the  end  of  six  months 
In  hot  climates,  acute  parenchymatous  inflammation  gives  rise  to  the 
occurrence  of  the  same  class  of  symptoms  as  I  have  described,  but  they  are 
usually  more  violent;  the  fever  is  of  a  higher  character,  often  accompanied 
by  delirium,  there  is  a  very  much  more  scanty  condition  of  urine,  and 
earlier  jaundice  or  a  yellow  hue  of  skin  and  eyes;  frequently  severe  vomit- 
ing, rapid  enlargement  of  the  liver,  vphich  occupies  and  bulges  the  hypo- 
chondriac space,  crowding  upon  the  parts  below  and  in  the  epigastrium, 
and  not  infrequently  terminating  fatally  in  from  five  to  seven  days.  It 
is  in  such  climates,  and  in  this  acute  form  of  the  disease,  that  it  manifests 
a  more  decided  tendency  to  suppuration,  and  the  formation  of  one  or 
more  abcesses,  if  the  patient  survives  beyond  the  first  week  from  the  be- 
ginning of  the  attack.  The  supervention  of  suppuration  in  the  acute 
form  of  the  disease  is  usually  indicated  by  the  development  of  chills, 
followed  by  profuse  sweats,  a  more  rapid  pulse  and  more  rapid  emacia- 
tion, loss  of  strength;  and  often  also  by  the  almost  entire  suppression  of 
urine,  accompanied  by  delirium  and  coma,  a  little  preceding  the  fatal 
termination. 

The  form  of  the  disease,  which  has  been  termed  acute  yellow  atrophy  of 
the  liver,  I  have  classed  among  the  acute  inflammations,  though  well  aware 
that  many  writers  doubt  its  inflammatory  character.  It  is  of  very  rare 
occurrence  in  temperate  and  cold  climates.  It  is  not  of  frequent  occur- 
rence in  any  climate,  but  cases  occur  much  more  frequently  within  the 
tropics  and  in  the  warmer  latitudes  than  elsewhere.  Its  symptoms  are 
usually  developed  rapidly,  though  oftentimes  in  a  manner  to  render  the 
diagnosis  extremely  obscure.  The  patients  are  generally  seized  with 
more  or  less  chilliness,  speedily  followed  by  an  increase  of  heat  and  rapid 
pulse,  though  this  oftentimes  varies  much  in  the  same  patient,  being  some- 
times 120  to  130  in  the  minute,  at  others  falling  as  low  as  70  or  80.  The  res- 
piratory movements  are  hurried  and  irregular.  There  are  severe  pains  in 
the  head,  with  frequent  turns  of  delirium,  or  high  excitement  and  occasion- 
ally severe  vomiting.  The  bowels  at  times  are  costive  and  at  other  times 
loose,  but  there  is  seldom  any  evidence  of  the  coloring  matter  of  bile  either 
in  the  matters  ejected  by  vomiting  or  passed  through  the  bowels.  The  urine 
from  the  beginning  is  very  scanty  and  high  colored,  containing  much  less 
than  the  natural  proportion  of  urea,  and  not  infrequently  an  excess  of  both 
leucin  and  tyrosin.  The  skin  and  eyes  also  become  deeply  yellow,  almost 
from  the  commencement  of  the  disease.  In  the  very  violent  cases,  during  the 
second  and  third  days,  petechial  spots  make  their  appearance  in  different 
parts  of  the  cutaneous  surface,  and  not  infrequently  hemorrhages  either 
from  the  mouth  and  gums,  or  from  the  stomach  by  vomiting,  and  some- 
times blood  passes  the  bowels,  or  is  mixed  with  the  urine.  Most  of  these 
cases  terminate  fatally  in  from  three  to  seven  days.  The  symptoms  refer- 
able to  the  right  hypochondriac  region  are  very  variable.  Generally  in 
the  commencement  there  is  acute  pain,  a  sense  of  heaviness  in  that  region 
increased  by  motion  of  the  diaphragm,  but  there  is  seldom  any  indica- 
tions of  enlargement  of  the  liver.  While  percussion  will  afford  evidence 
of  tenderness  over  the  hypochondriac  region,  sometimes  very  acute,  at 
other  times  very  moderate,  there  is  no  increased  area  of  dullness,  but  on 
the  contrary,  after  the  first  two  days,  the  liver  appears  to  occupy  less 
space  than  natural.  This  absence  of  any  indications  of  enlargement  of 
the  liver,  the  variableness  of  the  pain  referable  to  that  region,  coupled 
with  the  very  early  delirium,  violent  vomiting,  great  functional  disturb- 
ance of  the  kidneys,  would  be  likely  to  divert  the  attention  of  the  practi- 


ANATOMICAL   CHANGES.  593 

tioner  from  the  liver  as  the  seat  of  disease  altogether,  were  it  not  for  the 
coincident  and  early  supervention  of  yellowness  of  the  skin  and  eyes, 
and  the  presence  of  the  coloring  matter  of  bile  in  the  urinary  secretion. 

Anatomical  Changes. — The  anatomical  changes  which  take  place  dur- 
ing the  progress  of  acute  inflammation  in  the  liver  are  similar  in  kind 
to  those  which  result  from  inflammatory  processes  in  any  other  tissue  of 
the  body.  There  is  in  all  cases  intense  injection  of  the  blood  vessels, 
thereby  increasing  the  fullness  of  the  organ  and  rendering  the  color  more 
red,  but  as  the  cases  of  simple  inflammation  progress,  exudation  takes  place 
into  the  interstitial  spaces  of  the  tissue,  leucocytes  or  white  corpuscles  are 
found  permeating  the  vessels  or  outside  of  the  vessel  wal's,  and  lymphoid 
and  spindle  shaped  cells  are  found  multiplying  rapidly.  There  is  also 
more  or  less  obstruction  of  the  smaller  vessels  in  the  inflamed  parts.  In 
acute  cases,  the  surface  of  the  liver  is  variable  in  color,  some  portions  of  it 
being  deep  red,  others  of  a  more  decidedly  yellow  hue.  In  cases  that 
have  terminated  fatally  during  the  active  stage  of  the  disease,  the  texture 
of  the  liver  is  generally  softer  than  natural.  If  suppuration  has  taken 
place,  the  pus  will  generally  be  found  to  have  collected  into  one  or  more 
abscesses,  instead  of  being  difi^ased  through  the  parenchyma  of  the  organ. 
The  walls  of  the  abscesses  will  usually  be  denser  and  firmer  from  the  in- 
crease of  connective  tissue.  The  changes  which  result  in  that  variety  of 
disease  known  as  acute  yellow  atrophy,  consist  in  a  rapid  disintegration 
and  apparent  disappearance  of  the  secreting  cells  of  the  liver,  causing 
a  diminution  in  the  number  of  them  wherever  the  structure  is  ex- 
amined. In  place  of  the  secreting  cells  throughout  the  lobules  of  the 
liver,  there  is  found  by  microscopic  examination  aggregations  of  dark  bile 
pigments,  fatty  matter  and  masses  of  hgematin.  ]t  is  this  rapid  disappear- 
ance of  the  secreting  structure,  and  its  replacement  with  the  constituents 
just  mentioned,  that  apparently  causes  the  rapid  atrophy  of  the  organ;  it 
frequently  being  less  than  half  its  natural  size,  and  of  a  more  flattened 
form.  Its  color  is  also  changed  to  a  more  decidedly  yellow  hue,  more 
nearly  that  of  the  rhubarb  root.  The  connective  tissue  maintains  very 
nearly  its  natural  integrity,  and  in  some  places  appears  to  have  increased 
by  hypertrophy  or  sclerosis.  Many  of  the  branches  of  the  portal  veins 
are  obstructed  or  obliterated,  while  those  of  the  hepatic  artery  are  found 
dilated  and  enlarged,  and  those  of  the  hepatic  veins  nearly  natural.  These 
anatomical  changes  have  caused  some  pathologists  to  regard  the  disease 
as  not  inflammatory  in  its  character,  but  acute  fatty  degeneration  of  the 
organ,  resulting  either  from  some  morbid  condition  of  the  blood  or  from 
the  direct  infection  by  bacterial  germs.  In  nearly  all  the  cases  that  have 
been  examined  of  this  form  of  disease,  the  kidneys  have  been  found  coin- 
cidently  to  have  undergone  much  degeneration  of  structure  causing  an  al- 
most entire  suspension  of  their  secretory  function.  The  blood  itself  has  been 
found  to  contain  a  large  proportion  of  cholestrine  and  of  the  coloring  material 
of  the  bile,  and  in  some  instances  also  an  excess  of  urea.  This  would  lead 
to  the  suspicion  that  the  functions  both  of  the  liver  and  kidneys  are  early 
suspended,  allowing  the  fatty  constituents  of  the  bile  to  rapidly  accumulate 
in  the  blood.  And  it  is  undoubtedly  this  rapid  accumulation  of  the  ex- 
cretory elements  operating  as  poisons  upon  the  nervous  centers,  that 
produces  most  of  the  prominent  symptoms  and  phenomena  of  the  disease 
during  its  whole  progress,  and  which  leads  in  almost  all  instances  to  an 
early  fatal  result. 

Diagnosis. — Acute  hepatitis,  whether  mild  or  severe,  is  generally  ac- 
companied by  symptoms  so  well  marked  as  to  leave  no  difficulty  in  form- 
ing an  accurate  diagnosis.  The  chief  diseases  with  which  acute  hepatitis 
38 


594  HEPATITIS. 

may  be  confounded  are — acute  pleuritic  inflammation  in  the  right  side  of 
the  chest,  acute  rheumatism  located  in  the  diaphragm  and  lower  inter- 
costal muscles,  and  neuralgic  pains  in  the  sam-?  parts.  When  inflamma- 
tion affects  the  convex  surface  of  the  liver,  the  general  symptoms,  so  far 
as  they  relate  to  acuteness  of  pain,  interference  with  respiration, 
increased  frequency  of  pulse  and  general  fever,  are  closely  analogous 
to  pleuritis;  but  are  easily  differentiated  by  physical  examination.  In  the 
pleuritic  affection,  auscultation  in  the  first  stage  readily  reveals  friction 
sound,  and  in  the  second  stage  with  disappearance  of  the  friction  sound, 
we  have  dullness  on  percussion,  with  a  removal  of  the  ordinary  respira- 
tory murmurs  over  the  lower  iDart  of  that  side  of  the  chest.  While  in 
hepatitis  of  any  grade  or  degree  of  severity  the  respiratory  sounds  con- 
tinue natural  throughout  the  whole  depth  of  the  chest,  yielding  neither 
friction  in  the  beginning,  nor  absence  of  respiratory  murmur  with  dull- 
ness on  percussion  at  any  subsequent  stage.  But  while  auscultation  and 
percussion  thus  furnish  no  evidence  of  change  in  the  chest  above  the  dia- 
phragm, in  hepatitis  the  percussion  below  the  diaphragm  shows  both 
acute  tenderness  and  increase  of  dullness,  extending  downward  and  to 
the  left,  thereby  clearly  showing  that  the  disease  is  below  the  dia- 
phragm, and  involves  an  enlargement  of  the  liver  instead  of  any  changes 
in  the  chest,  as  would  be  the  case  in  either  pleurisy  or  pneumonia.  I 
have  seen  many  oases  of  subacute  rheumatism,  afflicting  the  diaphragm 
and  intercostal  muscles  that  have  been  mistaken  for  hepatitis.  As  the 
pain  of  rheumatism  is  dull  and  continuous,  very  much  like  that  affecting 
the  parenchyma  and  deeper  portions  of  the  liver,  and  may  give  rise  to  the 
same  tenderness  on  percussion  over  the  part,  there  is  necessity  for  care- 
ful examination  to  prevent  mistakes  in  such  cases.  In  the  rheumatic  af- 
fections you  get  no  friction  or  alteration  of  sjund  by  percussion  or  auscul- 
tation above  the  diaphragm.  But  there  is  this  clear  line  of  distinction 
between  the  rheumatic  affection  and  hepatitis.  The  former  is  never  ac- 
companied by  any  increased  area  of  dullness  in  the  right  hypochon- 
driac region,  neither  is  it  accompanied  by  the  peculiarly  dark  hued  urine 
occasioned  by  the  intermixture  of  the  coloring  matter  of  bile,  nor  by  yel- 
lowness of  the  skin  or  eyes;  while  hepatitis,  especially  of  an  acute  char- 
acter, is  accompanied  from  a  very  early  period  after  the  symptoms  com- 
mence by  not  only  an  increased  area  of  dullness  on  percussion  and  by  such 
enlargement  as  enables  the  margin  of  the  liver  to  hs  felt  below  the  ribs, 
causing  heaviness  and  dragging  sensations  on  turning  to  either  side,  but 
also  very  uniformly  by  a  characteristic  alteration  in  the  color  of  the  urine  as 
well  as  of  the  skin  and  conjunctiva  of  the  eye.  From  all  forms  of  neuralgia 
acute  hepatitis  is  distinguished  by  the  presence  of  tenderness,  fullness  of 
the  hypochondriac  space  and  more  or  less  general  febrile  movements,  as 
well  as  alterations  in  the  color  of  the  skin,  eyes  and  urine,  all  of  which 
symptoms  are  absent  in  the  neuralgic  affections.  In  addition  to  the  diag- 
nosis of  hepatitis  from  other  affections,  it  is  often  important  to  note  such 
diagnostic  symptoms  as  indicate  the  commencement  of  suppuration.  These, 
as  t  have  already  mentioned  when  speaking  of  the  clinical  progress  of 
the  disease,  are  usually  the  sudden  occurrence  of  a  chill,  followed  almost 
invariably  by  sweating,  and  a  decided  increase  in  the  frequency  of  the 
pulse,  with  diminution  of  its  volume  and  force.  The  recurrence  of  chills 
and  sweats  at  irregular  intervals,  with  increased  rapidity  of  emaciation 
and  increased  frequency  and  diminished  force  of  the  jjulse,  accompanied 
by  evidences  of  more  rapid  enlargement  in  some  one  direction  in  the 
hypochondriac  region,  will  justify  the  conclusion  that  suppuration  has 
taken  place.     The  diagnostic  symptoms  of  acute  yellow    atrophy    of  the 


PEOGNOSIS.  595 

liver  are  the  coincident  and  rapid  development  of  yellowness  of  the  skin 
and  eyes,  and  marked  diminution  of  the  urinary  secretion  and  its  change 
to  a  brownish  yellow  color  from  intermixture  of  bile  pigments  and  de- 
ficiency of  urea,  with  violent  disturbances  of  the  cerebral  functions,  rapid 
deterioration  of  the  blood,  as  indicated  by  extreme  depression,  with  ten- 
dency to  hsemorriiages,  either  in  the  form  of  patechial  spots  upon  the  sur- 
face or  haemorrhages  from  the  mucous  membrane,  associated  with  vomiting 
and  diarrhoea,  without  any  coincident  enlargement  of  the  hypochondriac 
region,  but  rather  wuth  rapid  diminution  in  the  area  of  dullness. 

Prognosis. — The  prognosis  in  ordinary  simple  acute  inflammation  of  the 
liver  in  temperate  climates  is  generally  favorable.  In  warm  climates  the 
prognosis  is  more  grave,  the  disease  having  much  more  tendency  to  de- 
velop rapid  structural  changes,  either  in  the  direction  of  softening,  acute 
fatty  degeneration  or  suppuration,  and  consequently  a  much  larger 
number  terminate  fatally.  The  special  form  known  as  acute  yellow  atro- 
phy is  extremely  dangerous,  terminating  fatally  in  almost  all  the  cases  in 
which  the  diagnosis  has  been  made  with  any  degree  of  certainty.  This 
form  of  disease  is  of  such  rare  occurrence  in  this  climate  that  I  have  no  rec- 
ollection of  "meeting  with  more  than  two  cases  that  could  be  justly  placed 
under  this  head.  Both  of  these  were  visited  in  consultation  with  other 
physicians,  and  were  in  the  advanced  stage  of  the  disease.  One  of  them 
vomited  blood  copiously,  and  both  terminated  fatally  within  the  first  five 
days  after  the  commencement  of  the  attack.  Both  of  these  cases  wer.^ 
females;  and  it  would  appear  from  statistics  which  have  been  gathered 
that  females  are  more  subject  to  this  form  of  the  disease  than  males,  and 
that  it  is  more  liable  to  occur  during  the  state  of  pregnancy  than  during 
any  other  time.  Much  the  larger  number  of  cases  have  occurred  between 
the   ages    of  fifteen  and  thirty  years. 

Treatment. — In  mild  cases  of  acute  inflammation  of  the  liver,  such  as 
are  occasionally  met  with  in  connection  with  sudden  exposure  to  cold  and 
damp,  and  with  attacks  of  malarious  fevers,  it  is  generally  sufficient  to 
confine  patients  to  rest  in  the  recumbent  position,  administer  some  mild 
evacuants,  and  the  pain  and  soreness  rapidly  disappear.  Perhaps  the 
best  evacuants  for  this  purpose,  consist  of  from  two  to  three  decigrams 
(gr.  iii  to  v)  of  calomel,  followed  in  about  three  hours  by  a  saline  laxative 
sufficient  to  procure  a  free  movement  of  the  bowels.  If  the  case  is  con- 
nected with  malarious'  influence  there  may  be  given  directly  with  the 
mercurial,  three  decigrams  (gr.  v)  of  quinine,  and  after  the  bowels  have 
been  moved  freely,  the  quinine  may  be  continued  in  the  same  doses, 
three  times  a  day  for  three  or  four  subsequent  days.  If  the  sense  of  full- 
ness and  tenderness  in  the  hypochondriac  region  proves  to  be  persistent, 
a  blister  may  be  placed  on  that  side,  and  internally  the  patient  may  be 
given  from  four  to  six  decigrams  (gr.  vi  to  x)  of  the  muriate  of  am- 
monium three  times  a  day  in  solution  with  syrup  of  licorice.  In  the 
more  severe  cases,  such  as  are  met  with  frequently  in  warm  climates, 
if  the  attack  has  supervened  suddenly,  and  the  patient  has  not  been 
previously  debilitated  by  ill  health  or  age,  it  will  often  be  advantageous  to 
commence  the  treatment  immediately  after  the  onset  of  the  inflammation 
by  one  free  venesection.  If  the  relief  is  not  satisfactory,  the  bleeding 
may  be  followed  in  eighteen  or  twenty-four  hours,  by  the  application  of 
eight  or  ten  leeches  over  the  hypochondriac  region;  and  both  before  and 
after  the  application  of  leeches  during  the  first  two  days,  the  whole  side 
may  be  kept  covered  with  narcotic  fomentations.  Internally,  immediately 
following  the  bleeding,  where  this  is  deemed  advisable,  it  is  better  to  give 
the   patient  a  jDowder,  consisting  of  six  decigrams  (gr.  x)  of  bi-carbonate 


Oiib  HEPATITIS. 

of  sodium  and  six  centigrams  (g;r.  i)  of  the  mild  chloride  of  mercury  every 
three  hours,  until  three  or  four  of  these  doses  have  Vjeen  taken.  If  they 
do  not  result  in  a  direct  operation  upon  tlie  bowels,  they  should  be  fol- 
lowed by  sufficient  rochi'Ue  salts,  or  citrate  of  magnesium  to  procure  a 
free  operation.  Following  the  free  movement  of  the  bowels,  the  patient 
may  be  put  directly  upon  the  use  of  the  muriate  of  ammonium,  in  the  same 
doses  I  have  previously  mentioned,  but  instead  of  three  times  a  day,  it 
should  be  given  once  in  three  or  four  hours;  and  if  the  patient  continues  to 
suffer  from  much  acute  pain  or  a  sense  of  soreness,  there  may  be  added  suf- 
ficient morphine  to  the  solution  of  muriate  of  ammonium,  to  give  it  a 
moderately  anodyne  influence.  If  the  skin  is  hot  and  dry  it  will  also  add 
to  the  efficiency  of  the  treatment  if  the  tartrate  of  antimonium  and  potas- 
sium is  added  to  the  same  solution  in  such  proportion  that  the  patient 
will  get  from  fifteen  to  twenty  milligrams  (gr.  ^  to  -J)  in  each  dose.  In 
acute  inflammatory  affections  of  the  liver,  where  it  is  not  complicated 
with  irritation  of  the  gastric  mucous  membrane,  I  have  derived  the  most 
satisfactory  results  from  the  use  of  a  combination  of  muriate  of  ammonium, 
tartrate  of  antimonium  and  potassium,  with  sulphate  of  morphia,  dissolved 
in  syrup  of  licorice,  commenced  immediately  after  the  first  free  opening 
of  the  bowels,  in  the  early  stage  of  the  disease.  In  some  cases  under 
treatment,  the  general  fever  diminishes,  the  acute  pain  disappears,  but 
there  remains  a  sense  of  fullness,  weight  and  tenderness,  with  evident  en- 
largement of  the  area  of  dullness  over  the  hepatic  region,  thereby  showing 
a  disposition  to  persist  and  perhaps  to  assume  a  chronic  form.  Counter- 
irritation  by  blistering  will  be  of  much  value  at  that  stage,  with  con- 
tinuance of  such  doses  of  the  muriate  of  ammonium  as  the  stomach  will 
best  tolerate.  But  in  those  very  rapid  and  severe  attacks,  where  after 
the  first  two  or  three  days  chilliness  supervenes,  and  the  phenomena  in- 
dicate the  existence  of  suppuration,  no  treatment  usually  produces  much 
modification  in  the  symptoms  until  suppuration  has  advanced  sufficiently 
to  allow  of  either  an  artificial  or  spontaneous  discharge  of  the  matter.  As  the 
tendency  to  spontaneous  discharge  is  usuall}^  either  directly  into  the  peri- 
toneum, or  through  adhesions  into  the  colon,  or  sometimes  into  the  stomach, 
or  at  other  times  upward  through  the  diaphragm  into  the  lungs,  or  through 
the  walls  of  the  abdomen  to  the  exterior,  all  of  which  involve  a  slow, 
tedious  process,  and  more  or  less  ultimate  danger  to  the  patient's  life,  it 
is  very  desirable  to  prevent  such  spontaneous  discharges  of  the  pus  by 
an  early  resort  to  aspiration,  and  if  need  be  to  a  sufficiently  free  opening 
to  admit  of  a  complete  drainage  of  the  abscess.  The  greater  number  of 
cases  of  suppuration  in  the  liver  progress  forward  and  downward  as  if 
tending  to  approach  the  surface  just  upon  the  lower  right  margin  of  the 
epigastric  region.  The  next  most  frequent  tendency  is  in  the  direction 
of  the  posterior  part  of  the  hypochondriac  space  usually  between  the 
eighth  and  ninth  ribs.  Whenever  the  results  of  physical  exploration  by 
palpation  and  percussion,  corroborated  by  the  general  symptoms  of  the 
patient,  are  sufficiently  characteristic  to  justify  a  confident  opinion  that 
an  abscess  has  formed,  you  may  feel  justified  in  making  an  exploratory 
puncture  with  the  aspirator  needle,  thereby  demonstrating  whether  pus 
exists,  and  can  be  reached  or  not.  It  has  been  re3ommended  by  very 
high  authority  that  in  such  nases,  a  free  incision  be  made  over  the 
most  prominent  part  of  the  swelling,  through  the  textures,  down  to  with- 
in a  few  lines  of  the  peritoneum,  not  puncturing  the  peritoneum  nor 
puncturing  the  abscess,  but  carrying  the  incision  two  or  three  inches  in 
length  down  close  to  the  peritoneum,  filling  it  with  cotton,  and  leaving 
it  for  two  or  three   days,  during  which   more  or  less  suppuration  takes 


CHRONIC    HEPATITIS.  597 

place  accompanied  by  adhesive  inflammation  in  the  adjacent  textures, 
thus  making  sure  of  the  adhesion  of  the  peritoneum  to  the  surface  of  the 
liver,  and  in  most  ins  ances  of  a  rapid  advance  of  the  abscess  to  spontane- 
ous discharge  from  the  bottom  of  the  incision. 

In  cases  where  matter  is  found,  and  it  is  too  thick,  as  sometimes 
happens,  to  flow  freely  through  the  ordinary  asp  rator  tube,  it  can  be  much 
more  freely  and  completely  evacuated  by  using  a  small  trochar  fitted  to 
a  Davidson's  syringe  in  place  of  the  aspirator  needle.  If  the  abscess  re- 
fills, after  it  has  been  aspirated  two  or  three  times,  and  consequently  you 
have  reason  to  suppose  that  there  are  certainly  adhesions  between  the  peri- 
toneal surfaces,  leaving  no  danger  of  matter  passing  into  the  abdominal 
cavity,  the  opening  can  be  enlarged  sulEciently  to  give  free  exit  to  the  mat- 
ter, and  drainaire  can  be  established  with  ordinary  antiseptic  precautions. 
Abscesses  in  the  liver,  whether  resulting  from  acute  or  chronic  inflam- 
mation always  involve  more  or  less  danger;  yet  where  they  can  be  evacu- 
ated judiciously  in  the  manner  I  have  indicated,  the  larger  proportion  of 
them  will  recover.  Of  six  cases  that  have  fallen  under  my  own  care,  as 
I  now  remember,  four  recovered,  two  were  relieved,  and  continued  for 
several  months,  but  ultimately  died  from  exhaustion  in  consequence  of 
continued  suppurat  on. 

Chronic  Hepatitis. — Chronic  inflammation  of  the  liver  is  met  with  in  prac- 
tice under  two  forms.  The  first  is  the  sequel  of  more  acute,  general  attacks 
of  hepatitis,  and  is  characterized  by  the  physical  signs  of  enlargement  of 
the  liver,  such  as  increased  area  of  dullness  on  percussion,  ability  to  trace 
the  edge  of  the  liver  below  the  margin  of  the  ribs,  a  constant  feeling  of 
weio-ht,  increased  to  a  dragging  sensation  when  the  patient  turns  on  the 
opposite  side,  very  generally  a  dull  pain  in  the  hypochondriac  region  which 
not  infrequently  extends  to  the  back  under  the  scapula,  sometimes  to  the 
shoulder,  an  acceleration  of  pulse,  a  slight  febrile  movement  in  the  after- 
noon and  evening,  a  gradual  loss  of  flesh  and  strength,  and  most  generally 
a  loss  of  appetite  and  some  degree  of  derangement  in  the  digestion  of  what 
food  is  taken.  In  a  majority  of  instances  the  skin  and  eyes  are  more  or 
less  tinged  a  yellow  color;  sometimes  deeply  so,  at  other  times  only  slightly. 
After  the  disease  has  continued  some  few  weeks,  dropsical  symptoms 
very  generally  supervene;  sometimes  a  slightly  oedematous  condition  of  the 
tops  of  the  feet,  about  the  malleoli  of  the  ankles  when  the  patient  is  sitting 
up,  will  be  observed  for  several  days  before  any  other  noticeable,  dropsical 
feature;  but  more  generally  no  symptoms  of  oedema  are  seen  in  the  areolar 
tissue,  either  of  the  face  or  extremities.  Very  generally,  however,  the 
patient  finds  in  addition  to  the  ordinary  fullness  of  the  right  hypochondriac 
region  that  the  lower  part  of  the  abdomen  also  begins  to  be  more  prom- 
inent and  heavy  than  natural.  At  the  same  time  the  urinary  secretion  is 
more  scanty,  and  also  tinged  with  the  coloring  matter  of  bile.  The  full- 
ness in  the  lower  part  of  the  abdomen  is  not  usually  accompanied  by 
pain  or  any  ill  feeling  other  tlian  that  of  weight,  and  it  increases  slowly 
from  day  to  day,  till  at  the  end  of  Irom  five  to  six  weeks  there  will  be 
consideralile  distensio.i  of  the  peritoneal  cavity,  and  in  proportion  as  this 
distension  increases  the  patient  suffers  much  from  a  sense  of  heaviness 
and  oppression  whenever  he  takes  food,  and  sometimes  is  provoked  to 
reject  it  by  vomiting.  If  the  abdomen  is  examined  at  any  time  there 
will  be  no  difficulty  in  detecting  distinct  fluctuation  of  fluid.  The  fluctu- 
ation becomes  more  and  more  distinct  as  the  accumulation  increases.  If  no 
measures  are  taken  for  the  relief  of  the  patient,  he  will  arrive  at  a  stage 
of  distension  from  the  accumulation  of  serous  fluid  in  the  cavity  of  the 
peritoneum,  such  as  to  compress  the  stomach,  thusi^reventiiig  the  reception 


598  CHKOJfIC    HEPATITIS. 

and  digestion  of  food;  to  crowd  the  diaphragm  upward  suflSciently  to 
very  much  impede  the  process  of  respiration,  thereby  causing  blueness  of 
the  lips,  coldness  of  the  extremities,  extreme  feebleness  of  the  pulse, 
drowsiness  and  yet  inability  to  sleep.  And  if  not  interfered  with,  the 
mind  becomes  incoherent,  the  urine  nearly  suppressed,  and  finally  coma 
and  death  supervene. 

Thus  far  I  have  spoken  simply  of  chronic  hepatitis,  as  it  is  occasion- 
ally met  with,  resulting  from  prior  acute  or  subacute  attacks.  We  occa- 
sionally meet  with  cases  in  practice  in  which  the  liver  is  attacked  with 
chronic  inilammation,  very  circumscribed  in  extent  and  almost  always 
secondary  to  or  as  a  complication  of  other  aiFections.  Chronic  dysentery 
especially,  is  every  now  and  then  complicated  with  circumscribed  in- 
flammaion  of  the  liver,  accompanied  by  very  obscure  symptoms,  until 
suppuration  has  supervened,  when  there  develops  in  a  few  weeks,  all  the 
phenomena  of  a  hepatic  abscess.  Similar  results  take  place  sometimes 
during  the  progress  of  chronic  inflammation  in  any  part  of  the  alimentary 
canal.  And  they  are  occasionally  met  with  during  convalescence  from 
general  fevers,  especially  those  of  a  typhoid  and  typhus  character.  Another 
form  of  chronic  hepatitis,  which  is  more  common  than  those  to  which  I 
have  already  alluded,  is  properly  styled  interstitial  inflammation.  It  oc- 
curs almost  exclusively  in  adults  or  persons  between  the  ages  of  fifteen 
and  fifty  years  who  are  addicted  more  or  less  to  the  use  of  alcoholic 
drinks.  Some  eminent  writers  claim  that  it  occurs  only  from  the  use  of 
whisky,  gin,  brandy  or  the  more  concentrated  alcoholic  beverages.  T 
am  not  satisfied,  however,  that  it  is  limited  exclusively  to  those  who  use 
such  drinks.  I  think  I  have  seen  a  few  very  well  marked  eases  of  this 
form  of  disease,  in  patients  who  had  certainly  not  used  any  form  of  alco- 
holic drink.  Such  cases  are  exceedingly  rare,  however,  while  thev  are  very 
common  in  those  who  have  habitually  used  this  class  of  beverages.  The 
disease  to  which  I  am  now  alluding  is  more  generally  termed  cirrhosis  of 
the  liver.  It  is  much  more  proper,  however,  to  designate  it  sclerosis, 
becau-e  cirrhosis  has  reference  to  yellow  color  and  the  patients  are  by 
no  means  always  jaundiced  or  yellow.  Neither  is  the  liver  itself  always 
of  a  yellow  hue,  consequently,  the  name  cirrhosis  is  not  strictly  applica- 
ble to  all  cases;  while  sclerosis,  which  relates  directly  to  the  patholog- 
ical changes  in  the  connective  tissue  of  the  liver,  has  reference  to  a  con- 
stant element  in  the  pathology  of  the  disease.  The  symptoms  which 
characterize  the  commencement  of  this  form  of  hepatitis  are  obscure,  and 
very  often  either  escape  altogether  the  attention  of  the  practitioner,  or 
are  misinterpreted,  till  the  disease  has  so  far  progressed  as  to  cause  the 
beginning  of  dropsical  effusion.  Whenever  an  opportunity  has  been 
afi"orded  to  study  the  clinical  history  of  this  class  of  cases,  I  have  found, 
among  the  earliest  symptoms,  obscure  pain  extending  from  the  center  of 
the  epigastrium  to  the  right,  through  nearly  the  whole  right  hypochon- 
drium;  better  described  as  a  dull,  heavy  sensation  than  anything  like 
acute  pain.  Percussion,  however,  over  any  part  of  the  hypochondriac 
region,  and  into  the  right  margin  of  the  epigastric,  pretty  unilormly  caused 
increase  of  soreness,  and  sometimes  the  sensation  of  nausea.  The  sore- 
ness was  also  increased  by  any  kind  of  motion  which  put  the  side  on  the 
stretch.  The  tongue  was  covered  with  a  yellow  thin  coat,  especially  over 
the  middle  and  back  part.  There  was  loss  of  appetite,  slight  acceleration 
of  pulse,  very  little  increase  of  temperature.  In  some  cases  there  was 
also  frontal  pain,  moderate  constipation  of  the  bowels,  high-colored  and 
scanty  urine,  and  occasionally,  slight  yellowness  of  the  conjunctiva,  but  sel- 
dom any  general  jaundice  or  noticeable  yellowness  of  the  whole   surface. 


ANATOMICAL   CHANGES.  599 

If  food  was  taken,  even  in  small  quantities,  there  was  pretty  uniformly  de- 
fective digestion  accompanied  by  eructations  of  gases  and  sometimes  acids. 
These  symptoms  usually  continued  for  about  one  week,  when  under  mild 
treatment  they  were  relieved.  Nearly  all  the  symptoms  disappear  during 
the  second  week,  and  the  patients  claim  to  Ije  very  well  except  a  lack  of 
the  usual  strength  or  power  of  endurance  and  the  continuance  of  some 
obscure  defect  in  the  dia:estiun  of  food. 

In  most  cases,  these  symptoms  will  be  so  slight  that  the  patient  thinks 
he  requires  no  further  medical  attendance.  But  at  the  end  of  three  or 
four  weeks  he  finds  himself  weaker,  tiring  easily,  with  a  little  increase  of 
indigestion,  gaseous  eructations  after  taking  food,  with  unusual  fullness 
of  the  abdomen.  The  latter  continuing  to  increase,  he  again  calls  upon 
his  physician,  who  on  examination  finds  him  pale  from  deficiency  of  red 
corpuscles  in  the  blood,  with  a  soft,  easily  compressible  pulse  which  is  a  little 
increased  in  frequency,  but  with  no  general  fever.  Sometimes  the  con- 
junctiva shows  a  tinge  of  yellow,  but  the  most  prominent  feature  of  the 
case  is  considerable  enlargement  of  the  abdomen.  On  examination  by 
palpation  and  percussion,  this  enlargement  is  found  to  consist  of  an  ac- 
cumulation of  fluid  in  the  cavity  of  the  peritoneum.  Occasionally,  if 
examination  is  made  very  closely,  at  this  stage,  in  addition  to  the  disten- 
sion of  the  peritoneal  cavity  with  serous  effusion,  traces  of  moderate  en- 
largement of  the  liver  may  still  be  found.  In  many  instances,  however, 
no  trace  of  enlargement  can  be  found;  but  on  the  contrary  the  line  of 
intestinal  resonance  produced  by  the  transverse  colon  will  be  found  fairly 
above  the  margin  of  the  ribs,  showing  that  the  liver  has  receded  by  a 
lessening  of  its  size  rather  than  otherwise.  From  this  time  the  symp- 
toms in  these  cases  are  pretty  uniform.  The  abdomen  becomes  more  and 
more  distended  with  serous  fluid,  the  patient  becomes  more  pale,  anagmic, 
less  able  to  be  on  his  feet  and  get  about,  and  from  the  mechanical  pres- 
sure in  the  peritoneal  cavity  backwards  upon  the  renal  vessels,  upward 
against  the  diaphragm  and  stomach,  respiration,  digestion  and  the  renal 
secretion  are  all  more  or  less  interfered  with.  Consequently  the  patient 
loses  strength  pretty  rapidly,  and  in  a  few  weeks  is  reduced  to  the  alter- 
native of  having  the  fluid  removed  from  the  cavity  of  the  abdomen  by 
some  means,  or  of  suffering  fatal  interference  with  the  respiratory  and 
digestive  functions,  or  as  occasionally  happens  in  such  cases,  from  such  a 
degree  of  suppression  of  the  urine  as  to  produce  uraemic  poisoning,  con- 
vulsions, coma  and  death. 

Anatomical  Changes. — The  anatomical  changes  which  take  place  in 
the  progress  of  this  variety  of  chronic  hepatitis,  are  the  result  of  a  slow 
inflammatory  process,  apparently  established  primarily  in  the  connective 
tissue,  constituting  the  capsule  of  Glisson  and  its  ramifications  through 
the  structure  of  the  liver  surroui  ding  individual  lobules  and  secreting 
cells.  The  morbid  excitability,  and  increased  vascularity  of  this  tissue 
constituting  the  inflimmation,  causes  an  increase  of  cell  proliferation 
making  the  lymphoid  and  spindle  cells  very  abundant,  and  by  their  ac- 
cumulation, sclerosis  or  hyp^rtrophy  of  the  connective  tissue  takes  place, 
and  by  pressure  directly  on  the  thin  walls  of  the  branches  of  the  portal 
vein,  obstructing  and  even  obliterating  a  large  proportion  of  the  smaller 
branches.  At  the  same  time,  the  hypertrophy  of  this  tissue  causes  more 
or  less  atrophy  of  the  secreting  cells  in  the  lobules,  and  in  some  instances 
their  separation  into  rows,  giving  them,  when  examined  under  the  micro- 
scope, much  the  appearance  of  biliary  ducts  studded  with  epithelium. 
The  biliary  ducts,  however,  and  the  ramifications  of  the  hepatic  arteries 
are  not  as  much  obstructed  as  the  branches  of  the  vena  porta.     The  hy- 


600  CHRONIC   HEPATITIS. 

pertrophy  of  the  connective  tissue  with  atrophy  of  the  secreting  lobules 
results  in  a  general  contraction  of  the  liver.  The  diminution  of  size  is 
very  unequal,  giving  it  a  nodulated  appearance  with  rounded  prominences 
on  its  surface  which  has  given  rise  to  the  name  "  hobnail  liver,"  The 
color  is  generally  lighter  or  more  yellow  than  natural.  The  size  of  the 
organ  continues  to  diminish  usually  in  proportion  to  the  duration  of  the 
disease,  until  in  some  instances  it  is  found  less  than  one  third  the  natural 
size.  In  a  patient  coming  under  my  care,  in  whom  the  disease  had  existed 
for  two  years  before  reaching  a  fatal  result,  a  post-mortem  revealed  the 
liver  hardly  larger  or  thicker  than  my  hand.  Post-mortem  examinations 
also  reveal  in  most  instances,  some  traces  of  chronic  inflammation  in  the 
mucous  membrane  of  the  stomach  and  duodenum,  and  in  most  cases  the 
spleen  is  also  found  to  have  undergone  some  degree  of  chang  -,  similar  in 
its  character  to  that  which  has  taken  place  in  the  liver;  and  probably 
from  the  action  of  the  same  causes.  The  dropsical  effusion  which  occurs 
very  constantly  in  connection  with  this  disease  is  limited  almost  entirely 
to  the  cavity  of  the  peritoneum  and  results  directly  from  obstruction  of 
the  portal  vessels.  When  the  abdomen  is  allowed  to  become  very  largely 
distended  with  effused  fluid,  the  pressure  upon  the  ascending  vena  cava 
and  common  iliacs,  in  the  lower  parts  of  the  abdomen  will  sometimes  so 
far  obstruct  the  return  of  blood  as  to  induce  much  oedema  of  the  lower 
extremities  and  scrotum,  but  as  a  direct  result  of  the  disease  of  the  liver, 
the  dropsical  effusion  is  limited  almost  entirely  to  the  cavity  of  the  peri- 
toneum. I  should  remark,  however,  that  the  contraction  of  the  liver  as 
the  result  of  sclerosis  of  the  connective  tissue  has  not  invariably  occurred. 
In  some  rare  cases,  the  liver  has  continued  to  be  its  full  size,  or  even 
larger  than  natural  throughout  the  whole  course  of  the  disease.  In  such 
cases  there  is  the  same  change  in  the  connective  tissue  and  more  or  less 
dropsical  effusion,  but  the  liver  remains  smooth  upon  its  surface,  although 
presenting  a  granular  appearance.  These  cases  have  been  regarded  by 
some  as  a  separate  and  distinct  form  of  disease  from  that  of  sclerosis  of 
the  liver.  Though  arising  evidently  from  the  same  causes,  in  the  same 
class  of  patients,  leading  to  similar  results,  and  the  anatomical  changes 
which  take  place  in  the  structure  the  same  in  all  respects  except  the 
failure  of  the  secreting  lobules  to  undergo  atrophy,  and  consequently 
there  occurs  no  progressive  diminution  of  the  size  of  the  organ. 

Diagnosis. — There  are  no  symptoms  that  can  be  said  to  be  absolutely 
diagnostic  of  this  form  of  disease  in  its  early  stage.  Wherever  in  a 
patient  accustomed  to  the  habitual  use  of  alcoholic  drinks  there  is  found 
distinct  tenderness  on  percussion  over  the  hepatic  region,  in  addition  to 
the  other  symptoms  that  I  have  before  described,  it  is  safe  to  assume  that 
there  is  at  least  danger  of  developing  this  form  of  disease.  The  only 
absolute  diagnosis,  however,  is  based  upon  the  physical  signs  of  contrac- 
tion of  the  liver,  or  its  occupying  less  space  than  natural,  coincident  with 
evidences  of  commencing  effusion  in  the  cavity  of  the  peritoneum. 

Prognosis. — The  prognosis  in  all  cases  of  well  established  chronic  in- 
flammation of  the  liver,  whether  as  the  result  of  prior  general  acute  at- 
tacks, or  whether  it  be  primarily  chronic,  of  the  interstitial  form  such  as 
I  have  just  been  describing,  is  not  favorable.  There  is  much  danger  that 
the  disease  will  persist  until  it  shortens  the  life  of  the  patient.  Yet  those 
cases  which  are  the  sequel  of  acute  attacks,  or  arise  from  any  cause  not  con- 
nected with  sclerosis,  if  they  have  not  been  allowed  to  progress  too  far, 
and  can  be  brought  under  judicious  treatment,  a  reasonable  expectation 
may  be  entertained  of  their  ultimate  recovery.  So,  too,  if  the  interstitial 
form  of  the   disease  is  actually  diagnosticated   early   before    the    liver 


TEEATMENT.  601 

has  undergone  marked  changes  in  its  structure,  or  before  any  dropsical 
effusions  have  occurred,  there  is  also  a  reasonable  chance  of  conducting 
the  patient  to  a  permanent  recovery.  But  in  all  instances  where  changes 
have  taken  place  to  such  an  extent  as  to  interfere  with  the  portal  circula- 
tion and  induce  the  beginning  of  dropsical  accumulation  within  the  peri- 
toneum, permanent  recovery  is  a  very  rare  occurrence.  The  work  of  the 
physician  in  such  cases  is  limited  almost  exclusively  to  the  palliation  of 
symptoms  and  prolongation  of  life,  with  little  or  no  probability  of  promot- 
ing a  cure. 

Treatment. — But  few  words  need  be  added  in  regard  to  the  treatment 
of  chronic  hepatitis.  Such  cases  as  come  under  the  observation  of  the 
physician  before  the  structural  changes  have  gone  sufficiently  far  to  in- 
duce dropsical  effusions,  wiil  be  most  efficiently  treated  by  the  use  of 
mild  saline  laxatives  to  procure  a  moderately  free  movement  of  the 
bowels.  If  the  urinary  secretion  is  quite  scanty,  the  patient  may  be  at 
the  same  time  put  upon  the  use  of  an  equal  mixture  of  liquor  aramonii 
acetatis  and  nitrous  ether,  in  doses  of  four  cubic  centimeters  (fl.  3') 
four  times  a  day.  If  there  be  any  quickness  of  pulse  or  slight  fever,  tinct- 
ure of  digitalis  may  be  added  to  this  mixture  in  such  proportions  as  to 
give  ten  or  twelve  minims  to  each  dose  of  the  other  ingredient.  After  the 
bowels  have  been  moved,  I  have  derived  more  advantag-e  from  the  use  of 
the  following  formula,  in  chronic  inflammation  with  more  or  less  indura- 
tion and  swelling  of  the  liver,  than  from  any  other  remedy  or  remedies 
that  I  have  used' 

5.     Ammonii  Muriatis  15.0  grams,  |ss 

Hydrargyri  Chloridi  Corosivi  .1       "  gr.  iss. 

Extracti  Conii  Fluidi  20.0     c.c.  3v 

Syrupi  Glycyrrhizas  145.0       "  fivss 

Mix.  Of  this  I  have  usually  directed  for  adults  four  cubic  centimeters 
(fl.  3i)  diluted  with  a  little  additional  water,  four  times  a  day.  Several  cases 
were  benefited  by  keeping  up,  during  the  first  one  or  two  weeks,  a 
moderate  degree  of  counter-irritation  over  the  right  h\pochondriac  region 
by  the  application  of  a  mixture  of  croton  oil,  tincture  of  iodine  and  sul- 
phuric ether  which  was  painted  over  a  moderate  extent  of  surface  morning 
and  evening  with  a  camel's  hair  pencil.  Usually,  in  two  or  three  days 
a  moderate  vesicular  eruption  is  produced  over  the  surface  to  which  the 
mixture  has  been  applied;  and  then  by  lightly  touching  it  once  a  day, 
or  once  every  alternate  day,  it  may  be  kept  at  such  a  degree  of 
soreness  as  is  desirable,  for  one  or  two  weeks.  In  most  cases  that  are 
curable  the  internal  alterants  that  I  have  mentioned  coincident  with  ex- 
ternal irritation  has  been  sufficient  to  produce  a  slow  but  steady  reduction 
of  the  inflammation  and  swelling  until  convalescence  has  been  estab- 
lished. As  the  patient  improves  the  number  of  doses  in  the  day  may  be 
diminished;  first,  to  three  a  day,  subsequently  to  one  morning  and  even- 
ino;,  until  recovery  has  so  far  advanced  as  to  allow  of  its  discontinuance. 
While  this  treatment  is  being  pursued,  due  attention  should  be  given  to 
the  condition  of  the  stomach  and  bowels;  the  latter  being  moved  at  least 
every  alternate  day,  if  they  are  not  disposed  to  keep  regular  without  the 
use  of  laxatives.  If  the  kidneys  need  prompting,  the  same  mixture  that 
I  have  just  mentioned  as  a  diuretic  will  be  sufficient  for  that  purpose. 

The  patient's  diet  should  be  very  simple,  unstimulating;  better  if  it 
can  be  made  to  consist  largely  of  farinacerms  articles  and  milk;  no  alcoholic 


602  CHEONIC  HEPATITIS. 

drinks  of  any  kind,  fermented  or  distilled,  should  be  allowed  in  any  of 
these  cases.  In  the  treatment  of  the  first  or  early  stage  of  interstitial  hep- 
atitis, more  commonly  called  cirrhosis,  before  any  dropsical  effusions  have 
taken  place,  the  exhibition  of  one  or  two  grains  of  blue  mass,  followed  by  a 
saline  laxative,  and  subsequently  by  two  or  three  doses  each  day  of  a  solu- 
tion of  the  muriate  of  ammonium,  corrosive  chloride  of  mercury  and  couiuiu 
(see  formula  on  preceding  page),  is  a  method  of  treatment  which  will  be 
found  perhaps  more  reliable  and  efficient  than  any  other.  To  afford 
a  chance  of  arresting  them,  however,  it  must  be  absolutely  adopted  early, 
before  such  changes  have  taken  place  as  to  cause  any  beginning  of 
dropsical  effusion.  After  such  effusions  have  taken  place  I  have  never 
known  treatment  to  result  in  anything  further  than  a  palliative  influence. 
The  great  question  for  the  practitioner  after  cirrhosis  or  sclerosis  of  the 
liver  has  advanced  far  enough  to  establish  serous  effusion  into  the  cavitv 
of  the  peritoneum,  is  by  what  method  will  he  be  enabled  to  retard  the 
accumulation  of  serum  and  sustain  the  functions  of  digestion  and  assimi- 
lation most  efficiently?  The  common  practice  is  to  endeavor  to  keep  down 
eft'usion  by  resorting  to  diuretics  and  hydragogue  cathartics.  The  first 
or  milder  class  of  diuretics,  so  long  as  they  can  be  made  to  influence  the 
urinary  secretion,  without  deranging  the  stomach  or  destroying  digestion, 
will  be  of  much  benefit  to  the  patient.  Hydragogue  cathartics  have  ever 
in  my  own  hands  appeared  to  do  the  patient  more  harm  than  good.  To 
produce  an  impression  in  reducing  the  amount  of  dropsical  accumulation, 
the  patient  must  be  physiced,  at  least  from  three  to  four  times  in. twenty- 
four  hours,  and  the  evacuations  must  be  copious  and  watery.  Less  than 
this  will  make  no  impression,  and  yet  I  have  never  found  a  patient  who 
could  be  kept  under  the  influence  of  podophyllin  or  any  other  hydrogogue 
cathartic  of  sufficient  activity  to  procure  any  number  of  evacuations, 
without  at  the  same  time  producing  inflammation  in  the  mucous 
membrane,  more  than  enough  to  offset  the  benefits  gained  in  lessening 
the  amount  of  dropsical  effusion.  Consequently  I  am  satisfied,  from  long 
and  abundant  experience,  that  the  use  of  hydragogue  cathartics  in- these 
cases  is  not  beneficial,  and  can  seldom  be  resorted  to  without  ultimate 
detriment  to  the  patient.  It  is  a  much  better  rule  to  keep  down  the 
dropsical  accumulation  as  far  as  practicable  by  the  milder  class  of  diuret- 
ics, and  when  these  fail  so  that  the  accumulation  and  consequent  disten- 
sion begins  seriously  to  inconvenience  the  respiration  by  crowding 
against  the  diaphragm,  and  equally  to  interrupt  digestion  by  pressure 
upon  the  stomach,  aspiration  or  direct  tapping  should  be  resorted  to  for 
the  removal  of  the  dropsical  fluid,  and  followed  by  bandaging  the  abdomen, 
and  by  such  diuretics  as  may  be  most  beneficial,  in  increasing  the  renal 
secretion,  and  thereby  retarding  the  dropsical  reaccumulation.  If  the 
latter  does  occur,  however,  aspiration  or  tapping  will  again  be  much  pref- 
erable to  the  depleting  effects,  or  more  properly  the  irritating  effects  of 
the  hydragogue  cathartics  upon  the  mucous  membrane  of  the  alimentary 
canal.  I  am  satisfied  that  my  patients  live  much  longer,  and  are  much 
more  comfortable,  by  a  judicious  repetition  of  the  tapping,  with  mild  tonics 
and  diuretics  internally,  and  a  judicious  regulation  of  the  diet  than  by 
any  other  process  I  have  been  able  to  adopt.  Of  course  as  the  cause  of  the 
dropsical  effusion  can  not  be  removed,  and  as  the  reaccumulation  generally 
takes  place  with  an  increased  degree  of  rapidity  as  the  case  progresses,  the 
blood  eventually  becomes  so  impoverished,  that  the  patient's  strength  gives 
way,  the  tissues  everywhere  become  imperfectly  nourished,  and  he  dies  in 
a  majority  of  instances  from  asthenia.  And  yet  in  a  considerable  number 
of  cases  the  final  termination  is  hastened  or  occurs  somewhat  suddenly  by 


SPLENITIS.  603 

perversion  of  the  action  of  the  kidneys,  retention  of  the  urine,  poisoninor 
of  the  nervous  centers  and  the  supervention  of  convulsions  and  coma;  or 
co:na  and  death  without  convulsions.  Sometimes  hemorrhages  take  place 
in  the  advanced  stage,  either  from  the  stomach  or  bowels,  leading  to  sudden 
and  fatal  results;  and  occasionally  eflfusioa  takes  place  into  the  pericardium 
or  into  the  cavity  of  the  pleura,  compressing  the  lungs  or  interferino- 
d:rectly  with  the  action  of  the  heart,  and  hastening  the  fatal  result  by 
either  or  both  of  these  processes. 


LECTUEE  LVII. 


Splenitis— Acule  and  Chronic :  Causes,  Clinical  History.  Anatomical  (  hanges,  Diagno=:is.  ProgTio- 
sis,  Trc'i I meut;  Neplinlis— Causes,  Diaguo^is;  Acute  Xephritis— Symptoms,  Anatomical  Changes, 
Diagnosis. 

GENTLEMEN:  The  spleen  being  an  organ  composed  largely  of  con- 
nective tissue  and  blood  vessels,  admits  of  ready  congestion,  or  en- 
gorgement and  extreme  changes  in  its  circulation,  without  necessarily 
developing  exudation,  or  true  inflammatory  action.  And,  perhaps,  no 
one  of  the  internal  organs  is  more  frequently  involved  in  some  degree 
of  hypeiiemia,  with  more  or  less  irritation,  sometimes  extensive  ex- 
udation and  changes  of  structure,  than  is  the  spleen,  during  the  prog- 
ress of  nearlv  all  of  the  acute  general  diseases.  As  you  have  noticed, 
while  I  was  speaking  of  the  general  fevers  and  directing  your  atten- 
tion to  the  post-mortem  appearances  and  pathological  changes  pre- 
sented in  both  the  periodical  and  continued  types  of  fever,  the  indi- 
cations of  morbid  action  in  the  spleen  were  among  the  most  frequent 
and  noticeable  of  any  in  the  cavity  of  the  abdomen.  While  this  is  true 
in  regard  to  those  affections  of  the  spleen  which  accompany  general, 
acute  or  infectious  diseases,  it  is  equally  true,  that  primary  idiopathic  in- 
flammation of  the  spleen  is  one  of  the  most  rare  occurrences  that  we 
meet  with  in  general  practice.  Still  it  occasionally  occurs,  from  general 
exposure  to  cold  and  wet  as  well  as  from  congestions  that  occur  during 
the  active  stage  of  other  forms  of  disease.  The  inflammation  may  present 
all  gradations  of  activity,  from  the  most  acute  and  rapidly  progressive,  to 
the  more  chronic  and  persistent  form.  AYhen  the  spleen  is  attacked 
with  acute  inflammation,  the  symptoms  are  usually  sufficiently  character- 
istic to  leave  little  or  no  doubt  in  regard  to  diagnosis.  The  organ  be- 
ing very  distensible,  the  congestion  of  vessels  necessarily  constituting 
the  first  stage  of  the  inflammatory  process  gives  rise  to  a  rapid  enlarge- 
ment of  it,  accompanied  by  more  or  less  pain,  dull  and  obscure,  if  the 
inflammation  is  restricted  to  the  interior  texture  but  more  acute,  sharp 
and  lancinating  if  it  invades  the  surface  covered  by  the  peritoneal  mem- 
brane. 

The  pain,  whether  dull  or  acute,  is  located  in  the  left  hypochondriac 
region,  oftentimes  near  the  posterior  hypochondrium,  shooting  upward  oc- 
casionally toward  the  scapula,  always  increased  on  taking  deep  inspira- 
tions, or  upon  putting  the  side  on  the  stretch,  and  still  more  increased 
by  percussion  and  pressure  directly  over  the  region  of  the  organ.  Per- 
cussion not  only  produces  decided  indications  of  tenderness,  but  it  also  in- 
dicates an  enlargement  of  the  area  of  dullness  beyond  that  which  natur- 
ally belongs  to  the  spleen  in  its  healthy  condition;  and  not  infrequently 


604  SPLENITIS. 

the  enlargement  is  suffieient  to  enable  you  to  touch  the  edge  of  the  spleen 
projecting  below  the  margin  of  the  ribs  on  the  left  side  by  simple  palpa- 
tion. Acute  inflammation  of  this  organ  is  sometimes  ushered  in  by 
chilliness,  but  more  frequently  without  a  noticeable  chill,  unless  it  is  con- 
nected with  coincident  existence  of  malarious  fever;  but,  whether  there  b& 
chill  or  not  at  the  beginning,  it  soon  gives  rise  to  a  moderate  grade  of 
general  fever,  indicated  by  rise  of  two  or  three  degrees  of  temperature, 
more  or  less  acceleration  in  the  frequency  of  the  pulse  and  its  fullness, 
more  than  the  usual  dryness  of  the  skin,  frequently  some  degree  of  coat- 
ing upon  the  tongue,  sympathetic  nausea  and  not  infrequently  vomiting 
whenever  drink  is  taken  a  little  too  freely.  The  symptoms  thus  developed 
in  acute  splenitis  usually  continue  not  more  than  from  three  to  five  days 
under  favorable  circumstances  before  they  begin  to  abate.  The  soreness 
diminishes,  the  fever  gradually  disappears,  and  soon  the  enlargement  is 
found  to  be  diminishing,  and  at  the  end  of  the  second  week  in  most  cases 
of  simple  attacks  of  inflammation,  convalescence  is  established,  and  the 
organ  returns  to  nearly  its  natural  size.  Such  is  not  always  the  case, 
however,  for  sometimes  after  the  acute  symptoms  have  progressed  for  five 
or  six  days  and  the  spleen  has  attained  a  size  sufficient  to  jut  two  or  three 
inches  below  the  margin  of  the  ribs,  the  pain  begins  to  abat;e,  the  febrile 
symptoms  diminish,  and  the  patient  becomes  comparatively  comfortable 
in  all  respects,  except  the  swelling  remains  and  there  also  remains  a  cer- 
tain degree  of  tenderness  to  pressure,  a  sense  of  weight  and  heaviness  in 
the  side,  scantiness  of  urine,  a  moderate  acceleration  of  pulse,  which  is  less 
firm  and  less  full  than  at  first,  but  still  moderately  increased  in  frequenc}', 
though  easily  compressed.  Such  a  case  may  continue  an  indefinite  p3riod 
of  time,  the  spleen  gradually  enlarging,  until  at  the  end  of  two  or  three 
months  its  lower  end  will  rest  upon  the  concavity  of  the  ileum,  or  fill 
nearly  the  whole  of  the  left  side  of  the  abdomen.  These  cases  are  said  to 
have  assumed  the  chronic  form.  I  have  seen  some  instances  in  which  the 
spleen  acquired  a  high  degree  of  density,  eventually  becoming  almost 
destitute  of  tenderness,  but  producing  a  progressive  diminution  of  the 
red  corpuscles  of  the  blood  and  giving  the  patient  a  strongly  marked 
spanremic  appearance,  accompanied  by  a  sense  of  weakness  and  inability  to 
maintain  active  exertion. 

There  is  still  another  class  of  cases,  occurring  chiefly  in  hot  climates,  in 
which  the  attack  of  inflammation  is  unusually  acute  and  severe.  The  swell- 
ing and  other  symptoms  progress  rapidly  for  five  or  six  days  when  the 
patient  is  attacked  with  irregular  rigors  and  sweats  accompanied  by  a  small 
and  rapid  pulse,  frequently,  more  or  less  delirum,  and  sometimes  epis- 
taxis.  The  patient  loses  strength  rapidly,  in  some  instances  the  bowels 
become  loose,  affording  several  thin,  brown,  or  bloody  evacuations  in  the 
twenty- four  hours,  and  if  no  relief  is  obtained  death  may  supervene  from 
exhaustion  or  from  the  recurrence  of  copious  hemorrhage  either  from  the 
stomach  or  the  bowels  before  the  end  of  the  second  week.  On  the  other 
hand  some  of  these  cases,  after  the  recurrence  of  chills  and  sweats  indi- 
cating suppuration  and  the  formation  of  abscesses,  in  a  few  days  discharge 
a  large  amount  of  pus  by  vomiting,  showing  that  an  abscess  has  formed  in 
the  spleen  and  discharged  its  contents  into  the  stomach.  I  think  some  in- 
stances are  on  record  in  which  adhesions  had  taken  place  between  the 
spleen  and  extreme  left  angle  of  the  colon,  and  abscesses  have  discharged 
from  the  spleen  into  that  section  of  the  colon,  and,  of  course  the  matter  made 
its  appearance  with  the  evacuation  from  the  bowels.  In  still  other  in- 
stances, abscesses  have  tended  to  the  surface  and  have  formed  adhesions 
with  the  abdominal  walls,  progressing  in  that  direction  till  fluctuation  was 


ANATOMICAL   CHANGES.  605 

distin;^aishable,  and  by  either  free  incision,  or  by  aspiration,  the  pus  has 
been  evacuated  in  the  same  manner  as  in  abscesses  of  the  liver.  But  sup- 
puration as  the  result  of  inflammation  in  the  spleen,  is  very  much  less 
frequent  than  in  the  liver — so  much  so  that  in  the  whole  period  of  my 
practice  I  have  met  with  not  more  than  one  or  two  instances  that  have 
been  diagnosticated,  either  before  or  after  death,  as  involving  suppura- 
tion, or  the  formation  of  an  abscess  in  the  spleen.  Acute  inflammation  in 
the  spleen,  whether  resultincr  in  suppuration  or  otherwise  is  more  frequent 
in  hot  than  in  the  colder  climates. 

The  subacute  attacks  of  inflammation  in  the  spleen  occur  frequently 
durinir  the  progress  of  malarious  fevers  in  all  countries  where  such  fevers 
are  prevalent.  Such  attacks  are  usually  of  the  milder  type  and  supervene 
in  connection  with  the  chill  belonging  to  the  general  disease,  and  are 
almost  always  so  far  relieved  or  modified  by  the  treatment  given  to  the 
general  disease  that  they  hardly  require  or  receive  separate  consideration. 
And  yet,  from  this  very  fact,  there  occur  now  and  then  cases  which  do  not 
subside  under  such  management,  but  only  become  modified  by  the  sub- 
sidence of  the  pain,  tenderness,  and  other  more  prominent  symptoms, 
while  the  organ  itself  remains  enlarged  from  congestion  and  exudation 
into  its  texture,  and  consequently  is  found  in  a  few  weeks  or  months, 
after  the  patient  has  been  supposed  to  be  convalescent,  still  giving  rise  to 
a  sense  of  heaviness,  weight,  and  sometimes  dull  pain  in  the  left  hypo- 
chondriac region  accompanied  by  impairment  of  appetite,  diminution  of 
red  blood  corpuscles  and  continued  sense  of  weakness.  When  examined 
the  hypochondriac  region  on  the  left  side  is  found  more  convex  than 
natural,  presenting  a  much  larger  area  of  dullness  than  belongs  to  the 
spleen,  and  its  thick  hardened  edge  is  easily  felt  by  palpation  below 
the  margin  of  the  ribs  from  the  left  margin  of  the  epigastric  region 
around  to  the  space  between  the  crest  of  the  ilium  and  lower  ribs. 
These  are  cases  in  which  the  subacute  inflammatory  action  established 
during  the  progress  of  acute  general  diseases  only  partially  subsides, 
leaving  the  connective  tissue  of  the  spleen  in  a  state  of  chronic  inflam- 
mation with  more  or  less  exudation  into  the  interstitial  spaces  of  the 
tissue.  Under  continued  hyperaemia,  or  chronic  inflammatory  action 
the  work  of  sclerosis  or  hypertrophy  of  the  connective  tissue  progresses. 
It  is  from  neglect  of  the  earlier  stages  of  these  cases,  especially  in 
malarious  fever,  and  sometimes  in  the  typhoid  and  typhus  grades,  that 
the  patient  is  found,  oftentimes  months  and  sometimes  years  after  con- 
valescence from  the  general  disease,  with  a  chronic  persistent  enlarge- 
ment and  induration  of  the  spleen.  This  may  continue  slowly  to  pro- 
gress, till,  as  I  have  previously  said,  it  fills  up  the  whole  of  the  left  side, 
and  by  its  mechanical  pressure  upon  surrounding  tissues  gives  rise  to 
much  discomfort  and  blood  impoverishment,  and  ultimately  shortens  the 
life  of  the  patient.  In  a  few  instances  the  inflammatory  affection  un- 
doubtedly commences  purely  in  the  chronic  form,  without  being  preceded 
by  either  an  acute  or  subacute  attack. 

In  its  early  stage  the  symptoms  are  somewhat  obscure,  and  often  escape 
attention  or  lead  to  the  suspicion  that  the  patient  is  laboring  under  some 
gastric  derangement  or  indigestion,  till  the  organ  has  attained  sufiicient 
size  and  hardness  to  attract  attention  by  its  weight  and  fullness,  and 
direct  exploration  by  percussion  and  palpation,  completes  the  diagnosis 
and  renders  the  practitioner  aware  of  the  true  cause  of  the  patient's 
suffering. 

Anatomical  Changes. — The  spleen  when  examined  during  the  early 
stage  of  acute  inflammation  presents  all  the  evidences  of  intense  engorge- 


606  IXFLAMMATIOX    OF    THE    SPLEEIST. 

ment  of  its  vessels,  the  accumulation  of  blooi  causing  an  increasad 
redness  and  swelling.  Wlien  cut  across,  blood  ooz3S  from  its  vessels  in 
greater  quantities  than  is  normitl,  and  all  the  evidences  of  copiojs  exuda- 
tion into  the  interstitial  tissue  are  present;  the  exudation  being  com- 
posed of  numerous  lymphoid  cells,  migrating  corpuscles,  more  or  less  red 
corpuscles,  fibrillateil  fibrine,  and  liquor  sanguinis,  produce  varying  degrees 
of  density  in  the  structure  of  the  organ.  In  most  cases  where  an  acute 
inflammation  has  supervened  as  a  complication  of  acute  general  disease,  the 
texture  of  the  organ  is  soft  or  impaired;  when  not  connected  with  a  general 
disease,  but  occurring  from  ordinary  exposure  as  a  form  of  acute  inflim- 
mation,  the  liquor  sanguinis  exuding  into  the  interstitial  spaces  of  the  tissue, 
is  more  firmly  coagulable  or  plastic,  the  connective  tissue  itself  undero^oes 
more  rapid  hepatization  and  hj-pertrophy,  and  the  density  of  the  organ  is  in- 
creased. As  a  general  rule  in  such  casas,  the  density  will  be  increased 
in  proportion  to  the  duration  of  the  disease;  consequently  when  it  assumes 
the  chronic  form  the  connective  tissue  becomes  greatly  thickened,  hyper- 
trophied  by  the  a  Idition  of  plastic  raxterial,  and  the  interspaces  become 
filled  with  lymphoid  cells  of  various  sizes  and  shapes,  not  only  giving 
rise  to  great  engorgement  of  the  organ  as  a  whole,  but  giving  to  its 
texture  much  greater  density  and  firmness. 

In  nearly  all  these  cases,  however,  the  exterior  of  the  spleen  retains  its 
smoothness  and  evenness  of  surface. 

JJiagnosis. — As  I  have  already  intimated,  the  diagnosis  of  acute  inflam- 
mation of  the  spleen  is  not  difficult  or  obscure.     The  sudden  development 
of  acute  pain,  tenderness  to  pressure  on  percussion,  more  or  less  general 
febrile  movement,  and  particularly  in  addition  to  this,  the  rapid  enlargement 
of  the  organ,  as  indicated  by  an  increased  area  of  dullness  on  percussion, 
leaves  no  room  for  doubt  as  to  the  nature  and  seat  of  the  disease.       From 
pleurisy  it   is  of  course  distinguished  by  the  fact,  that  the  pain,  enlarge- 
ment and  fullness  are  all  located  below  the  attachment  of  the  diaphragm, 
and   the   further  fact,   that  there  is  neither  friction  sound  coincident  with 
the  respiratory  movements  on  that  side  of  the  chest,  nor  dullness  extend- 
ing  above   the  diaphragm  to  indicate  any  efi"asion  that  might  exist  in  the 
second  stage  of  pleurisy.     From  gastritis  it  is  distinguished  by  the  decided 
difference  in  the  character  of  the  pain,  and  by  the  absence  of  the  persistent 
vomiting,  acute   epigastric   tenderness   and  distension  which  exist  in  the 
latter  disease,  and  are  not  present  in  the  splenitis.       But  there   are    some 
cases  of  chronic  inflammation,  and  enlargement  or  induration  of  the  spleen, 
in  which,  after  the  disease  has  continued  for  a  considerable  length  of  time, 
there  may   be   some   difficulty  in    arriving   at  a  satisfactory  and  positive 
diagnosis  from    the    enlargement   that   belongs    to    leucocythfemia,    per- 
nicious   antemia,    sometimes    to    cirrhosis    of  the    liver,    or    occasionally 
results  from    malignant  growths    in   the  tissue    of   the    spleen.       But   if 
you   remember  that  the   splenic   affection   connected    with    the    leucocy- 
thaemia    is    accompanied  by    other  evidences    of   the    same   general   dis- 
ease   in    other  glands,   coincidently,   as   was   described    when    I    treated 
more  particularly  of  that  affection,  and  the  same  in  regard  to    the   coinci- 
dent conditions  in  pernicious  anfemia  and  cirrhosis,  it  will  enable   you  to 
keep  clear  the  line  of  distinction  between  simple  chronic  inflammation  and 
induration,  and  splenic  affections  accompanying  the  other   diseases  just 
named.      In  regard   to  malignant  growths  causing  enlargement   of  the 
spleen  there  ai-e  two  almost  constant  points  of  difference,  which  should 
engage  your  attention  ;  the  first  is,  that  malignant  growths  in  the  spleen 
commence   obscurely  with   little   or  no   evidence  of  inflammatory  action 
during   all   their  early  history,  and  are  accompanied  by  a  much  more  de- 


INFLAMMATION   OF    THE    PANCEEAS.  607 

cided  general  cachexia  than  belong'S  to  ordinary  chronic  inflammation  of 
that  organ.  The  other  is  that  nearly  all  malignant  growths  involving  the 
spleen  cause  it  to  become  irregular  in  its  outline,  nodulated  upon  its  sur- 
face, some  points  being  more  prominent  and  dense  than  others,  while  the 
enlargement  from  simple  inflammation  is  more  general,  and  preserves  a 
more  even  and  uniform  condition  of  the  surface. 

Prognosis. — Nearly  all  the  cases  either  of  acute  or  chronic  inflammation 
of  the  spleen,  if  brought  under  judicious  management  during  the  early 
period  ot  their  progress,  terminate  favorably.  Consequently,  there  is  not 
a  very  high  ratio  of  mortality  resulting  from  this  afi^ection  in  any  grade, 
acute  or  chronic,  except  when  it  has  been  neglected  during  the  early 
stage,  or  when,  as  occasionally  happens  in  warm  climates,  the  inflamma- 
tion has  assumed  that  rapidly  advancing  and  suppurative  character  that 
corresponds  almost  directly  with  what  is  denominated  acute  yellow 
atrophy  of  the  liver.  But  when  in  the  earlier  stages  of  their  progress, 
chronic  cases  have  been  neglected  until  the  organ  has  acquired  a  large 
size,  and  greater  density  of  structure,  it  is  very  liable  to  remain  an  in- 
definite period  of  time  without  undergoing  resolution  by  any  process  of 
treatment  that  has  yet  been  devised.  Still,  life  may  be  prolonged  many 
years.  When  it  does  terminate  fatally,  it  is  more  generally  from  the 
efl"ects  of  mechanical  pressure  interfering  with  the  function  of  surrounding 
organs,  than  from  direct  influence  of  the  disease  of  the  spleen  itself. 

Treatment. — In  regard  to  the  treatment  of  all  grades  of  inflammation  of 
the  spleen,  I  need  do  no  more  than  remind  you  that  the  same  principles 
and  the  same  remedies  are  applicable  here  as  in  the  treatment  of  corre- 
sponding grades  of  inflammation  in  the  liver.  I  have  not  been  enabled  to 
detect  any  essential  difl'erence  in  the  eti'ects  of  remedies,  or  in  the  necessity 
for  their  use,  between  the  corresponding  grades  of  inflammation  in  the 
liver  and  in  the  spleen;  consequently  we  will  not  repeat  here  what  was 
said  with  a  sufficient  degree  of  detail  in  the  preceding  lecture. 

Inflammation  of  the  Pancreas. — That  the  pancreas  is  sometimes  the 
seat  of  inflammatory  action  there  can  be  no  doubt.  In  many  instances, 
in  making  post-mortem  examinations  where  the  patient  has  suff'ered  dur- 
ing life  from  inflammation  within  the  abdominal  cavity,  the  pancreas  has 
been  found  to  present  all  the  evidences  of  acute  or  subacute  inflammation. 
That  it  is  very  rarely  the  primary  seat  of  this  form  of  disease  is  also  un- 
doubtedly true.  Its  deep-seated  position  makes  it  difficult  to  trace 
its  outline  unless  it  be  greatly  enlarged  or  indurated,  and  difficult 
to  determine  whether  any  given  pain  or  tenderness  is  located  in  that 
organ,  or  in  any  of  the  textures  or  viscera  surrounding  it.  That  some  of 
the  cases  with  which  we  meet  of  very  obscure  and  persistent  derangements 
of  the  later  stages  of  digestion,  or  of  the  changes  that  naturally  take  place 
in  the  duodenum,  as  well  as  the  rare  cases  of  diarrhoea,  characterized  by 
fatty  dejections,  are  connected  with  an  inflammatory  condition  of  the 
pancreas,  I  have  no  doubt.  Some  writers  have  reported  a  few  cases  of 
sudden  death  in  which  the  only  post-mortem  appearances  were  the  pres- 
ence of  acute  inflammation  of  the  pancreas.  In  other  cases  of  chronic 
disease  terminating  fatally,  post-mortem  examinations  have  revealed 
various  degenerative  conditions  of  the  pancreas,  in  some  instances,  fatty 
degeneration  of  its  texture,  in  others  sclerosis,  or  hypertrophy  of  the 
connective  tissue.  Perhaps  the  most  frequent  disease  that  is  seen  of  a 
non-inflammatory  or  malignant  character  consists  of  the  scirrhus  or  col- 
loid form  of  cancer,  chiefly  occupying  the  head  of  the  pancreas,  and  gen- 
erally connected  with  scirrhus  of  the  pylorus,  or  of  the  adjacent  tissues. 

Two  instances  have  come  under  my  own  observation,  of  scirrhus  of  the 


608  NEPHRITIS. 

pancreas,  causing  the  head  of  it  to  become  twice  its  natural  size,  to  be  easily 
felt  through  the  walls  of  the  abdomen,  and  recognized  as  belonging  to  the 
pancreas,  rather  than  the  pylorus  or  other  tissue  by  the  elongation  of  the 
tumor  transversely  in  reference  to  the  abdomen,  and  at  the  same  time  the 
absence  of  some  of  the  symptoms  of  obstruction  in  the  pyloric  orifice,  that 
usually  accompany  cancers  in  that  part.  There  are  no  well  established 
diagnostic  symptoms  by  which  you  can  recognize  the  various  inflammatory 
conditions  of  the  pancreas,  and  consequently  it  would  be  futile  in  the  pres- 
ent state  of  our  knowledge  to  undertake  the  consideration  of  them  more 
in  detail.  I  shall,  therefore,  next  direct  your  attention  to  the  inflamma- 
tions of  the  kidneys,  and  other  portions  of  the  urinary  apparatus. 

Iiiflainmatioyis  of  the  Genito-  Urinary  Organs. — Under  the  designation 
"genito-urinary  organs"  is  included  the  kidneys,  urinary  passages,  and 
the  male  and  female  organs  of  generation.  But  the  universal  custom  of 
considering  diseases  affecting  the  female  organs  of  generation  in  works 
upon  midwifery  and  gynecology,  and  those  of  the  male  organs  including 
the  urinary  passages  and  bladder,  in  works  upon  surgery,  remove  the  con- 
sideration of  these  from  the  field  of  practical  medicine;  consequently 
there  is  left  for  us  to  consider  only  the  inflammations  afl'ecting  the  kid- 
neys. 

Nephritis. — In  considering  the  inflammatory  conditions  of  these  impor- 
tant organs  it  will  be  convenient  to  group  them  under  the  following  heads: 
simple  hyperaemia  or  renal  congestion,  acute  and  chronic  diffuse 
nephritis,  and  acute  suppurative  nephritis.  Hyperaemia,  or  con- 
gestion of  the  texture  of  the  kidney,  may  occur  from  three  sep- 
arate pathological  conditions;  first,  from  directly  increased  determina- 
tion of  blood,  causing  the  condition  properly  denominated  active 
congestion;  second,  from  paralysis,  or  diminution  of  the  vasomotor 
influence  over  the  arterioles  of  the  kidneys,  by  which  they  are  allowed  to 
dilate  and  receive  more  blood  than  normal,  and  third,  similar  vasomotor 
paralysis  or  impairment  of  the  venous  radicles,  by  which  the  blood  accu- 
mulates in  the  venous  side  of  the  circulation  in  those  organs.  The  causes 
which  may  give  rise  to  these  various  forms  of  hyperemia  of  the  vessels  of 
the  kidneys  are  various.  The  first  or  active  grade  of  hypenismia  most 
frequently  results  from  the  action  of  irritating  substances  taken  into  the 
stomach,  and  carried  to  the  kidneys  for  elimination;  such  as  the  slighter 
grades  of  irritation  arising  from  cantharides,  turpentine  and  other  sub- 
stances, that  are  capable  of  being  eliminated  freely  from  the  blood  through 
these  organs,  and  are  more  or  less  irritating  in  their  influence. 

It  is  probable,  also,  that  these  forms  of  disease  may  originate  from  con- 
stant exposure  to  cold,  sudden  wetting,  over-heating,  or  warmth.  The 
causes  capable  of  giving  rise  to  paralysis  of  the  vasomotor  nerves  belong- 
ing to  the  arterioles  of  the  kidneys  are  well  understood;  but  the  hyper- 
semia  of  the  smaller  veins,  constituting  what  some  writers  term  true  pas- 
sive congestion  of  the  external  portion  of  the  kidney,  originates  or  may 
originate  from  all  those  pathological  con<litions  which  interfere  materially 
with  the  oxygenation  and  decarbonization  of  the  blood.  It  is  therefore 
this  form  of  renal  congestion  that  occurs  frequently  in  connection  with 
such  structural  diseases  of  the  heart  as  induce  more  or  less  constant  over- 
fullness  of  the  vessels  of  the  lungs,  the  advanced  stages  of  phthisis,  some 
cases  of  pneumonia,  the  typhoid  grades  of  general  acute  diseases,  and 
any  of  the  general  dropsies,  which  proceed  far  enough  to  produce 
dyspnoea,  or  cardiac  obstruction,  and  thereby  lessen  the  amount  of 
oxygen  taken  up  and  of  carbonic  acid  gas  eliminated  through  the  lungs. 
You  will  thus  perceive    that  passive    congestion    of  the    kidney  occurs 


SYMPTOMS.  609 

almost  exclusively  as  a  secondary  aflfection  resulting  from  serious 
prior  diseases,  and  not  as  a  primary  affection.  In  a  large  proportion  of  all 
the  cases  of  acute  general  disease  that  terminate  fatally,  especially  those 
of  an  infectious  character,  post-murtem  examination  shows  more  or  less 
passive  congestion  of  the  kidneys.  When  renal  hyperasmia  arises  from 
prior  acute  diseases,  it  attracts  no  more  attention  than  any  other  second- 
ary functional  derangement,  usually  disappearing  with  the  subsidence 
of  the  cause  with  which  it  is  associated.  On  the  other  hand,  when  a  con- 
gested condition  of  the  kidney  remains,  after  the  subsidence  of  the 
cause  that  may  have  induced  it,  there  is  danger  that  it  will  so  far  inter- 
fere with  the  elimination  of  the  natural  elements  of  urine  as  to  allow  the 
blood  to  retain  an  excess  of  these  elements  and  lead  to  some  one  of  the 
more  serious  consequences  of'urasmic  poisoning,  such  as  violent  vomiting 
and  purging,  or  the  sudden  occurrence  of  convulsions,  followed  by  more  or 
less  paralysis,  and  sometimes  by  coma  and  death.  It  is  necessary,  therefore, 
that  attention  be  given  in  all  cases  to  the  condition  of  the  kidneys  during 
the  progress  of  such  diseases  as  interfere  with  the  respiratory  function, 
either  directly  or  indirectly,  so  far  as  to  impair  the  function  of  the  vaso- 
motor nerves  connected  with  the  renal  vessels.  The  symptoms  which 
indicate  renal  hyperjemias  during  life  vary  with  the  varying  pathological 
conditions  that  I  have  already  mentioned.  Perhaps  in  all  cases  of  active 
determination  of  blood  to  the  kidney,  under  the  influence  of  irritating 
agents,  the  urinary  secretion  is  decidedly  diminished  in  quantity,  usually 
redder  than  natural,  containing  less  urea,  and,  for  a  time  at  least,  some 
albumen.  The  hypercemia  dependent  upon  dilatation  of  the  arterioles  is 
more  frequently  accompanied  by  increased  flow  of  urine  above  the  natural 
standard.  Indeed,  some  writers  have  considered  the  real  c.mse  of  dia- 
betes insipidus  to  be  a  paralyzed  and  passively  congested  condition  of  the 
arterioles.  The  urine,  however,  while  increased  in  quantity,  has  a  low 
specific  gravity,  seldom  contains  any  abnormal  elements,  but  simply  a 
large  excess  of  water  in  proportion  to  its  solid  constituents.  The  exces- 
sive flow  of  water  diiiiinishes  the  watery  element  of  the  blood,  often  giv- 
ing rise  to  increased  thirst,  more  or  less  shrinking  of  the  tissues,  or  emaci- 
ation, generally  decided  loss  of  strength,  or  power  of  endurance,  and 
much  wakefulness,  and  other  symptoms  indicating  nervous  excitability. 
It  is  undoubtedly  this  form  of  hyperaemia  of  the  kidney  depending  upon 
dilatation  of  the  arterioles  that  gives  rise  to  the  copious  secretion  of  lim- 
pid urine,  so  characteristic  of  many  cases  of  hysteria.  On  the  other  hand, 
in  those  cases  of  renal  hypergemia  dependent  upon  impairment  of  the 
vasomotor  influence  over  the  renal  veins,  there  is  almost  uniformly  a  dim- 
inution in  the  quantity  of  urine  secreted.  Frequently  it  is  of  a  dark, 
brownish  color,  sometimes  containing  epithelial  cells,  often  red  corpuscles 
of  blood,  and  not  infrequently  traces  of  albumen.  The  quantity  of  ureas 
is  also  in  these  cases  very  generally  diminished.  If  the  congestion  is 
connected  with  the  existence  of  some  permanent  structural  disease  of  the 
heart  or  lungs,  and  consequently  not  capable  of  any  permanent  removal, 
the  secretion  of  smaller  quantities  of  urine,  and  the  consequent  favoring 
of  the  accumulation  of  the  watery  element  of  the  blood  in  the  vessels,  in- 
creases the  tendency  to  general  dropsical  infiltration  of  the  areolar  tissue 
in  all  parts  of  the  body.  Consequently,  if  no  dropsical  effusions  have  ex- 
isted prior  to  the  occurrence  of  this  form  of  renal  congestion,  it  is  soon  fcil- 
lowed  by  the  development  of  some  indications  of  general  oedema.  This 
is  seen  first  in  the  morning,  when  the  patient  rises  from  the  bed,  more  no- 
ticeably in  the  face  and  loose  tissues  of  the  eyelids,  and  more  proiuinently, 

39 


610  ACUTE    DIFFUSE   NEPHRITIS. 

if  the  patient  sits  up  during  the  day  -with  the  feet  in  a  dependent  condi- 
tion, in  the  tips  of  the  feet  and  ankles.  And  ultimately  the  renal  congestion 
continues,  general  dropsy  and  infiltration  of  the  areolar  tissues  throughout 
the  whole  system  almost  necessarily  follows.  As  this  general  anasarca 
increases  throughout  the  system  the  urinary  secretion  becomes  less 
and  less  in  amount,  till  oftentimes  the  elimination  of  urea  is  so  small  that 
the  symptoms  of  urfemic  poisoning  supervene,  and  frequently  hasten  the 
fatal  termination  of  the  case.  The  anatomical  changes  which  result  from 
this  hyperjemic  condition  of  the  kidnev  vary  much,  both  from  the  vary- 
ing degrees  of  intensity  of  the  congestion  and  its  duration.  Perhaps  in 
all  cases  of  active  congestion  the  kidney  is  somewhat  increased  in  size, 
and  presents  more  or  less  of  a  mottled  color;  portions  of  it  being  paler 
than  natural,  while  other  parts  are  deep  red,  or  of  intermediate  shades  of 
color.  Those  cases  dependent  on  venous  congestion  almost  always  pre- 
sent a  moderate  degree  of  enlargement  of  the  kidney,  with  a  dark  red  ap- 
pearance of  the  pyramidal  bodies,  some  degree  of  exudation  in  the  mal- 
pighian  tufts,  and  around  the  glomeruli,  and  sometimes  a  slight  extravasa- 
tion of  blood. 

Diagnosis. — The  diagnosis  of  the  different  grades  of  hyperjemia,  or  renal 
congestion,  depends  mainly  upon  the  coincident  condition  of  the  patient 
in  relation  to  other  diseases,  and  the  direct  quantity  or  quality  of  the  urine. 
It  is  rare  that  in  any  of  these  cases  there  ]s  sufficient  pain,  either  in  the 
region  of  the  kidnej-s  or  on  evacuating  the  water,  to  attract  attention,  or 
to  indicate  the  pathological  condition.  Sometimes,  however,  when  active 
congestion  arises  from  sudden  exposure  to  cold,  or  from  the  existence  of 
direct  irritating  substances  circulating  in  the  blood,  there  will  be  a  mod- 
erate degree  of  dull,  aching  pain  directly  in  the  region  of  the  kidneys, 
sometimes  shooting  downward  in  the  direction  of  the  ureters.  Unless 
the  hyperaemia  continues  until  it  develops  active  inflammation,  the  pain 
is  only  moderate  and  of  temporary  duration,  while  the  condition  of  the 
urine  will  aid  in  establishing  a  diagnosis.  In  the  first  class  of  cases  it  is 
small  in  quantity,  with  a  diminished  proportion  of  urea,  and  very  gen- 
erally contains  some  traces  of  albumen,  with  occasional  fibrinous  casts, 
but  usually  less  than  in  actual  nephritic  inflammation.  The  characteristic 
condition  of  the  second  form  of  congestion,  dilatation  of  the  arterioles,  is 
increased  flow  of  urine  with  less  than  the  normal  proportion  of  urea,  and 
other  natural  excretory  elements  of  urine,  and  an  entire  absence  of  morbid 
elements  of  any  kind.  The  third  is  characterized  by  diminution  of  the 
amount  of  urinary  secretion,  its  darker  color,  more  generally  slight  traces 
of  albumen,  fat  granules,  and  frequently  traces  of  red  corpuscles  of  the 
blood.  These  conditions  are  generally  associated  with  more  or  less  gen- 
eral dropsy,  or  with  the  last  stages  of  wasting  suppurative  diseases.  Of 
the  treatment  of  these  hypeifemias  it  is  unnecessary  to  speak  till  we  con- 
sider the  different  grades  of  inflammation  of  the  kidney. 

Acute  Diffuse  JS^ephritis,  or  Acute  Drighfs  Disease. — x\cute  inflamma- 
tion, invading  the  structure  of  the  kidney  generally,  constituting  what  we 
have  designated  as  acute  diffuse  nephritis,  seldom  occurs  as  a  primary  or 
idiopathic  affection,  but  in  far  the  larger  number  of  cases,  it  occurs  either 
during  the  progress,  or  as  the  sequel,  of  some  one  of  the  acute  general  dis- 
eases of  an  infectious  character.  Perhaps  three  fourths  of  all  the  cases 
met  with  in  general  practice  originate  in  connection  with,  or  during  con- 
valescence from,  scarlet  fever.  Less  frequently  it  follows  the  other  erup- 
tive fevers,  such  as  measles,  small-pox  and  erysipelas.  Occasionally  cases 
occur  during  the  convalescing  period  from  both  typhoid  and  typhus  fevers, 
but  very  rarely  from  the  othei'  general  febrile  affections.     When  the  dis- 


SYMPTOMS.  Gil 

ease  originates  idiopathically,  or  independent  of  the  prior  existence  of 
other  diseases,  it  is  generally  caused  by  the  direct  impression  of  cold  and 
damp.  Sleeping  in  cold  or  damp  rooms  or  beds,  going  into  the  water 
when  the  body  is  at  a  higli  temperature  from  previous  exercise,  or  becom- 
ing thoroughly  wet,  and  then  suddenly  chilled,  are  conditions  most  likely 
to  cause  an  attack.  This  form  of  disease  is  also  capable  of  being  in- 
duced by  the  action  of  direct  irritants.  The  introduction  into  the  system 
of  caiitharides,  either  by  the  mouth  or  absorbed  from  blistered  surfaces, 
oil  of  turpentine,  oil  of  mustard,  cubebs,  carbolic  acid,  and  a  variety  of 
other  substances,  have  occasionally  been  found  capable  of  producing  du-ect 
irritation  and  inflammation  of  the  renal  structure. 

Si/injytoms. — Whatever  may  be  the  direct  cause,  whether  it  be  the  con- 
ditions growing  out  of  previous  diseases,  the  direct  irritants  introduced 
into  the  svstem,  or  the  impression  of  cold  and  damp  upon  the  surface,  the 
symptoms  which  indicate  the  comm  jucement  of  an  acute  attack  of  nephri- 
tis, are  usually  well  marked.  They  consist  of  pain  pretty  severe  in 
the  back  and  loins,  increased  by  motion  or  turning  the  body,  acceleration 
of  pulse  with  increased  fullness,  decided  increase  of  tempei-ature  of  the 
body,  more  frequent  respirations,  considerable  thirst,  much  restlessness, 
an  expression  of  anxiety  in  the  countenance,  and  a  very  decided  diminution 
in  the  quantity  of  urine  secreted.  Sometimes  the  desire  to  urinate  is  ac- 
companied by  a  sense  of  heat,  at  other  times  by  no  apparent  local  irrita- 
tion in  the  urinary  passages,  and  the  urine  passes  only  at  regular  intervals 
and  in  very  small  quantities — what  is  passed  is  usually  either  of  a  turbid 
appearance,  or  redder  than  natural,  and  pretty  uniformly  yields  a  copious 
precipitate  of  albumen  upon  the  application  of  heat  or  nitric  acid.  If  the 
urine  be  further  analyzed,  it  will  be  found  to  contain  decidedly  le.ss  than 
the  natural  proportioti  of  urea  and  excretory  elements  of  urine,  while  the 
microscope  will  usually  detect  more  or  less  red  corpuscles  of  the  blood, 
fibrinous  casts,  shreds  of  solidified  fibrin,  and  usually  some  epithelium, 
evidently  from  the  urinary  tubles.  The  assemblage  of  symptoms  which 
I  have  described,  leave  no  reasonable  doubt  as  to  the  existence  of  some 
degree  of  diffuse  nephritic  inflammation.  If  it  is  not  speedily  relieved, 
additional  sj-mptoms  of  striking  importance  follow.  In  the  more  acute 
class  of  cases,  within  twenty-four  hours  from  the  commencement  of  the 
attack,  the  retained  urea  will  be  found  to  manifest  its  irritant  effects, 
either  upon  the  mucous  membrane  of  the  digestive  organs,  or  perhaps 
more  frequently  upon  the  nervous  centers,  if  upon  the  first,  there  is 
vomiting,  active  and  severe,  followed  not  infi'equently  by  copious  watery 
diarrhoea,  rapidly  exhausting  the  patient,  and  giving  the  case  much 
the  appearance  of  genuine  cholera  morbus  ;  while  in  the  second  class 
of  cases,  in  which  the  irritant  effects  are  developed  in  the  nervous 
centers,  there  is  first  jerking  of  the  muscles,  sudden  motions  of  the 
limbs,  some  degree  of  delirium,  and  if  no  modification  of  the  progress 
of  the  disease  is  made  by  treatment,  during  the  latter  part  of  the  second 
or  the  third  day,  in  a  large  proportion  of  the  cases,  general  convulsions 
will  occur.  Sometimes  the  first  severe  general  convulsion  is  followed 
by  coma,  dilated  pupils,  stertorous  breathing,  entire  suppression  of  the 
urinary  secretion  and  death  in  a  few  hours.  At  other  times  the  convul- 
sion after  a  few  minutes  ceases,  leaving  the  patient  drowsy,  breathing 
heavily,  and  after  from  ten  to  thirty  minutes,  consciousness  is  regained, 
and  for  a  time  varying  from  a  few  minutes  to  two  or  three  hours,  the 
patient  will  appear  much  as  before  the  convulsion  occurred,  when  sud- 
denly another  paroxysm  will  occur,  of  the  same  character  as  the  first,  fol- 


G12  ACUTE    DIFFUSE    NEPHRITIS. 

lowed  by  the  same  results,  only  leaving  the  patient  more  dull  and  de- 
pressed, the  pulse  quicker,  smaller  than  usual,  the  extremities  cooler,  with 
a  constant  puffiness  of  the  face,  some  general  tumefaction,  especially 
of  the  hands  and  feet,  producing  the  appearance  of  a  moderate  degree 
of  oedematous  infiltration  into  the  areolar  tissue.  The  urinary  secretion 
is  now  usually  exceedingly  small  and  so  highly  albuminous  as  to  form  a 
coagulum,  almost  like  the  white  of  an  egg.  Very  frequently  also  more 
decided  quantities  of  blood  appear  in  the  urine.  The  patient  may  now 
pass  into  another  convulsion,  ending  in  entire  coma,  collapse  and  death,  or 
without  further  convulsions,  the  breathing  may  become  more  labored,  irreg- 
ular and  sio-hing,  the  mind  more  dull,  making  it  difficult  to  arouse  the  indi- 
vidual, pupils  steadily  dilated,  very  frequently  the  axes  of  vision  are  not  par- 
allel, the  eyes  being  turned  in  different  directions,  and  one  pupil  possibly 
more  dilated  than  the  other.  Often  one  arm  and  one  leg  afe  found  entirely 
paralyzed,  while  there  are  frequent  automatic  movements  of  the  other, 
such  as  drawing  up  the  leg,  putting  it  down,  and  tossing  the  hand  in 
different  directions.  And  by  the  fourth  or  fifth  days  entire  coma  super- 
venes, accompanied  by  involuntary  discharges  from  the  bowels,  entire 
suppression  of  the  urine  and  an  early  death.  The  progress  of  these  cases 
varies  much  in  different  patients.  I  have  seen  some  cases  terminate 
fatally  within  thirty-six  hours  from  the  first  appearance  of  the  renal 
trouble,  by  violent  convulsions  and  coma.  Others  have  been  so  slow  as 
to  reach  a  fatal  result  only  at  the  end  of  from  seven  to  nine  days.  More 
frequently,  when  they  terminate  fatally  in  the  acute  stage,  deatii  super- 
venes between  the  end  of  the  second  and  the  commencement  of  the  fifth 
day.  The  symptoms  of  acute  nephritis,  as  I  have  just  described  them, 
are  more  particularly  applicable  to  that  class  of  acute  cases  which  follow 
scarlatina,"  and  the  convalescing  stage  of  other  eruptive  diseases.  Almost 
identically  the  same  assemblage  of  symptoms  and  succession  of  changes 
and  results  take  place  in  those  cases  of  acute  nephritis  that  occur  in 
the  latter  stages  of  pregnancy,  and  sometimes  culminate  at  the  time  of 
delivery,  giving  rise  to  what  is  denominated  puerperal  convulsions  or 
eclampsia. 

I  recollect  two  cases  of  acute  nephritis  caused  directly  by  the  influ- 
ence of  cold  and  wet:  One  was  a  laboring  man,  working  upon  the  open 
prairie  in  the  latter  part  of  summer,  and  camping  out  during  the  night 
with  imperfect  protection,  who  suffered  a  thorough  wetting  from  a  copious 
shower  of  rain  during  the  night,  followed  by  a  sudden  change  in  the  tem- 
perature of  the  atmosphere.  In  this  case,  within  twenty-four  hours  after 
the  wetting,  the  patient  was  taken  with  severe  dull  pain  in  the  loins 
and  directly  opposite  the  two  lower  ribs  and  their  junction  with  the 
spine.  Pain  was  increased  by  moving  the  body;  febrile  reaction  took 
place  sufficient  to  cause  the  temperature  to  rise  to  30°  C.  (102°  F.); 
the  skin  was  dry  and  hot,  face  suffused  with  redness,  puffiness  under 
the  eyes,  a  heavy  dull  pain  in  the  frontal  region  of  the  head,  a  white  coat 
uponthe  tongue,  pulse  110  per  minute  and  moderately  full,  bowels  quiet, 
and  the  urinary  secretion  exceedingly  small,  not  more  than  from  two  to 
four  ounces  being  voided  three  times  during  the  twenty-four  hours  pre- 
ceding my  visit.  On  examination,  the  urine  contained  a  large  proportion 
of  albumen,  some  fibrinous  shreds,  and  a  considerable  number  of  red  cor- 
puscles of  the  blood.  By  active  treatment,  this  case  was  relieved  in 
three  or  four  days,  and  ultimately  so  far  recovered  as  to  leave  no  perma- 
nent injurious  consequences.  Another  case,  originated  from  getting  the 
feet  wet  and  cold  near  the  period  of  menstruation.  It  happened  to  the 
mother  of  a,  family,  aged  about  thirty-five  years,  in  whom  the  attack  was 


ANATOMICAL   CHANGES.  613 

characterized  by  pain  in  the  back,  extending'  more  or  less  to  the  limljs. 
Almost  immedldtely  drowsiness  occurred,  and  such  a  disposition  to  sleep 
tiiat  she  was  incapable  of  being  aroused  sufficiently  to  fix  her  attention  on 
at;ything.  There  was  increased  heat  of  skin,  a  quick,  rather  sharp  pulse, 
ijut  the  respirations  were  slow,  variable,  sometimes  sighing.  There  were 
Slight  jerkings  of  the  muscles,  but  no  general  convulsions.  From  the 
early  a{)p'^arance  of  dullness,  approaching  stupor,  the  patient  made  but 
little  ccmplaint,  and  consequently  her  danger  was  not  discovered  till  the 
disease  had  progressed  thirty-six  hours  from  the  time  of  its  commencement. 
At  that  time  I  found  her  in  the  state  I  have  just  described.  She  had  passed 
no  more  than  two  ounces  of  urine  in  the  previous  twelve  hours.  This,  on 
examination,  contained  so  large  a  proportion  of  albumen,  that  when  to  a 
small  quantity  in  a  test  tube  was  added  a  few  drops  of  nitric  acid,  the  co- 
agulum  occupied  the  whole  space.  This  patient  proceeded  directlv  and 
rapidly  to  complete  coma;  dilatation  of  the  pupils  occurrer],  paralysis  of  the 
sphincters,  involuntary  discharges  from  the  bowels,  and  death  on  the  third 
day.  This  case  will  serve  to  illustrate  some  of  the  features  of  the  disease, 
and  especially  to  impress  upon  your  minds  the  extreme  danger  which  ac- 
companies acute  attacks  of  nephritic  inflammation.  You  will  perceive  that 
the  chief  characteristic  symptoms  are  the  marked  diminution  in  the  quan- 
tity of  urine,  the  appearance  of  albumen  in  it,  coincident  with  diminution 
in  the  proportion  of  urea  and  excretory  elements;  the  almost  immediate 
appearance  of  more  or  less  puffiness  from  cedematous  infiltration  into  the 
subcutaneous  areolar  tissue,  more  especially  of  the  face  and  eyelids,  tops 
of  the  feet  about  the  malleoli  of  the  ankles  and  backs  of  the  hands.  Sub- 
sequently there  is  a  filling  up  of  the  areolar  tissue  almost  universally 
throughout  the  system  from  serous  infiltration.  To  these  must  be  added 
an  almost  constant  tendency  to  develop  symptoms  of  ureemic  poisonino-^ 
either  in  the  digestive  organs  or  nervous  centers. 

Anatotnical  Changes. — The  anatomical  changes  presented  on  makino- 
post-mortem  examinations  of  patients  having  died  from  acute  diffuse 
nephritis,  differ  much.  The  most  constant  of  these  changes  are  altera- 
tions in  the  color  and  size  of  the  kidney;  the  organ  being  prettv  uni- 
formly moderately  increased  in  size,  and  more  vascular,  that  is,  con- 
taining a  larger  amount  of  blood  than  natural.  Yet  there  is  seldom 
that  intense  red  color  which  characterizes  most  of  the  textures  of  the 
body  in  a  state  of  acute  inflammation.  But  there  are  limited  portions  of 
the  cortical  texture  of  the  kidney  and  of  the  pyramidal  bodies  that  are  of 
a  deep  red  color,  while  others  are  perhaps  paler  even  than  natural.  Close 
examination  will  also  show,  in  nearly  all  the  cases,  more  or  less  hemor- 
rhagic exudation,  or  mild  extravasations  of  blood,  especially  about  the  mal- 
pighian  tufts,  and  around  the  glomeruli.  The  microscope  will  show  more 
or  less  of  the  migrating  or  white  corpuscles  in  the  interstitial  spaces  of  the 
tissues,  disturbance  of  the  epithelium  in  the  urinary  tubules,  the  presence 
in  them,  also,  of  more  or  less  of  the  fibrinous  casts,  hyaline  bodies,  altered 
epithelial  cells,  very  orenerally  some  fat  granules,  and  hypertrophy  of  the 
connective  tissue.  The  most  characteristic  anatomical  changes  are,  the 
mild  hemorrhagic  exudations,  fibrinous  casts  in  the  tubules,  accumula- 
tions of  exuded  liquor  sanguinis  in  the  malpighian  bodies  and  around 
the  glomeruli,  the  latter  of  which  are  not  infrequently  blocked  up, 
while  the  alterations  in  color  and  size  are  much  more  variable.  The 
texture  of  the  kidneys,  as  altered  in  acute  nephritis,  is  softer  than  natural, 
and  the  capsule  easily  detached. 

Diagnosis. — The  princij^ial  diagnostic   symptoms  I  have  already  speci- 


614  ACUTE    DIFFUSE    NEPHEITIS. 

fied,  when  speaking  of  the  clinical  history  of  the  disease,  and  need  not 
repeat  tliem  at  this  time. 

Prognosis. — Although  acute  diffuse  nephritis  is  a  severe  and  dangerous 
malady,  liable  to  occur  at  any  period  of  life,  and  if  left  to  itself  extremely 
liable  to  terminate  unfavorably,  yet  under  prompt  and  judicious  treat- 
ment the  larger  proportion  of  cases  recover.  But  such  are  the  conse- 
quences of  interfering  with  the  depurative  action  of  the  kidneys,  that 
often  under  the  best  of  management  a  considerable  ratio  of  mortality 
will  attend  the  more  severe  attacks  of  this  disease.  As  a  general  rule,  so 
long  as  the  amount  of  urine  secreted,  and  the  proportion  of  urea  con- 
tained in  it,  is  sufficient  to  prevent  the  development  of  symptoms  of 
ursemic  poisoning,  the  prognosis  may  be  considered  favorable.  If  the 
case  proceeds  so  far  as  to  develop  the  consequences  of  retention  of  urea 
and  the  excretory  elements  of  the  urine,  so  far  as  to  induce  either  the 
preliminary  nervous  startings,  or  any  degree  of  general  convulsive  move- 
ments, the  danger  must  be  admitted  to  be  grave.  Yet  a  considerable 
number  of  cases,  after  proceeding  to  this  extent,  will  be  found  to  yield 
promptly  to  judicious  treatment.  There  is  some  tendency  in  the  acute 
form  of  diffuse  nephritis  to  partially  subside,  and  end  in  the  chronic  form 
of  the  disease.  When  it  does  so,  although  life  may  be  prolonged  many 
months  and  sometimes  two  or  three  years,  the  patient  seldom  raak^s  an 
entire  recovery  but  ultimately  succumbs,  under  the  effects  of  general 
dropsical  infiltrations,  first,  into  the  areolar  tissues  and  subsequently  into 
the  serous  sacs  or  cavities  of  the  body. 

Treatment. — In  the  treatment  of  those  cases  which  are  described 
under  the  head  of  hypertemia  or  congestion  of  the  kidneys,  it  is  necessary 
to  exercise  proper  discrimination  in  regard  to  the  special  pathological 
conditions  which  may  give  rise  to  the  accumulation  of  blood  in  those 
organs.  It  will  readily  occur  to  you  that  a  case  of  hyperasmia,  caused  by 
active  determination  of  blood  to  the  kidneys,  would  require  very  different 
treatment  perhaps  from  a  passive  hyperajmia  originating  from  diminution 
of  vasomotor  influence  over  either  the  veins  or  arterioles.  When  cases 
are  met  with  of  the  first  variety — that  is,  depending  upon  active  deter- 
mination of  blood,  and  yet  not  having  advanced  to  the  stage  of  true 
infiamrnation,  it  is  usually  sufficient  to  commence  the  treatment  by  the 
application  of  diy  cups  to  the  loins,  and  the  administration  of  some  com- 
bination that  will  lessen  the  force  and  frequehcy  of  the  arterial  circula- 
tion, and  at  the  same  time  promote  moderate  evacuations  from  the  bowels. 
A  solution  of  the  bitartrate  of  potassium,  in  the  proportion  of  ten  grams  ' 
to  one  hundred  and  eighty  cubic  centimeters  of  water,  may  be  made,  of 
which  the  patient  can  take  eight  cubic  centimeters,  or  an  ordinary  dessert- 
spoonful every  four  hours,  until  it  shall  promote  moderately  free  evacua- 
tions from  the  bowels.  If  there  is  considerable  general  febrile  movement, 
with  some  degree  of  acceleration  and  fullness  of  the  pulse,  it  will  increase 
the  efficacy  of  the  remedy  if  four  minims  of  the  tincture  of  veratrum 
viride  is  added  to  each  dose  of  the  solution  of  the  bitartrate.  Usuallj^, 
this  medication  results  within  the  first  twenty-four  hours  in  procuring  an 
increased  flow  of  urine,  two  or  thr;  e  free  evacuations  from  the  bowels, 
and,  in  most  cases,  of  simple,  active,  renal  hypeixemia,  will  afford  all  the 
relief  that  is  necessary.  Cases  which  may  have  resulted  from  the  taking 
of  some  irritating  substance  as  cantharides,  turpentine,  etq.,  may  be 
treated  in  the  same  manner  as  just  mentioned,  accompanied  by  the  free 
use  of  diluent  drinks,  such  as  mucilage  of  slippery  elm  (ulmus  fulva),  gum 
arable,  or  flax  seed.  In  those  cases  of  renal  hypeijemia  dependent  on 
impairment  of  vasomotor   influence,  which  constitute    the  most  common 


TREATMENT.  615 

class  of  cases,  arisinf^,  as  previously  described,  from  imperfect  oxygena- 
tion and  decarbonization  of  the  blood,  much  of  the  treatment  must  consist 
in  the  adndnistraiion  of  such  remedies  as  are  calculated  to  niitiu^ate  the 
severity  of  the  primary  disease,  of  which  the  renal  trouble  is  only  a  com- 
plication. In  addition  I  have  found,  in  almost  all  the  castas  m  which 
dio-italis  could  be  well  borne,  that  it  constituted  a  valuable  lemedy,  both 
by  its  influence  in  increasing  the  force  and  steadiness  of  the  heart's  action 
and  in  encouragino-  increased  secretory  activity  in  the  structure  of  tlie 
kidney.  In  some  instances,  I  have  derived  much  advantage  by  combining 
digitalin  and  ergotin  in  moderate  doses,  and  giving  them  at  intervals 
varying  from  once  in  four  to  once  in  six  hours. 

In  the  cases  dependent  on  alteration  in  the  vasomotor  influence  over 
the  arterioles  of  the  kidney,  accompanied  by  increased  flow  of  urine, 
occurring  most  frequently  in  nervous  and  hystei'ical  conditions,  the  most 
appropriate  remedies  are  such  as  exert  a  direct  tranquilizing  influence 
over  the  nervous  excitability.  The  bromides,  the  hydrate  of  chloral,  the 
different  pi'eparations  of  valerian,  and  sometimes,  though  rarely,  moderate 
doses  of  the  compound  powder  of  opium  and  ipecacuanha  with  camphor, 
given  at  night,  will  constitute  the  remedies  that  usually  succeed,  unless 
the  case  has  gone  so  far  as  to  constitute  actual  diabetes  insipidus,  or  a 
habitually  increased  flow  of  urine.  If  it  has  assumed  that  form,  the  use  of 
these  remedies,  in  connection  with  the  use  of  full  doses  of  ergotin,  will 
usually  be  found  most  efficient.  When  the  renal  affection  passes  beyond 
the  stage  of  hypertemia,  and  constitutes  an  attack  of  inflammation  of  an 
acute  character,  the  appropriate  remedial  agents  must  be  well  chosen,  and 
applied  with  promptness,  in  order  to  secure  the  best  results  in  behalf  of 
the  patient.  Inyoung,  vigorous  subjects,  especially  of  a  sanguine  tem- 
perament, if  the  attack  has  come  on  suddenly  by  exposures  to  cold  and 
wet,  and  the  general  febrile  reaction  is  active  and  well  marked,  there  is 
no  doubt  but  that  one  free  venesection  is  beneficial,  and  can  hardly  be 
omitted,  with  full  justice  to  the  patient.  If,  however,  venesection  is  not 
deemed  advisable,  the  application  of  leeches,  if  they  can  be  commanded, 
in  numbers  suited  to  the  age  of  the  patient  and  the  gravity  of  the  disease, 
wdl  be  the  next  most  efficient  remedy  at  the  commencement  of  the  attack. 
The  leeches  may  be  applied  directly  over  the  region  of  the  kidneys,  and 
after  they  have  filled  and  fallen  oflF,  the  bleeding  from  the  bites  may  be 
promoted  by  the  application  of  warm,  wet  cloths.  In  several  instances, 
where  leeches  were  not  readily  at  command,  the  application  of  dry  cups, 
producing  a  strong  revulsive  effect  over  the  lower  part  of  the  dorsal  and 
upper  lumbar  regions,  has  been  productive  of  some  degree  of  relief.  At 
the  same  time  that  these  measures  are  being  carried  out,  it  is  well  to  open 
the  bowels  freely,  and  give,  in  addition,  such  remedies  as  are  calculated 
to  lessen  general  febrile  excitement,  and  promote,  as  much  as  possible, 
eliminations  from  the  skin,  thereby  preventing  the  accumulation  of  urea 
and  other  effete  constituents  in  the  blood,  while  the  action  of  the  kidneys 
is  restrained  by  the  inflammation.  Although  many  writers  and  teachers 
have  objected  to  the  use  of  mercurials  in  renal  afiections,  my  own  experi- 
ence has  been  decidedly  in  favor  of  giving,  as  early  as  possible,  a  powder 
containing  three  decigrams  (gr.  v)  each  of  calomel  and  nitrate  of  potas- 
sium, and  repeating  it  every  three  hours,  till  four  doses  are  taken,  unless 
it  sooner  produces  a  free  movement  of  the  bowels.  If,  when  it  comes 
time  to  take  the  fourth  or  fifth  dose,  no  evacuations  have  taken  place  from 
the  bowels,  I  substitute,  in  the  place  of  the  powders,  either  the  liciuid 
citrate  of  magnesia,  Rochelle  salts,  or  the  sulphate  of  magnesia,  and  con- 
tinue their  use  until  free  evacuations  have  been  obtained.     In  the  mean- 


616  ACUTE    DIFFUSE    NEPHRITIS. 

time,  if,  as  often  happens  when  the  disease  comes  on  suddenly  and 
actively,  following  some  one  of  the  eruptive  fevers,  and  the  urinary  secre- 
tion is  extremely  small,  pulse  rapid,  breathing  hurried,  skin  hot,  I  have 
given  between  each  of  the  doses  of  calomel  and  nitrate  of  potassium  a 
sedative  and  diaphoretic  mixture,  consisting  of  the  liquor  ammonia 
acetatis  sixty  cubic  centimeters  (fl.  jii),  spirits  of  nitrous  ether  thirty  cubic 
centimeters  (fl.  |i),  and  tincture  of  veratrum  viride  four  cubic  centimeters 
(fl.  3i)i  of  which  four  cubic  centimeters  (fl.  3')  may  be  given  well  diluted 
with  sugar  and  water  between  each  of  the  doses  of  the  powder  previouslv 
mentioned.  1  have  sometimes,  instead  of  giving  this  mixture,  derived 
greater  advantage  by  giving  bi tartrate  of  potassium  and  digitalis  in  com- 
bination, either  in  the  form  of  infusion  of  the  digitalis  leaves  in  which  the 
bitartrate  is  dissolved,  which  I  think  is  the  best  method,  or  a  solution  of 
the  bitartrate  in  water  with  the  fluid  extract  of  digitalis  added  in 
proper  proportion  for  efficient  action.  The  objects,  as  you  will  perceive, 
are  to  get,  as  early  as  possible  in  the  progress  of  the  disease,  a  free  opening 
of  the  bowels,  relying  chiefly  for  that  purpose  upon  the  calomel  and 
nitrate  of  potassium,  aided,  if  need  be,  by  a  saline  cathartic,  to  lessen  the 
force  and  frequency  of  the  circulation,  and  promote  elimination  from  the 
skin,  by  either  the  digitalis  and  bitartrate,  or  the  veratrum  viride  or 
aconite  in  connection  with  the  liquor  ammonia  acetatis.  By  the  bleeding, 
general  or  local,  the  free  action  of  the  bowels  and  skin,  coupled  with  some 
sedative  influence  upon  the  arterial  circulation,  it  is  often  the  case  that 
the  fullness  of  the  vessels  of  the  kidney  become  relieved,  and  in  from 
twenty-four  to  thirty-six  hours  all  the  symptoms  of  the  patient  are  much 
ameliorated.  The  urine  becomes  more  copious,  with  much  less  albumen 
in  it;  the  fever  abates,  and  it  is  only  necessary  to  keep  a  moderate 
influence  of  the  diaphoretics  and  sedatives  through  two,  or  three  subse- 
quent days  to  complete  the  relief.  The  use  of  such  tonics  as  tincture  of 
the  chloride  of  iron  will  then  hasten  the  recovery  of  the  patients  from  the 
state  of  anfemia  and  debility  in  which  they  are  apt  to  be  left. 

And  if,  after  the  remedies  just  mentioned  have  been  pushed  for  the 
first  twenty-four  hours,  free  evacuations  have  been  obtained  from  the 
bowels,  yet  the  amount  of  secretion  from  the  kidneys  remains  very  scanty, 
or  somewhat  tinged  with  blood,  and  the  initial  symptoms  of  uraemic 
poisoning  begin  to  show  themselves,  such  as  twitching  of  the  muscles, 
more  or  less  dullness,  stupor,  wandering  of  the  mind,  with  increasing 
oedema  of  the  face,  it  may  be  well  to  administer  pilocarpine,  or  the  in- 
fusion of  the  leaves  of  the  jaborandi,  in  sufficient  doses  to  produce  its 
specific  eff"ects  upon  the  skin  and  salivary  glands,  with  the  hope  of  pre- 
venting further  accumulation  of  the  elements  of  the  urine  by  eliminating 
them  through  the  skin  and  mucous  membranes,  thereby  giving  further 
time  for  obtaining  relief  of  the  inflammatory  action  in  the  kidneys.  I 
recollect  no  case  coming  under  my  own  observation,  in  which,  if  the  active 
treatment  that  1  have  indicated  has  been  instituted  promptly  during 
the  first  twelve  hours  after  the  commencement  of  acute  renal  disea  e, 
relief  has  not  been  obtained,  and  before  the  patient  has  suifered 
from  any  paroxysms  of  convulsions,  or  serious  derangement  of  the 
cerebral  functions.  But  I  have  met  with  many  cases,  where,  during  the 
first  twenty-four  hours  active  measures  were  not  instituted,  in  which  the 
patients,  when  coming  under  observation  were  already  exhibiting  all  the 
symptoms  of  commencing  urasmic  poisoning,  either  by  drowsiness,  jacti- 
tations, twitching  of  the  tendons,  extensive  oedematous  infiltration  into 
the  areolar  tissue  over  the  greater  portion  of  the  surface  of  the  body, 
extreme  diminution  of  the  renal  secretion,  and  sometimes  active  convul- 


TREATMENT.  617 

sioiis.  "When  called  thus  lato,  the  pulse  is  usually  beji-inning  to  assume 
a  small  and  rapid  character,  there  is  some  alteration  in  the  pupils,  and 
altogether  a  condition  which  seems  to  contra-indicate  the  abstraction  of 
blood.  Yet  occasionally  at  that  late  period,  free  dry  cupping  over  the  lower 
part  of  the  back  and  hjins  has  still  been  of  advantage.  But  the  great  object 
in  such  cases  has  been  to  procure  speedy  and  thorough  ev.icuations 
through  the  skin  and  alimentary  canal.  To  procure  these,  if  the  pulse 
is  not  too  weak,  I  give  sufficient  pylocarpine  to  cause  an  early  and  full 
perspiration,  and  follow  it  directly  with  one  moderately  full  dose  of 
calomel  and  nitrate  of  potassium.  If  it  does  not  operate  in  from  two 
and  a  half  to  three  hours,  I  administer  a  saline  cathartic,  and  in  the  mean- 
time have  an  infusion  of  the  digitalis  leaves  with  bitartrate  of  potassium 
prepared,  so  that  as  soon  as  the  patient  is  fairly  over  the  action  of  the 
pylocarpine,  and  the  movement  of  the  bowels,  it  can  be  given  in  such 
doses  as  will  be  tolerated.  If  you  put  eight  grams  of  the  bitartrate 
and  an  equal  amount  of  the  digitalis  leaves  into  2G0,  c.  c.  of  boiling- 
water,  stirring  them  occasionally  till  the  infusion  becomes  cool,  a  table- 
spoonful  of  this  may  be  given  at  first  every  two  hours  to  adults  and 
smaller  doses  proportioned  to  the  age  in  children,  watching  its  effects 
closely.  If  the  specific  effects  of  digitalis  are  manifested  in  rendering 
Lhe  pulse  slow,  the  dose  must  be  immediately  diminished  to  one  half  and 
the  length  of  the  intervals  between  the  time  of  administration  doubled, 
thereby  avoijijig  the  exaggerated  effect  of  the  digitalis  upon  the  pulse 
and  respiration.  I  could  enumerate  a  considera^jle  number  of  cases  oi 
acute  nephritis  following  scarlet  fever,  in  which  the  renal  affection  had 
been  permitted  to  continue  unchecked,  till  severe  and  repeated  convul- 
sions had  occurred,  and  the  patient  was  apparently  in  an  extremely  crit- 
ical condition,  when  the  treatment  I  have  just  indicated  brought  about 
entire  relief  and  recovery.  I  think,  gentlemen,  you  may  regard  it  as  a 
positive  rale  in  practice,  that  when  cerebral  disturbance,  especially  in  the 
form  of  convulsive  movements,  or  approaching  stupor,  coma,  and  paral- 
ysis, is  the  result  of  the  retention  in  the  blood  of  effete  constituents  of 
urine,  or  of  any  other  toxferaic  ageut,  little  or  no  advantage  will  be  gained 
by  the  administration  of  remedies,  simply  calculated  to  diminish  nerve 
excitability,  or  to  act  as  nervous  sedatives  and  anodynes,  simply  because 
they  in  no  degree  either  neutralize  the  toxa3mic  agents  in  the  blood,  nor 
promote  their  expulsion. 

It  is  better,  therefore,  in  all  these  cases,  to  direct  your  attention  al- 
most eyclusively  to  the  removal  of  the  accumulated  retained  products  on 
the  one  band,  through  such  channels  as  nature  affords;  while  on  the  other 
hand,  you  leave  no  efficient  means  unemployed  to  relieve  the  direct  full- 
ness and  congestion  of  the  vessels  in  the  kidneys.  You  will  occasionally 
meet  with  cases  perhaps  in  which,  after  several  convulsions,  the  pulse 
presents  that  smallj  irregular  quality,  the  extremities  that  coolness,  and 
the  face  that  pale,  bloated  aspect  which  would  cause  you  to  hesitate 
about  the  adoption  of  active  evacuant  remedies  through  fear  of  exhaus- 
tion. Experience  shows  that  there  is  far  less  danger  from  exhaustion  pro- 
duced by  efficient  evacuations,  provided  they  carry  with  them  the  tox- 
emic agents  from  the  blood,  than  from  the  continued  action  of  these 
agents,  which  are  already  paralyzing  the  cerebral  centers,  and  endanger- 
ing the  life  of  the  patient.  As  proof  of  this  1  might  relate  a  number  of 
cases:  One  of  comparatively  recent  occurrence  was  that  of  a  girl  thirteen 
years  of  age,  who  had  passed  through  a  mild  grade  of  scarlet  fever.  In 
a'-out  four  days  after  the  subsidence  of  the  general  febrile  disease,  while 
the  skin  was  still  rough  from  desquamation,  she  began  to  show  symptoms  oi 


618  ACUTE   DIFFUSE   NEPHRITIS. 

subacute  renal  inflammation,  which  increased  steadily  for  two  or  three  sub- 
sequent days;  at  which  time  the  urine  had  become  very  scanty,  and  highly 
colored  with  blood.  The  usual  tests  showed  a  large  proportion  of  albu- 
men in  the  urine,  and  there  was  general  serous  infiltration  or  oedema  of  the 
areolar  tissues.  In  the  early  j^art  of  the  evening  she  was  seized  with  gen- 
eral convulsions.  A  physician  from  the  neighborhood  was  immediately 
summoned,  and  was  with  her  all  the  night,  and  until  after  breakfast  the 
following  morning.  Hs  administered  very  dilio'ently  the  bromides  and 
chloral  alternately,  and  in  combination  with  moderate  doses  of  digitalis, 
but  without  apparently  in  any  degree  modifying  the  convulsions,  which 
continued  to  recur.  And  in  the  morning,  when  I  saw  the  patient,  invol- 
untary discharges  had  taken  place  from  the  bowels,  a  very  moderate 
quantity  of  urine  had  been  passed  for  the  preceding  twelve  hours,  the 
patient  was  profoundly  stupid,  the  axes  of  vision  not  parallel,  the  extrem- 
ities cool,  with  a  very  weak,  quick  pulse.  Learning  the  history  of  the 
case,  and  the  efforts  to  control  the  convulsions  by  nervous  sedatives  and 
quieting  agents,  and  the  entire  inadequac}^  of  the  eliminations  through 
any  channel,  I  immediately  advised  that  she  be  put  upon  powders  of  cal- 
omel and  nitrate  of  potash,  and  have  them  repeated  every  two  hours,  with 
a  dose  of  the  infusion  of  digitalis  and  bitartrate  of  potassium  between, 
taking  the  two  prescriptions  alternately,  only  an  hour  apart.  Soon  after 
the  third  dose  of  calomel  and  nitrate  of  potassium  the  bowels  moved  very 
copiously,  but  such  was  the  unconsciousness  of  the  patient  at  the  time  that 
the  evacuations  took  place  entirely  involuntarily  in  the  bed.  No  more 
convulsive  movements  followed,  and  in  less  than  an  hour  some  urine  was 
voided,  but  as  it  was  passed  in  bed,  the  quantity  could  not  be  ascer- 
tained. The  patient  began  to  breathe  more  naturally,  and  after  another  free 
movement  of  the*  bowels  the  powders  were  omitted  and  the  digitalis  and 
bitartrate  were  continued  alternately  with  moderate  doses  of  carbonate  of 
ammonium  and  camphor.  During  the  next  four  hours  two  more  copious 
evacuations  occurred  from  the  bowels,  and  one  quite  free  discharge  of 
urine.  Before  it  had  passed,  the  symptoms  had  so  far  improved  that  the 
patient's  attention  could  be  aroused  momentarily,  she  could  take  plain 
nourishment  without  much  difficulty  in  swallowing,  and  from  that  time 
on  there  was  a  steady  improvement  until  ultimate,  complete  recoverv  took 
place.  I  am  the  more  particular  to  dwell  upon  the  necessity  of  using 
direct  and  active  measures  for  relieving  the  vascular  fullness  of  the  kid- 
neys at  the  outset,  and  the  subsequent  establishment  of  those  eliminations 
through  the  skin  and  mucous  membranes  as  will  most  efficiently  carry  off 
the  effete  materials  that  are  retained  on  account  of  the  arrest  of  the  func- 
tion of  the  kidneys;  because  I  have  so  frequently  seen  patients  whose 
lives  were  lost  during  the  persistent  efforts  of  the  physician  to  overcome 
the  nervous  symptoms  and  convulsions  by  ordinary  antispasmodics,  nerve 
sedatives  and  anaesthetics  without  any  adequate  effort  to  remove  the  of- 
fending cause  existing  in  the  blood  and  circulating  "through  the  nervous 
centers.  After  the  patient  is  relieved  from  the  more  mixed  symptoms 
and  the  function  of  the  kidnej^s  is  in  a  great  degree  restored,  very  much 
care  is  required  for  several  weeks  to  regulate  the  patient's  diet,  causing 
him  to  avoid  all  active  exertion,  either  mental  or  physical,  to  avoid  the  use 
of  all  stimulating  drinks,  especially  of  the  alcoholic  class,  and  to  use  such 
tonics  as  tend  to  sustain  the  action  of  the  kidneys  and  ultimately  tore- 
store  the  tone  of  the  renal  vessels  to  their  natural  condition.  Of  the 
tonics,  probably  none  are  better  than  the  tincture  of  the  chloride  of  iron 
during  the  convalescing  stage  of  these  cases.  No  diet  is  better  than  that 
consisting  chiefly  of  milk  and  farinaceous  articles.     If,  as  sometimes  hap- 


CHEONIC    NEPHEITLS.  619 

pens,  the  pulse  continues  to  have  a  quick  jerking  quality,  with. softness 
and  ready  compressibility,  showinjy  irritability  with  diminution  of 
strength,  or  tone  in  the  vessels,  moderate  doses  of  digitalis  may  be  con- 
tinued for  a  considerable  time.  In  some  cases  T  have  used  ergot,  or 
ergotine,  in  connection  with  the  digitalis,  with  benefit. 

One  measure  that  is  very  generally  recommended  in  the  first  stfige  of 
these  cases,  especially  in  children,  I  have  omitted  to  mention.  I  allude 
to  the  use'  of  the  warm  bath.  In  children  and  young  subjects  much  im- 
|)ortance  is  attached  by  many  to  immersing  the  patient  almost  wholly, 
directly  at  the  commencement  of  the  disease,  in  the  warm  bath  for  the 
purpose  of  producing  early  relaxation  of  the  skin,  as  well  as  exerting 
some  revulsive  influence  from  the  kidneys.  After  the  patient  is  taken  out 
of  the  bath,  the  trunk  of  the  body  is  wrapped,  especially  the  loins  and  ab- 
domen, with  napkins  or  a  folded  sheet  wet  in  warm  water,  to  which  may 
be  added  the  fluid  extract  or  tincture  of  digitalis  so  as  to  bring  this 
agent  in  contact  with  the  skin.  By  the  warm  bath  followed  by  the  warm 
wet  bandage  around  the  trunk  of  the  body,  the  latter  containing  mote  or 
less  digitalis,  it  is  supposed  that  much  benefit  may  be  obtained:  first,  by 
the  action  of  the  warmth  upon  the  surface  in  promoting  cutaneous  relaxa- 
tion and  elimination;  and  secondly,  by  some  degree  of  absorption  of  the 
digitalis  through  the  cutaneous  surface.  Theoretically,  this  measure 
should  produce  decided  benefits,  and  I  would  encourage  its  use,  especial- 
ly in  the  early  stage  of  the  disease. 


LECTUEE    LVIII. 


Chronic  Nephritis— Its  Causes,  Symptoms,  Anatomical  Changes,  Diagnosis,  Prognosis,  and  Treat- 
ment. 

GENTLEMEN:  Cases  of  chronic  nephritis  are  met  with  in  practice 
much  more  frequently  than  those  of  an  acute  form.  In  some  in- 
stances they  are  the  sequelae  or  result  of  a  prior  acute  attack.  Much 
more  frequently,  however,  the  chronic  grade  is  primary,  so  far  as  the  renal 
affection  is  concerned,  and  in  its  causation  is  very  generally  the  sequel  or 
completion  of  prior  morbid  conditions.  Etiologically,  the  cases  of 
chronic  nephritis  met  with  in  practice  may  be  arranged  in  four  groups; 
the  first,  which  embraces  much  the  smaller  number,  is  the  result  of  im- 
perfectly relieved  acute  attacks;  the  second  depends  directly  upon  the 
action  of  some  toxasmic  or  irritant  material,  either  retained  in  the  blood, 
or  received  in  connection  with  food,  drink  or  medicine;  the  third  origi- 
nates during  the  progress,  or  in  the  convalescent  stage  of  acute  general 
diseases,  more  particularly  of  the  eruptive  fevers,  and  the  fourth  occurs  as 
a  complication  in  the  progress  of  chronic  structural  diseases,  such  as  cardiac 
affections,  pulmonary  obstructions  and  long  continued  ulcerative  con- 
ditions of  the  mucous  membrane  of  the  alimentary  canal.  The  particular 
causes  alluded  to,  as  producing  the  second  class  of  cases,  are  chiefly  such 
agents  as  cantharides,  oil  of  turpentine,  oil  of  mustard,  arsenical  prepa- 
rations, carbolic  acid,  and  more  frequently  than  all  of  these,  the  habitual 
use  of  alcoholic  drinks.  The  latter  agent  probably  produces  at  least  two 
thirds  of  all  the  chronic  cas;  s   of  nephritis    that  are   met  with  in  general 


620  CHRONIC    NEPHEITIS. 

practice.  They  are  usually  alluded  to  under  the  name  of  albuminaria 
or  Bright's  disease.  Concerning  the  causes  constituting  the  third  class,  I 
have  already  commented  sufficiently  in  speaking  of  the  causes  of  acute 
nephritis.  It  is  probable  that  this  class  of  cases  originate  in  irritation 
set  up  in  the  renal  tubules,  coincidently  with  the  specific  inflammations 
that  occur  in  the  cutaneous  surface,  or  in  the  fauces  and  glaiids  of  the 
neck,  and  after  the  subsidence  of  the  general  disease,  there  remains  a 
similar  disturbed  and  irritable  condition  of  the  renal  tubules  and  secret- 
ing structure  of  the  kidneys  as  exists  in  the  cutaneous  tissue  during  the 
piocess  of  desquamation.  It  is  this  impairment  of  the  natural  relations 
of  the  secreting  cells,  urinary  vessels  and  uriniferous  tubules,  that  gives 
rise  to  the  congested  condition  and  consequent  moderate  diminution  in 
the  elimination  of  urinary  materials.  This,  if  overlooked,  gradually  in- 
creases from  day  to  day,  till  in  one,  two,  or  sometimes  three  weeks  from 
the  time  the  patient  is  supposed  to  be  convalescent,  he  begins  to  show 
some  degree  of  dropsical  infiltration  both  in  the  face  and  extremities. 
And  this  is  often  the  first  thing  to  attract  the  attention  either  of  the  pa- 
tient or  his  friends.  Tiie  mode  by  which  renal  disease  is  established  in 
connection  with  organic  or  structural  disease  of  the  heart,  lungs  and  other 
chronic  diseases  differs  in  different  cases.  In  affections  of  the  heart,  where 
the  kidneys  become  most  frequently  involved,  it  would  seem  that  the  renal 
disease  begins  substantially  with  the  occurrence  of  venous  congestion. 
Obstructing  the  circulation  through  the  heart  causes  direct  congestion  of 
pulmonary  capillaries,  leading  in  its  turn  to  defective  oxygenation  and 
decarbonization  of  the  blood.  This  causes  the  blood  circulating  in  the 
structure  of  the  kidney  to  be  deficient  in  the  oxygen  necessary  for  main- 
taining the  normal  properties  of  the  secreting  cells,  and,  consequently,  less 
urine  is  eliminated.  The  same  condition  of  the  blood  causes  dilatation  of 
the  renal  vessels,  and  soon  establishes  habitual  passive  congestion  with 
some  escape  of  albumen  in  the  urine.  The  occurrence  of  this  scanty 
secretion  of  albuminous  urine  is  generally  accompanied  also  by  more  or 
less  epithelial  cells,  fat  granules,  hyaline  casts,  and,  of  course,  causes  a  rapid 
relative  increase  in  the  watery  elements  of  the  blood,  and  the  hastening 
on  of  general  dropsical  symptoms.  It  is  probable  that  the  renal  affection 
and  dropsy  so  often  accompanying  the  advanced  stage  of  all  the  slow,  wast- 
ing forms  of  disease,  have  the  same  origin,  namelv:  the  inefficient  action  of 
the  blood  in  its  impaired  and  impoverished  condition  upon  the  secreting 
cells  and  vessels  of  the  kidneys,  failure  of  the  eliminations  is  the  result, 
and  by  such  failure  more  water  is  retained  in  the  blood,  and  this  in  its 
turn  hastens  the  general  dropsical  effusion  throughout  the  system.  The 
rnodus  operandi  of  alcohol  in  producing  chronic  renal  disease  is,  in  part  at 
least,  ot  a  similar  character.  The  daily  impregnation  of  the  blood  with  a 
limited  quantity  of  alcohol  diminishes  the  amount  of  oxygen  taken  up 
through  the  air  cells  of  the  lungs,  and  the  carbonic  acid  gas  eliminated. 
Consequently  the  blood  is  deficient  in  its  oxygenation  and  decarboniza- 
tion, and  is,  therefore,  incapable  of  promoting  a  natural  degree  of  activity 
in  any  of  the  important  secreting  structures  of  the  body.  Indeed  it  retards 
the  natural  molecular  movements  throughout  the  system  and  retains  the 
organic  atoms  of  the  tissues  beyond  their  natural  duration  and  until 
they  undergo  more  or  less  fatty  degeneration.  It  is  thus  that  the  texture 
of  the  kidneys  becomes  impaired.  Sometimes  a  decided  inflammatory 
action  is  set  up  and  hypertrophy  or  sclerosis  of  the  connective  tissue 
occurs  with  desquamation,  or  casting  off  of  the  epithelium.  This 
leads  ultimately  to  a  contracted  granular  condition  of  the  kidnev, 
which    constitutes    the    typical    form    of   Bright's   disease,   as    originally 


SYMPTOMS.  621 

described  by  Dr.  Bright  liirnself.  Tn  other  instances  the  degenerative 
ciianges  take  more  the  direction  of  fatty,  amylaceous  or  waxy  degener- 
ation, in  which  the  kidneys,  instead  of  being  contracted  and  firm,  become 
large,  pale  and  flibby.  With  these  allusions  to  the  various  causes  which 
give  rise  to  chronic  nephritis,  the  different  pathological  conditions  which 
are  present,  you  will  be  ready  to  infer  what  is  a  very  important  clinical 
fact;  that  under  the  head  of  chronic  nephritis  there  are  included  in  the 
books,  and  by  different  writers,  a  considerable  variety  of  morbid  con- 
ditions arising  from  the  action  of  various  causes,  differing  decidedly  one 
from  another,  and  while  the  general  result  in  the  end  is,  in  all  of  them,  or 
nearly  all,  general  dropsy,  progressive  impoverishment  of  red  corpuscles 
and  ultimate  death  of  the  patient,  yet  they  reach  this  final  result  by  some- 
what different  processes,  and  in  very  variable  periods  of  time. 

Symptoms. — The  symptoms  of  chronic,  diffuse,  interstitial  nephritis 
vary  much,  as  might  be  expected  from  the  varying  character  of  the  causes 
which  are  capable  of  inducing  it.  In  the  great  majority  of  instances  the 
early  symptoms  are  obscure,  and  are  often  either  overlooked  or  misinter- 
preted till  in  some  cases  several  weeks  or  months  have  elapsed,  or  there 
are  indications  of  ursemic  poisoning  and  dropsical  effusions  which  first 
attract  the  attention  of  the  practitioner  to  the  real  source  of  the  difficulty. 
In  most  cases,  in  the  early  stage  of  this  form  of  disease,  the  patient  com- 
plains of  little  else  than  simply  progressively  increasing  weakness,  of  get- 
ting tired  easily,  of  a  proneness  to  mental  depression,  a  variableness  of  appe- 
tite, and  also  a  variable  condition  of  the  digestive  functions.  Sometimes 
food  is  taken  and  digested  well,  but  more  frequently  digestion  is  accompa- 
nied by  more  or  less  flatulency,  and  a  moderate  degree  of  constipation — the 
latter  sometimes  alternated  with  temporary  turns  of  diarrhoea.  The  patient 
soon  presents  unusual  paleness  of  countenance,  indicating  diminution  of 
the  proper  proportion  of  red  corpuscles  in  the  blood,  with  a  puffy  or  slightly 
swollen  appearance  of  the  face,  especially  on  rising  from  the  bed  in  the 
morning.  In  most  instances  in  this  early  stage  there  are  some  pains,  or, 
more  properly,  a  tired  feeling  in  the  back  and  loins,  and  a  more  frequent 
desire  to  urinate  than  natural;  the  urine  being  for  the  most  part  pale  in 
color,  sometimes  abundant,  more  frequently  scanty.  Many  of  this  class  of 
patients  also  complain  of  frequent  turns  of  headache.  When  the  par- 
oxysms of  headache  are  severe,  they  are  usually  accompanied  by  nausea 
and  vomiting.  With  the  headache  a  sense  of  heaviness  and  dizziness  are 
common  symptoms,  and  sometimes  temporary  dimness  of  vision  or  dark 
spots  before  the  eyes.  After  these  symptoms,  or  some  of  them,  have  con- 
tinued for  a  variable  period  of  time,  often  from  two  to  three  or  four 
months  the  indications  of  dropsical  effusion  become  more  marked,  usually 
first  in  the  face,  underneath  the  eyes  in  the  morning,  from  which  it  dis- 
appears partially  during  the  day,  but  in  proportion  as  it  recedes  from  the 
face  the  puffiness  and  swelling  of  an  oedematous  character  increases  in 
the  tops  of  the  feet  about  the  malleoli  of  the  ankles  and  parts  most  de- 
pendent. Dropsical  symptoms  having  thus  begun  continue  slowly  but 
steadily  to  increase,  till  there  is  a  more  or  less  pale,  ansemic  and  bloat- 
ed hue  of  the  countenance,  while  the  oedematous  infiltration  of  the  feet, 
ankles  and  legs  gradually  increases  till  it  occupies  the  whole  of  the  lower 
extremities,  up  to  the  seratura  and  lower  part  of  the  abdomen.  At  that 
stage  of  the  disease,  wheti  the  dropsical  symptoms  become  more  marked, 
the  urine  usually  becomes  more  scanty  in  quantity,  sometimes  being 
tinged  with  blooJ,  but  more  frequently  presenting  simply  a  slightlv  tur- 
bid and  pale  appearance.  The  bowels  at  this  sta^e  of  the  disease  are  al- 
most always  variable,  being  most  of  the  time  inclined  to  constipation,  but 
this  is  alternated  q-^qy^  few  days    with    temporary    turns  of   looseness  or 


622  CHKONIC    NEPHRITIS. 

slight  diarrhoea.  Th3  digestion  of  food  becomes  still  more  imperfect 
than  in  the  early  stage,  the  appetite  also  much  more  variable  or  lost.  The 
disturbances  of  the  nervous  system,  such  as  headache,  giddiness,  tempo- 
raiy  appearance  of  spots  before  the  eyes,  all  become  more  marked  and  fre- 
quent than  in  the  early  stage.  All  this  assemblage  of  symptoms  con- 
tinue steadily  to  progress,  if  not  modified  by  treatment,  until  dropsical  in- 
filtrations come  to  fill  the  areolar  tissue  beneath  the  skin  over  almost  the 
entire  surface  of  the  body;  being  most  prominent  in  the  most  dependent 
parts,  which  are  usually  the  lower  part  of  the  trunk  of  the  body  and  lower 
extremities.  Later  the  legs  become  so  full  as  to  give  the  skin  a  very 
tense  and  shining  appearance,  and  in  the  advanced  stages  frequently 
cause  buUas  or  blisters  to  make  their  appearance,  followed  by  superfi- 
cial ulcerations  and  the  dripping  of  serum,  sufficient  to  keep  the  clothes 
of  the  patient  and  the  bed  upon  which  he  lies  constantly  wet.  The 
more  fully  the  tissues  of  the  body  are  infiltrated  with  the  serum  the 
more  scanty  as  a  rule  the  urine  becomes  till  in  the  advanced  stages  the 
amount  passed  each  day  is  very  small,  when  the  symptoms  usually  take 
one  of  three  directions.  In  at  least  one  third  of  the  cases  after  the  patient 
arrives  at  this  stage  the  elimination  of  urea  and  excretory  elements  of 
urine  become  so  small  that  the  accumulation  of  these  materials  in  the 
blood  begin  to  display  their  toxic  effect  upon  the  nervous  centers  and 
cause,  first,  muscular  twitchings,  more  decided  headache,  dimness  of  vision, 
sometimes  dullness  of  hearing,  and  finally  general  convulsions,  dilatation 
of  the  pupils  of  the  eyes,  coma  and  death.  Perhaps  one  third  of  all  the 
casesof  chronic  interstitial  nephritis,  or  chronic  Bright's  disease,  as  it  is 
more  frequently  called,  ter-minate  fatally  through  urgemic  po'soning.  Death 
does  not  occur  always  by  action  upon  the  brain,  however,  for  in  some  in- 
stances instead  of  producing  the  nervous  symptoms  followed  by  convulsions 
and  coma,  which  I  have  described,  violent  vomiting  and  purging  takes 
the  place  of  the  convulsions,  producing  exhaustion  almost  as  rapidly  as 
an  attack  of  cholera.  In  some  of  these  instances  after  the  patient  has 
been  much  reduced  by  the  copious  evacuations,  enough  of  the  urea  and 
elements  of  a  tCxic  character  are  carried  away  with  the  evacuations  from 
the  mucous  membranes  to  relieve  the  patient  temporarily,  and  he  is 
restored  to  a  better  condition  than  before  the  attack.  The  improvement, 
however,  lasts  only  for  one,  two  or  three  weeks,  when  a  repetition  of  the 
same  symptoms  may  take  place  exhausting  the  patient  still  further,  and 
sometimes  ending  in  fatal  collapse.  Another  mode  by  which  a  con- 
siderable proportion  of  these  cases  terminate  after  the  dropsical  effusions 
have  come  to  pervade  the  tissues  of  the  body  generally,  and  the  urine  has 
become  very  scanty,  is  by  the  supervention  of  local  inflammations;  particu- 
larly the  sudden  occurrence  of  peritonitis,  pleuritis  or  pericarditis,  followed 
by  copious  effusion  into  these  respective  cavities.  Perhaps  the  pleura  is 
more  frequently  attacked  than  any  other  of  the  serous  membranes.  From 
the  supervention  of  acute  inflammation  in  any  of  these  serous  surfaces  the 
patient  becomes  rapidly  prostrated;  the  amount  of  effusion  into  the  cavity 
usually  so  far  embarrassing  the  respiratory  and  digestive  functions  as  to 
soon  terminate  life.  In  another  class  of  cases  without  the  supervention  of 
any  noticeable  inflammation,  after  the  general  areolar  tissues  of  the  body 
have  become  thoroughly  infiltrated  with  serous  fluid,  effusion  begins  to 
take  place  into  the  serous  sacs,  and  sometimes  into  the  pulmonary  tissue, 
causing  hydro-thorax,  ascites,  sometimes  hydrops  pericardii,  and  frequently 
pulmonary  oedema.  The  latter  usually  speedily  terminates  fatally  from 
interference  with  the  oxygenation  and  decarbonization  of  the  blood.  In 
addition  to  the    symiDtoms   which    I  have   detailed    in  giving    the  clinical 


ANATOMICAL  CHANGES.  623 

history  of  these  cases,  from  the  early  stao^e  to  the  end,  it  is  proper  to  men- 
tion, as  of  not  infrequent  occurrence  during  the  more  protracted  cases,  and 
esp3cially  in  thos3  which  are  associated  with  a  considerable  degree  of 
dyspnoea  from  time  to  time,  hypertrophy  of  the  heart,  which  adds  to  the 
tendency  to  congestion  both  in  the  lungs  and  in  the  brain.  Another 
very  important  item  connected  with  the  symptoms  of  these  cases  is  the 
condition  of  the  urine.  From  the  earliest  period  in  their  progress  this 
secretion  is  found  to  contain  more  or  less  albumen.  This  is  readily  made 
manifest  by  the  ordinary  tests  of  heat  and  nitric  acid,  The  amount  of 
albumen  varies  much.  In  some  instances  it  will  be  so  small  through  all 
the  early  stage  of  the  disease  as  to  cause  a  mere  white  cloudiness  in  the 
test  tube  on  the  application  of  heat  and  nitric  acid.  But  when  the  dis- 
ease is  further  advaiiced  the  amount  of  albumen  becomes  larger,  and  in 
many  instances  wnll  equal  one  third  or  one  half  of  the  whole  bulk  of  the 
urine  as  it  settles  in  the  test  tube.  Usually  about  in  the  same  proportion 
as  the  albumen  increases,  the  natural  excretory  elements  of  the  urine, 
urea,  etc.,  diminish  in  their  relative  proportion.  Upon  examination 
under  the  microscope  the  urine  presents,  in  nearly  all  these  cases,  cells 
of  renal  epithelium,  together  with  hyaline  casts,  fibrinous  shreds  and  tubu- 
lar casts,  which  are  fibrinous  material  molded  in  the  shape  of  the  urin- 
iferous  tubules.  In  the  midde  and  advanced  stages  of  the  disease  these 
tubular  casts  will  almost  always  be  more  or  less  dotted  over  with  fat 
granules. 

The  three  most  important  items  connected  with  the  symptomatology  of 
this  form  of  renal  disease,  are  the  appearance  of  albumen,  epithelium  and 
tubular  casts  in  the  urine;  the  supervention  of  dropsical  infiltration, 
always  commencing  in  the  areolar  tissue,  but  influenced  much  by  gravity 
as  to  its  location;  and  the  retention  of  urea  and  effete  elements  of  urine  in 
the  blood  as  indicated  by  their  efl'ects  upon  the  nervous  centers  and  rau- 
cous membranes.  The  tendency  of  all  these  cases  when  thoroughly  es- 
tablished, is  towards  a  fatal  termination;  yet  progressing  with  a  very  vari- 
able degree  of  rapidity,  sometimes  there  will  be  intervals  of  considerable 
duration  in  which  the  symptoms  of  the  disease  remain  stationary,  or  im- 
prove. This  condition  excites  in  the  patient  more  or  less  the  expectation 
of  recovery.  Nevertheless  it  ultimately  proves  temporary,  and  is  followed 
by  a  return  of  all  the  more  prominent  and  active  symptoms  of  the  disease. 
Another  complication  that  occasionally  makes  its  appearance  in  connec- 
tion with  Bright's  disease,  sometimes  early  in  its  progress,  but  more  fre- 
quently in  the  middle  and  latter  stages  of  advancement,  is  amaurosis,  or 
loss  of  vision.  This  occurrence  is  caused  by  a  retenitis  resulting  quickly 
in  the  formation  of  white  or  yellowish  stellated  spots  in  the  retina,  with  a 
considerably  increased  size  of  the  blood  vessels.  The  stellated  spots  are 
regarded  as  the  result  of  fatty  degeneration  of  the  structures. 

Anatomical  Chamges. — Chronic  albuminuria  or  diffuse  chronic  nephritis 
when  terminating  fatally,  leaves  the  kidney,  on  post-mortem  examination 
in  one  of  the  three  following  conditions:  In  the  first  condition  the  kidney 
is  enlarged,  whiter  or  paler  than  natural,  less  dense  in  texture;  the  capsule 
is  easily  detached.  When  the  organ  is  laid  open  and  examined  minutely, 
the  coats  of  the  smaller  arteries  are  usually  found  hypertrophied,  or  thick- 
ened, the  tubules  more  or  less  full  and  obstructed  with  tubular  casts,  evi- 
dences of  fatty  degeneration  throughout  a  large  part  of  the  cortical  texture, 
the  glomeruli  surrounded,  many  of  them,  by  fibrinous  exudation  intermin- 
gled with  fat  granules,  and  generally  so  altered  as  to  allovv  of  a  very  free  pas- 
sage of  the  serum  of  the  blood  directly  into  the  urinary  tubules.  In  the 
second  variety  the  appearances  are  very  similar  in  all  respects  to  that  just 


624  CHRONIC    NEPHEITIS. 

described,  with  the  exception  that  the  cortical  portion  of  the  kidney  has 
undergone  more  of  a  degenerative  change  either  of  a  fatty,  or  amyla- 
ceous character.  The  latter  is  shown  by  the  characteristic  blue  tint  on  the 
application  of  iodine,  and  produces  what  is  usually  called  the  waxy  or 
amylaceous  kidney.  The  third  variety  presents  the  typical  condition  of 
the  kidneys,  originally  described  by  Dr.  Bright,  and  to  which  was  origi- 
nally applied  the  name  of  Bright's  disease.  This  change  consists  in  the 
contraction  of  the  kidneys,  causing  them  to  be  diminished  in  size,  of  a 
deeper  red  color,  frequently  mottled  a  little  unon  the  exterior,  and  some- 
times showing  numerous  small,  gray,  granular  specks,  or  deposits  beneath 
the  capsule.  When  laid  open  the  cut  surface  presents  a  red  granular  ap- 
pearance, denser  than  natural,  the  connective  tissue  throughout  being  some- 
what hypertrophied.  The  thickening  and  hardening  of  this  structure 
with  much  fibrinous,  fatty  and  granular  material  occupying  the  interstitial 
spaces  in  the  cortical  structure  surrounding  the  glomeruli  and  malpighian 
tufts  make  the  condition  somewhat  analogous  to  sclerosis,  more  frequent- 
ly described  as  cirrhosis  of  the  liver.  Some  writers  have  claimed 
that  these  different  appearances  of  the  kidney  indicate  only  different 
stages  in  the  progress  of  one  and  the  same  disease.  This,  however,  is  not 
probable;  if  it  were  there  would  be  some  uniformity  in  finding  one  variety 
of  these  appearances  in  cases  that  had  died  early,  another  variety  later, 
and  another  still  later;  but  post-mortem  examinations  connected  with  the 
history  of  cases,  do  not  present  any  such  uniformity  or  coincidence  of  one 
variety  of  appearances  with  any  particular  duration  of  the  disease.  And 
while  they  are  all  consequences  of  some  inflammatory  action  pervading 
the  connective  tissue  and  vascular  structure  of  the  kidney  their  variation 
does  not  depend  upon  the  duration  or  stage  of  progress  so  much  as  it 
does  upon  the  particular  influences,  or  combination  of  influences,  that 
have  determined  the  development  of  the  disease,  or  exerted  more  or  less 
modifying  influence  upon  its  progress. 

Diagnosis. — Perhaps  the  only  reliable  diagnostic  symptoms,  or  signs  of 
the  existence  of  chronic  nephritis  are  the  presence  of  more  or  less  albumen, 
coincident  with  renal  epithelium  and  tubular  casts  in  the  urine,  taken  in 
direct  connection  with  the  precedi;  g  gradual  failure  of  strength,  pallor  of 
countenance,  and  more   or  less  of  dropsical  appearances  in  the    areolar 
tissue  and  dependent  parts  of  the  body,  or  of  the  extremities.     The  simple 
appearance  of  albumen   alone  in    the  urine   is  by  no   means  evidence  of 
chronic   nephritis,  or  any   structural  change   of  the  kidney.     As  we   have 
had  occasion  to  point  out,  when  speaking  of  the  different  forms  of  hyper- 
asmia  and  simple  congestion  of  the  kidneys,  albumen  is  of  common  occur- 
rence in  all  those  conditions  in  which  the   capillary   vessels  of  the  kidney 
become  more  or  less  overcrowded  with  blood;  whether  from  active  deter- 
mination of  blood  to  the  part,  or  mere  passive  accumulations  from  defect- 
ive vasomotor  influence   over  the  circuhition.      But   when  the  symptoms 
of  failure  in  the  patient  have  been     gradual,    presenting    progressively 
increasing  paleness,  puffiness  of  the   features,  and   the  albumen    becomes 
a  constant  element  in  the  urine,  associated  directly  with  more  or  less  of  the 
tubular  casts  and  epithelium,  there  can  be  little,  if  any,  doubt,  about  the 
existence  of  chronic  interstitial,  or  diffuse  nephritis.    The  practitioner,  how- 
ever,  should  never  be  satisfied  with  the  examination  of  a  single  specimen 
of  urine.     It  is  better  that  the  specimen  to  be  examined  be  taken  from  the 
urine  passed  in  the  morning  before  the  patient  has  taken  food,  and  then  at 
least  two  or  three  specimens  be  examined  at  intervals  of  three  or  four  days. 

If,  with  the  general  symptoms  that  I  have  indicated  such   examinations 
show  the  materials  in  the  urine  that  I  have  mentioned,  there  need  be  no 


PROGNOSIS.  625 

doubt  or  hesitation  in  pronouncing  positively  in  regard  to  the  diagno- 
sis. It  is  true,  there  are  many  cases  so  plain  that  a  single  examination, 
in  connection  with  the  symptoms,  is  sufficient  to  remove  all  doubt;  but 
this  is  not  generally  the   case  in  the   earlier  stages  of  the  disease. 

JProgiiosis. — Some  writers  represent  the  prognosis  in  chronic  nephritis 
as  unii'ormly  unfavorable;  the  disease  in  their  estimation  uniformly  ter- 
minating ultimately  in  the  death  of  the  patient.  My  own  experience  has 
led  me  to  differ  from  these  conclusions,  so  far  as  to  regard  a  considerable 
number  of  cases  that  present  all  the  symptoms  that  are  regarded  as  neces- 
sary to  constitute  proof  of  chronic  nephritis,  as  capable  of  terminating 
in  recovery.  I  know  of  no  instance  of  recovery,  however,  if  the  disease 
has  existed  for  a  considerable  period  of  time  before  being  brought  under 
judicious  treatment;  and  it  is  proper  to  add  that  the  great  majority  of 
cases,  whether  treated  early  or  latp,  and  in  the  most  skillful  hands,  will 
eventually  reach  a  fatal  result.  The  cases  which  have  come  under  my 
observation,  and  ultimately  terminated  favorably,  originated  during  the 
convalescent  stage  of  the  eruptive,  or  some  one  of  the  general  fevers.  In 
one  instance  a  case  came  under  my  care  in  the  hospital,  which  had  super- 
vened during  the  convalescence  of  the  patient  from  typhoid  fever,  and 
after  the  disease  had  existed  for  six  or  seven  months  recovery  took  place. 
In  another  insiance  a  young  man,  in  whom  the  disease  appeared  to  origi- 
nate from  long  continued  exposure  to  cold  and  damp  in  illy  ventilated 
apartments,  recovered  after  the  disease  had  continued  between  five  and 
six  months.  I  have  seen  a  considerable  number  of  cases  following  scarlet 
fever,  in  which  the  disease  supervened  so  gradually,  with  so  little  active 
symptoms  as  to  indicate  certainly  no  more  active  grade  of  inflammatory 
action  than  what  would  be  properly  called  chronic,  in  which  recovery  has 
taken  place  after  the  disease  had  continued  from  six  to  ten  weeks.  But 
in  nearly  all  the  cases  in  which  the  real  disease  has  resulted  from  intem- 
perate habits  or  the  habitual  use  of  alcoholic  beverages,  or  in  connection 
with  constitutional  syphilis,  or  with  well  marked  gouty  or  scrofulous  dia- 
thesis, they  have  proceeded  with  much  uniformity  to  a  fatal  result. 

Treatment. — In  the  treatment  of  all  cases  of  chronic  interstitial  or  dif- 
fuse nephritis,  the  practitioner  should  have,  three  objects  constantly  in 
view,  namely,  the  arrest  of  the  inflammatory  process  itself  by  lessening 
the  vascular  fullness  and  irritability  of  the  structure  of  the  kidney;  the 
prevention  of  the  accumulation  in  the  blood  of  the  excretory  elements  of 
the  urine,  thereby  avoiding,  or  postponing  as  far  as  possible,  the  toxic 
effects  of  these  agents  upon  the  blood,  and  especially  upon  tlie  nervous 
centers;  and  the  palliation  or  removal  of  the  dropsical  accumulations  and. 
other  complications  liable  to  arise  in  the  progress  of  the  case.  For  the 
accomplishment  of  the  first  of  these  objects,  the  dtie  regulation  of  the 
diet,  drinks  and  general  hygienic  management  of  the  patient  is  of  great 
importance.  All  alcoholic  beverages,  both  fermented  and  distilled,  should 
be  rigidly  excluded  from  the  patient's  use;  the  diet  should  consist  largely 
of  milk  and  farinaceous  articles,  with  a  limited  amount  of  vegetables  and 
fruit,  while  meat  should  be  used  rather  sparingly.  As  a  drink  perhaps  no 
article  is  better  than  either  buttermilk  or  milk  whey.  Some  mineral 
waters  have  been  recommended,  and  in  the  early  stage  of  the  disease 
I  have  thought  some  advantage  was  derived  from  having  the  patient 
use  as  freely  as  convenient  such  mineral  waters  as  are  represented  by  the 
Bethesda  springs,  at  Waukesha,  in  Wisconsin.  The  patient's  clothing 
should  be  such  as  to  protect  the  surface  as  much  as  possible  from  sudden 
atmospheric  impressions,  especially  cold  and  damp.  Flannel  worn  next 
to  the  skin  is  best  lor  this  purpose,  and  should  be  continued  throughout 
40 


15  grams 

3iv 

75  c.  c. 

|iiss 

75     " 

|iiss 

80     " 

21 

626  CHRONIC    NEPHRITIS. 

the  year.  Many  patients  also  derive  advantage  from  a  warm  alkaline 
bath,  at  least  twice  a  week,  as  warm  as  can  be  borne  comfortably,  with  a 
view  of  producing  exhalation  from  the  cutaneous  surface,  as  well  as  acting 
derivatively  upon  the  circulation  in  the  kidneys.  The  exercise  of  the 
patient  should  be  limited;  avoiding  all  attempts  at  active  muscular  exer- 
cise, sufficient  to  produce  weariness.  Frequent  riding  in  the  open  air, 
especially  in  clear  weather,  is  w^ll  calculated  to  maintain  appetite  and 
promote  the  general  health  of  the  patient.  In  addition  to  these  hygienic 
measures  I  have  certainly  seen  patients  derive  much  benefit,  especially 
during  the  earlier  stages  in  the  progress  of  the  disease,  from  the  use  of 
the  following  formula: 

^     Potassii  Nitratis 

Extracti  Galii  Fluidi 
Extracti  UvseUrsi  Fluidi 
Extracti  Ergotae  Fluidi 

Mix.  Of  this  I  have  usually  given  four  cubic  centimeters  (fl.  3i),  mixed 
with  half  a  wine  glass  full  of  sweetened  water  from  three  to  four  times  a  day. 
In  other  instances,  more  especially  those  in  which  the  bowels  are  inclined 
to  costiveness,  I  have  derived  some  benefit  from  the  use  of  an  infusion  of 
digitalis  leaves,  holding  in  solution  the  bitartrate  of  potash,  given  in  such 
'doses  as  the  patient  will  bear  without  inducing  too  much  effect  from  the 
•digitalis  upon  the  circulation  on  the  one  hand,  and  without  causing  ex- 
cessive looseness  of  the  bowels  by  the  bitartrate  upon  the  other.  Most 
patients  will  bear  profitably  six  to  eight  cubic  centimeters  (fl.  3"ss  to  3ii)  of 
an  infusion,  made  by  placing  eight  grams  (3ii)  of  the  bitartrate  of  potas- 
sium and  the  same  amount  of  digitalis  leaves  in  two  hundred  and  sixty 
^centimeters  (Iviii)  of  boiling  water,  three  or  four  times  a  day.  Both  of 
these  formulae  that  I  have  given,  have  a  tendency  to  increase  the  elim- 
ination of  the  watery  elements  of  the  urine,  while  they  improve  the  vaso- 
.motor  influence  over  the  smaller  blood  vessels  and  thereby  lessen  the 
hypersemia  or  congested  condition  of  these  vessels  in  the  kidney.  Either 
of  the  prescriptions  may  be  rendered  somewhat  anodyne  by  adding  to 
them  a  due  proportion  either  of  the  conium  or  hyosciamus.  If  the 
patient  is  already  showing  considerable  evidence  of  anaemia,  it  will  in 
most  instances  produce  a  most  beneficial  effect,  to  give  from  ten  to  twenty 
minims  of  the  tincture  of  the  chloride  of  iron,  largely  diluted  with  water, 
after  each  meal  time.  Many  recommend  also  the  use  of  astringents,  more 
particularly  tannic,  gallic  acid,  and  other  vegetable  astringents,  with  a  view 
of  lessening,  by  their  action  upon  the  vessels  of  the  kidneys,  the  excretion 
of  albumen.  I  have  seen  many  patients  to  whom  this  class  of  rem- 
edies have  been  administered  in  considerable  variety,  but  I  have 
never  known  any  beneficial  results  from  their  use.  There  is  a  pretty 
uniform  expression  on  the  part  of  the  writers  and  teachers  in  oppo- 
sition to  the  use  of  mercurials  in  all  stages  of  chronic  nephritis.  Pre- 
cisely on  what  grounds  this  interdiction  rests  is  seldom  stated,  and  is  not 
very  apparent  from  anything  connected  with  the  pathology  of  the  disease. 
And  while  I  can  see  no  indication  for  the  use  of  calomel  and  blue 
mass,  particularly,  either  for  cathartic  purposes  or  for  active  alterative 
influences,  I  must  state  as  a  clinical  fact,  that  I  have  seen  in  a  con- 
siderable number  of  cases  of  well  marked  chronic  nephritis,  often  of  con- 
siderable duration,  very  much  improvement  follow  the  use  of  small  doses 
of  the  bichloride  of  mercury  in  connection  with  tonics  and  a  proper  reg- 
ulation of  the  diet.    As  long  ago  as  1848,  while  residing  in  the  city  of  Now 


TREATMENT.  627 

York,  a  man  in  the  middle  period  of  life,  affected  with  general  dropsy, 
from  chronic  nephritis — the  urine  containinor  albumen,  tubular  casts, 
epithelium  and  fat  granules — came  under  my  care  after  he  had  pre- 
sented himself  at  one  of  the  college  clinics  of  Dr.  Willard  Parker,  then 
professor  of  surgery  in  the  "College  of  Physicians  and  Surgeons"  of  that 
city,  where  the  case  was  thoroughly  and  critically  examined  and  decided 
to  be  one  of  hopeless  chronic  diffuse  nephritis,  having  its  origin  in  the 
moderately  intemperate  habits  of  the  patient.  The  dropsical  eti'usion  had 
invaded  the  areolar  tissues  throughout  the  whole  periphery  of  the  body. 
The  case  came  under  my  care  as  a  charity  patient,  and  desiring  to  make 
the  poor  man  as  comfortable  as  possible,  I  put  him  upon  the  internal  use 
of  bichloride  of  mercury  and  tincture  of  cinchona  in  such  proportion  that 
he  would  get  two  milligrams  (gr.  1-30)  of  the  bichloride,  with  four 
cubic  centimeters  (fl.  3i)  of  the  tincture  of  cinchona,  diluted  with  sugar 
and  water,  four  times  a  day.  At  the  same  time  he  was  directed  to  pre- 
pare an  infusion  of  yellow  dock  and  sarsaparilla  roots,  with  bitartrate  of 
potassium,  of  which  he  was  to  take  a  wine  glass  full  after  each  meal. 
Alcoholic  drinks  were  rigidly  prohibited,  and  a  diet  consisting  mostly  of 
milk,  farinaceous  articles  and  vegetables,  with  only  a  limited  amount  of 
meat,  was  allowed.  Although  this  case  had  been  in  progress  for  nearly- 
one  year  since  the  initial  symptoms  manifested  themselves,  and  his  limbs 
were  so  large  from  oedematous  infiltration,  that  it  was  difficult  for  him  to 
walk,  his  symptoms  slowly  improved  under  this  treatment  until  in  about 
three  months  he  was  able  to  go  about  with  facility,  and  went  out  of  the  city 
into  the  suburbs,  and  did  some  work  during  the  season  of  cutting  hay. 
Though  he  did  not  get  well  he  continued  very  much  improved  for  more 
than  twelve  months  after  he  came  under  my  care;  at  which  time  I  left  the. 
city  and  subsequently  lost  all  track  of  the  patient.  I  mention  this 
because  it  was  the  first  case  that  came  under  my  care  in  which  I  gave  the 
bichloride  of  mercury.  Its  administration  was  founded  upon  the  recom- 
mendation of  the  same  remedy  in  similar  cases  by  one  of  the  most  distin- 
guished members  of  the  staff  in  attendance  upon  the  New  York  hospital, 
and  from  that  period  up  to  the  present  time  in  purely  chronic  cases  of 
nephritis,  in  which  there  is  no  direct  tendency  to  irritation  of  the  mucous 
membrane  of  the  alimentary  canal,  and  the  patients  are  not  extremely 
anaemic,  I  have  certainly  seen  decided  benefit,  sometimes  amounting  to 
an  entire  arrest  of  the  progress  of  the  disease  for  a  considerable  period  of 
time,  and  in  others  to  a  more  effectual  retardation  than  was  obtained  by 
the  use  of  any  other  one  remedy.  I  have  never-pushed  the  remedy  to 
the  extent  of  any  specific  mercurial  impression  upon  the  mouth  and  gums, 
and  I  advise  that  in  all  instances  of  its  use  the  effects  be  noted  sufficiently 
to  guard  against  any  such  impression  or  any  considerable  disturbance  of 
intestinal  discharges.  But  that  it  sometimes  is  decidedly  beneficial  I  have 
had  opportunities  even  within  the  last  few  weeks  to  judge  in  a  case  to  which 
I  was  summoned  at  a  distance  in  the  country,  where  consultation  was 
had  almost  exclusively  for  the  purpose  of  deciding  whether  mercurials  in 
this  form  should  be  used  or  not.  And  after  the  administration  of  the 
bichloride  in  small  doses  in  connection  with  diuretics  and  tonics,  the 
patient  improved  to  a  very  unexpected  degree.  But  I  would  by  no  means 
advise  the  indiscriminate  use  of  the  bichloride  in  chronic  nephritis  in  any 
stage  of  its  progress.  However,  I  think  its  entire  prohibition  is  as  inju- 
dicious as  the  prohibition  of  mercurials  in  aiding  to  procure  the  evacuation 
of  retained  excretory  matter  in  many  of  the  cases  of  acute  nephritis.  The 
remedies  which  are  most  efficient  in  accomplishing  the  second  purpose, 
namely,  to  prevent  such  a  degree  of  accumulation  of  the  effete  constituents 


628  CHEONIC    NEPHRITIS. 

of  the  urine  as  to  endanger  the  development  of  toxgemic  effects  in  the 
system,  are  essentially  the  same  as  have  been  recommended  for  accomplish- 
ing the  first.  But  whenever,  either  from  absence  of  any  treatment  or  in- 
efficiency of  the  remedies  used,  the  accumulations  of  these  effete  constitu- 
ents have  alreaily  increased  until  they  begin  to  exhibit  their  effects  either 
upon  the  nervous  structures  or  mucous  membranes,  then  the  question  will 
be  how  best  to  effectually  promote  their  elimination,  at  least  to  a  sufficient 
degree  to  ward  off  the  immediate  danger  of  fatal  consequences  to  the 
patient.  Perhaps  for  immediate  relief  the  administration  of  a  sufficient 
amount  of  pilocarpine  or  of  the  fluid  extract  of  jaborandi  to  produce  free 
diaphoresis,  will  be  valuable  in  many  cases,  and  yet  it  is  necessary  to  note 
carefully  the  degree  of  debility  of  the  patient,  and  the  danger  of  pro- 
ducing too  much  depressing  effect  upon  the  circulation  by  the  use  of  this 
remedy.  The  bowels  may  also  be  opened  freely  where  they  are  in  any 
degree  constipated,  by  such  remedies  as  promote  copious  liquid  discharges, 
as  the  bitartrate  of  potassium  in  combination  with  jalap,  or  suitable  doses 
of  elaterium.  In  addition  to  these  and  other  agents  that  act  freely  in  pro- 
moting eliminations  through  the  alimentary  canal,  and  through  the  skin, 
immersing  the  patient  in  a  warm  bath,  or  in  a  hot  air  bath,  may  also  pro- 
duce some  beneficial  effect.  But  in  a  large  proportion  of  the  cases,  after 
urea  and  other  elements  of  the  urine  have  accumulated  to  such  an  extent 
as  to  produce  a  decided  impression  upon  the  nervous  centers,  all  remedies 
that  may  be  used  will  be  found  to  produce  only  temporary  relief.  The 
toxasmic  symptoms  return  again  and  again  till  a  fatal  result  supervenes. 
When  in  the  progress  of  the  case  the  continuance  of  the  secretion  of  the 
natural  elements  of  urine  is  sufficient  to  prevent  uraemic  poisoning,  yet  the 
progressive  impoverishment  of  the  blood  leads  to  an  increase  of  the  drop- 
sical effusions,  until  infiltration  of  the  tissue  is  so  universal  that  not  only 
the  areolar  tissue  but  the  abdominal  cavity  becomes  filled  up,  the  urinary 
secretion  extremely  small,  the  heart's  action  more  or  less  weak,  and  the 
descent  of  the  diaphragm  impeded,  rendering  respiration  imperfect  and 
oppressed,  the  blood  is  imperfectly  decarbonized,  giving  the  lips  a  blue- 
ish,  leaden  tint,  and  is  accompanied  by  more  or  less  coldness  of  the  ex- 
tremities, drowsiness  and  yet  inability  to  take  the  recumbent  position,  and 
to  sleep  on  account  of  the  feeling  of  suffocation.  Under  such  circum- 
stances there  is  evidently  imminent  danger  of  the  supervention  of  oedema 
of  the  lungs  and  death  from  apnoea,  or  such  a  degree  of  failure  in  the  oxy- 
genation and  decarbonization  of  blood  as  to  produce  general  paralysis, 
coma  and  death  from  suspended  cerebral  function.  When  the  patient 
progresses  in  this  direction  till  the  infiltration  begins  to  crowd  upon 
the  chest  and  render  the  breathing  more  or  less  oppressed,  and  the  use  of 
hydragogue  cathartics,  diuretics,  hot  baths  and  pilocarpine  have  ceased  to 
ward  off  further  progress,  the  only  resort  that  has  been  effectual  in  my 
hands  in  affording  relief,  has  been  the  making  of  free  incisions  into  the 
ankles;  not  mere  punctures  as  directed  by  most  writers,  but  one  free  in- 
cision in  each  ankle,  an  inch  or  more  long,  and  deep  enough  to  cut 
through  all  layers  of  fascia  down  to,  or  close  to  the  periosteum.  Make 
the  incision  on  the  inner  part  of  the  ankle,  above  the  internal  malleolus. 
An  incision  of  this  kind  into  each  ankle  will  cause  a  very  free  exit  of 
serous  fluid.  The  body  and  limbs  should  be  placed  a  little  inclined, 
with  oil  cloth,  or  oil  silk  under  the  limbs  in  such  a  way  as  to  direct 
the  serum  into  some  vessel,  and  thus  prevent  the  bed-clothes  from  becom- 
ing wet.  In  most  cases  it  will  effectually  drain  all  the  tissue  of  the  body 
in  three  or  four  days.  I  have  practiced  this  in  a  considerable  number  of 
cases  with  entire  success  so  far  as  regards  the  removal  of  the  dropsical 


TREATMENT.  629 

accumulations.  And  in  almost  every  instance,  as  soon  as  the  water  was 
fully  drained  from  the  tissues,  the  kidneys  resumed  an  increased  elimination 
of  urine,  the  breathing  became  full  and  free,  the  blood  better  oxygenated, 
and  the  patient  apparently  took  a  new  lease  of  life.  In  two  or  three  cases 
in  which  I  had  supposed  that  the  patients  were  utterly  hopeless,  the  relief 
obtain«iJ,  insteai  of  proving  temporary,  becam  epermanent.  The  serous 
fluid  usually  continues  to  drain  freely  through  these  inc  sions  for  several 
weeks,  and  if  the  incisions  are  well  cared  for,  the  limbs  kept  well 
washed,  the  m  irgins  of  the  incisions  bathed  with  a  little  glycerine,  or 
vaseline  every  day,  it  is  very  rare  that  they  give  the  patient  any  trouble 
from  Erysipelas,  or  much  pain  from  heat  and  smarting.  But  in  most  in- 
stances they  slowly  heal,  and  in  from  four  to  eight  or  ten  weeks  they  will 
be  closed  up,  and  with  the  exception  of  three  or  four  cases,  to  which  I  have 
just  alluded,  the  dropsical  accumulations  slowly  return.  In  cases  of  this 
class  in  which  the  renal  disease  remains  and  increases,  and  there  is  con- 
sequently a  slow  return  of  the  dropsical  accumulations,  the  incisions  have 
afforded  the  patients  a  number  of  months  of  additional  life,  and  I  have,  in 
a  few  instances  after  they  have  become  again  thoroughly  filled  up,  repeated 
the  incisions  and  thus  parpetuated  life  apparently  from  three  to  twelve 
months  longer  than  it  would  have  otherwise  continued.  I  am  well  sat- 
isfied, however,  that  one  reason  why  the  secretion  of  the  urine  diminishes 
so  markedly  and  ultimately  becomes  arrested  so  as  to  hasten  a  fatal  ter- 
mination in  a  large  pi-ojiortion  of  these  cases,  is  that  the  pressure  of  the 
accumulated  dropsical  effusion  upon  the  renal  vessels,  and  in  some  instan- 
ces more  or  less  actual  oedomatous  Infiltration  in  the  renal  tissues,  consti- 
tutes one  of  the  causes  for  finally  suspending  thj  secretory  action  alto- 
gether. And  again,  whenever  by  any  process  the  areolar  tissues  are 
drained  of  this  fluid,  and  the  circulation  in  all  the  capillary  vessels  through- 
out this  kind  of  structure  in  the  body,  and  especially  in  the  periph- 
ery, is  restored,  the  pressure  upon  the  vessels  and  structure  of  the  kidney 
is  relieved  somewhat  in  the  same  proportion  as  elsewhere;  and  it  is  in  con- 
sequence of  this  that  there  is  so  uniform  an  improvement  in  the  secretion 
of  the  kidney,  which  u-sually  lasts  for  a  long  time  after  the  patient  has 
been  relieved  from  dropsical  accumulations  by  this  mode  of  tapping. 
Thorough  incisions  through  all  the  tissues  down  to  the  vicinity  of  the 
periosteum  in  the  ankles,  with  the  limbs  in  a  moderately  dependent  posi- 
tion, almost  as  certainly  drain  all  the  tissues  of  the  body  of  general  oedera- 
atous  infiltration  as  the  insertion  of  the  trochar  into  the  peritoneum 
drains  the  cavity  of  that  membrane  of  fluids  that  have  accumulated  in  it. 
In  regard  to  the  treatment  of  the  various  complications  such  as  the  super- 
vention of  pleurisy,  peritonitis,  cardiac  disease,  etc.,  during  the  progress 
of  marked  renal  trouble,  I  have  only  to  remark  that  they  are  to  be  treated 
on  the  same  principles  as  we  would  treat  these  affections  under  other  cir- 
cumstances, making  due  allowance  for  the  general  conditioa  of  the 
patient.  In  most  cases,  whatever  treatment  is  adopted,  proves  only  palli- 
ative, or  at  best  postpones  for  a  brief  period,  the  final  result — death,  of 
the  patient. 


630  SUPPUKATIVE   NEPHRITIS. 


LECTURE   LIX. 


Suppurative  Nephritis— Its  Causes,  Symptoms,  Anatomical  Chianges,  Diagnosis,    Prognosis,  and 
Treatment. 

GENTLEMEN:  Under  the  head  of  Suppurative  Nephritis  may  be  in- 
cluded several  affections  of  the  kidneys,  differing  in  their  etiology 
and  clinical  history,  but  all  accompanied  by  the  formation  of  pus  in  the 
parenchyma  of  those  organs.  The  causes  which  lead  to  suppuration  or  to 
the  accumulation  of  pus  in  the  kidneys  are  various,  and  the  accumulations 
consequently  present  several  distinct  forms.  All  those  conditions  of  the 
blood,  usually  included  under  the  heads  of  pyaemia  and  septiceemia  are 
liable  to  be  accompanied  by  suppurative  inflammation  or  purulent  depos- 
its in  the  kidneys.  In  this  class  of  cases  the  pus  is  usually  collected  in 
small  but  numerous  abscesses,  varying  in  size  from  a  pin's  head  to  that  of 
a  pea,  or  several  of  these  small  abscesses  may  be  united  together  forming 
a  larger  one  the  size  of  a  hickory  nut.  Examination  of  the  kidney  in  this 
class  of  cases  shovps  usually  several  stages  in  the  progress  of  this  form  of 
disease.  In  the  beginning,  the  inflammatory  process  will  cause  the  ap- 
pearance of  white,  or  yellow  spots,  which,  when  examined  more  closely 
with  the  aid  of  the  microscope,  will  be  found  to  consist  of  small  portions 
of  the  renal  substance  affected  with  necrosis  or  death  of  the  cell  structure, 
with  generally  more  or  less  pus  globules  recognizable,  and  in  the  midst 
of  them  a  group  of  bacterial  germs.  By  most  writers  of  the  present  day, 
it  is  supposed  that  the  lodgment  of  these  bacteria  from  the  blood,  consti- 
tutes the  commencement  of  the  disease  in  the  kidney,  and  that  they  are 
the  special  cause  inducing  inflammation,  necrosis  or  death  of  the  immedi- 
ately surrounding  tissue  and  subsequent  degeneration  into  pus.  In 
most  cases  the  same  kidney  will  present  all  the  different  stages  of 
progress,  from  the  simple  accumulation  of  groups  of  bacteria  with 
the  first  appreciable  change  or  impairment  of  the  tissue  in  contact  with 
them  in  some  places,  more  decided  death  or  necrosis  of  the  tissue  with 
pus  cells  diffused  in  it  in  others,  and  still  further,  places  where  the  puru- 
lent degeneration  is  more  complete,  and  distinct  abscesses  have  attained  a 
size  easily  recognizable  without  magnifying  power.  In  almost  all  cases 
arising  from  pyiemic  and  septictemic  conditions  the  renal  disease  is  as  I 
have  just  described,  and  results  in  the  formation  of  numerous  small  ab- 
scesses. There  is  another  class  of  cases  which  originate  not  from  general 
septicferaia,  but  from  inflammation  previously  existing  in  other  parts  of 
the  urinary  organs,  or  in  the  parts  within  the  pelvis.  They  occur  so  fre- 
quently in  connection  with  pelvic  inflammations  after  stirgical  opera- 
tions upon  the  urinary  organs,  that  they  have  been  called  surgical  kid- 
neys. In  such  the  evidences  of  inflammation  in  the  parenchyma  of  the 
kidney  is  more  general;  the  suppuration  takes  place  more  rapidly  and 
ends  in  the  formation  of  one  or  more  abscesses.  Sometimes,  indeed,  the 
suppurative  processes  resulting  from  previous  abscesses  and  ulcerations  in 
connection  with  the  pelvis  or  urinary  organs,  rapidly  disorganizes  the 
whole  substance  of  the  kidney  and  ultimately  converts  it  into  a  purulent 
mass.  And  sometimes  the  suppurative  inflammation  invades  the  areolar 
tissue  exterior  to  the  kidney  constituting  a  peri-nephritic  suppuration. 
Perhaps  this  form  of  destructive  suppurative  inflammation  in  the  paren- 
chyma of  the  kidney  is  more  liable  to  follow  primary  abscesses  in  the  pros- 
tate gland  than  in  any  other    part    connected    with    the    urinary  organs. 


SYMPTOMS.  631 

Next  in  froquency  is  their  occurrence  after  operations  for  the  removal  of 
urinary  calouli  from  tlie  bladder.  Another  class  of  cases  in  some 
inensure  intermediate  between  those  connected  with  pyaemia  or  septicaemia 
and  the  more  generally  rapid  suppurative  conditions  of  the  kidney  result- 
ing from  injuries  or  surgical  operations  and  abscesses  in  other  portions 
of  the  urinary  apparatus  to  which  I  have  alluded,  arise  mostly  from,  or  in 
connection  with,  suppurative  pericarditis,  or  the  formation  of  continuous 
suppurative  processes  in  the  lungs.  Suppurative  pericarditis  itself  is  not 
a  very  frequent  affection;  but  in  the  larger  proportion  of  the  cases  that 
have  occurred  in  which  examinations  have  been  made,  secondary  abscesses 
have  been  found  in  the  kidneys  sometimes  in  one,  but  more  frequently  in 
both.  There  is  some  liability  to  the  formation  of  these  nephritic  abscesses 
during  the  progress  of  any  long  continued  internal  suppurative  process,  in 
almost  any  part  of  the  body.  In  very  many  of  the  cases  of  suppurative  ne- 
phritis resulting  in  the  formation  of  abscesses,  whether  large  or  small,  there 
is  also  coincident  inflammation  in  the  lining  of  the  pelvis  of  the  kidnev, 
accompanied  by  the  establishment  of  suppurative  processes  exterior  to 
the  inflamed  organs.  Tnis  is  what  constitutes  a  peri-nephritic  inflam- 
mation, or  peri-nephritis.  In  other  instances  the  inflammation  is  limited 
to  the  lining  of  the  pelvis  of  the  kidney,  and  does  not  extend  to  the  paren- 
chyma of  the  secreting  structure.  Such  cases  are  denominated  pyelitis. 
And  those  cases  of  pyelitis  uncomplicated  by  extension  of  inflammation 
to  the  parenchyma  of  the  kidney,  may  originate  simply  from  extension  of 
inflammation  from  the  bladder,  through  the  ureters  to  the  pelvis  of  the 
kidney,  as  I  have  seen  in  several  instances  of  chronic  cystitis.  More  fre- 
quently, however,  the  pyelitic  inflammation  has  either  resulted  from 
ordinary  causes,  such  as  exposure  to  cold  and  damp,  which  is  followed  in  a 
short  time  by  suppuration  in  the  inflamed  membrane  ;  or  far  more 
frequently,  pyelitis  originates  from  the  formation  of  urinary  calculi  in 
the  pelvis  of  the  kidney,  or  in  the  infundibular  spaces.  The  formation  of 
nephritic  calculi  almost  always,  sooner  or  later,  gives  rise  to  the  establish- 
ment of  chronic  suppurative  inflammation  in  the  whole  linino-  membrane 
of  the  pelvis  of  those  organs,  and  not  infrequently  causes  also  an  obstruc- 
tion of  the  ureter  by  the  lodgment  of  calculi  in  it,  whereby  both  the 
urine  and  muco-purulent  material  resulting  from  pyelitic  inflammation  is 
prevented  from  passing  into  the  bladder,  and  escaping  through  the  ure- 
thra, and  its  retention  causes  distension  of  the  pelvis  first,  and  subsequent- 
ly more  or  less  of  the  ureters,  generally  giving  rise  to  a  swelliiio-  sufB- 
cient  to  be  easily  detected  by  examination  through  the  abdominal  parie- 
tes,  and  distinguished  from  other  tumors. 

Symptoms. — There  are  no  local  symptoms  that  usually  accompany  the 
formation  of  pus  in  those  cases  of  suppurative  nephritis  arising  from  sep- 
ticfemia,  or  pyaemia,  and  the  existence  of  such  condition  of  the  kidney  is 
only  detected  by  post-mortem  examination.  The  patients  of  this  class 
are  always  laboring  under  the  general  symptoms  of  pyaemia  or  septicae- 
mia, and  the  establishment  of  the  colonies  of  bacteria,  as  the  nuclei  of 
numerous  small  abscesses  or  collections  of  pus  gives  rise  to  no  pains  that 
attract  attention  from  the  more  general  symptoms,  nor  do  they  usually  so 
far  interfere  with  the  secretion  of  urine,  as  to  arrest  the  elimination  of 
urea,  and  cause  the  retention  of  the  elements  of  urine  sufficient  to  pro- 
duce urfemic  poisoning.  In  some  instances  where  that  change  in  the 
structure  of  the  kidney  is  very  extensive,  there  may  be  a  decided  dimi- 
nution in  the  quantity  of  the  urine,  and  a  sudden  development  either  of 
convulsions,  or  the  supervention   of  coma  and   death.     But  in   the  great 


632  SUPPUEATIVE    NEPHRITIS. 

majority  of  instances  of  this  class  the  result  depends  not  upon  the  renal 
disease,  but  upon  the  general  coincident  condition  of  the  system,  of 
which  the  renal  difficulty  is  only  a  secondary  development.  Should  the 
general  disease  be  controlled,  and  the  formations  of  pus  in  the  kidney  be 
limited  to  the  condition  of  very  minute  abscesses,  in  which  the  pus  is  sup- 
posed to  be  capable  of  undergoing  a  species  of  caseous  degeneration  and 
partial  removal,  there  is  a  possibility  of  the  recovery  of  the  patient  with- 
out permanent  impairment  of  the  function  of  the  kidney.  In  those  cases 
of  suppurative  inflammation  of  the  kidney  depending  upon,  or  secondary 
to,  surgical  operations,  or  primary  abscesses  in  the  prostate  gland,  or  in 
other  parts  within  the  pelvis,  the  lung,  or  in  the  course  of  the  urinary  pas- 
sages, there  are  local  symptoms  which  are  more  or  less  distinctive  of  the 
renal  affection.  The  patient  usually  begins  to  complain  of  dull,  aching, 
persistent  pains  in  the  loins,  often  extending  into  the  hips  and  sacrum,  ac- 
companied by  dry  skin,  increased  frequency  of  pulse,  increased  temper- 
ature, especially  in  the  afternoon  and  evening,  with  sufficient  diminution 
to  constitute  a  perceptible  remission  in  the  morning.  There  is  much 
restlessness  on  the  part  of  the  patient,  scantiness  of  urine,  frequently 
causing  heat  and  burning  on  passing  it,  and  in  from  two  to  five  days 
there  usually  occur  decided  chills,  followed  by  brief  paroxysms  of  high 
fever  and  copious  sweating.  On  the  supervention  of  the  chills  and  sweats 
the  pulse  becomes  smaller  and  more  frequent,  the  temperature,  eopecially 
during  the  afternoon  and  evening,  rises  higher,  when  the  patient  be- 
comes more  or  less  incoherent  or  troubled  with  dreams.  The  urinary 
secretion  ra\y  be  small  or  it  may  be  nearly  natural  in  quantity,  but  it 
becomes  now  mixed  with  pus,  which  gives  it  a  slightly  turbid  appearance 
when  it  is  passed,  but  on  allowing  it  to  stand  falls  a.s  a  layer  of  whitish 
matter  at  the  bottom  of  the  vessel.  Microscopic  examination  shows  it  to 
be  made  up  almost  entirely  of  pus  mingled  with  some  renal  epitlielial 
cells,  and  sometimes  red  corpuscles  of  blood.  The  patient  rapidly  loses 
flesh  and  strength,  and  in  some  instances  the  proportion  of  urea  in  the 
urine  is  very  much  diminished.  In  such  cases  the  stomach  becomes  ex- 
cessively irritable,  causing  the  prompt  rejection  of  everything  that  is 
taken  upon  it,  whether  food,  drink  or  medicine.  The  progress  of  such 
cases  from  this  time  on  is  very  variable,  as  regards  duration.  In  some 
instances  which  have  come  under  my  observation,  the  patients  presented 
daily  the  phenomena  of  the  regular  hectic  type  of  general  fever,  with 
progressive  emaciation  and  total  inability  to  retain  anything  upon  the 
stomach,  much  of  what  was  taken  regurgitating  without  the  act  of  vomit- 
ing. The  intestines  remaining  entirely  empty,  become  contracted,  while 
the  urine  is  constantly  impregnated  with  a  considerable  quantity  of 
pus,  and  death  takes  place  from  simple  asthenia,  at  the  end  of  from  three 
weeks  to  three  months.  In  other  instances,  however,  as  the  disease  pro- 
gresses the  destruction  of  the  renal  tissue  becomes  so  great  as  to  prevent 
the  elimination  of  the  natural  effete  elements  of  urine  and  their  retention 
in  the  blood  causes  toxic  effects  upon  the  brain  and  nervous  centers, 
bringing  on  the  usual  muscular  twitchings,  more  or  less  convulsive  move- 
ments, coma  and  death.  Such  cases  usually  progress  much  slower  than 
those  I  have  just  previously  mentioned.  In  addition  to  the  symptoms 
that  I  have  already  mentioned  in  the  cases  of  more  general  suppurative 
inflammation,  the  kidney,  usually,  after  the  first  three  or  four  days,  be- 
comes enlarged  sufficient  to  be  detected  by  examination,  and  somatim^s 
it  attains  a  size  sufficient  to  present  a  distinct  tumor,  which  can  be  easily 
included  between  the  fiigers  of  one  hand  pliced  undirneath  the  eleventh 
or  twelfth  riba  posteriorly,  and  those  of  the  other  placed  directly    under 


SYMPTOMS.  633 

the  margin  of  the  ribs  opposite  the  angle  of  the  colon  on  either  side  anterior- 
ly. The  shape  of  the  tumor  thus  included  between  the  two  hands  may  be 
traced  sufficiently  to  clearly  indicate  its  origin  as  distinguislied  from  that 
of  enlargement  of  the  spleen  or  any  accumulations  within  the  angles  or 
sigmoid  flexure  of  the  colon.  The  formation  of  such  a  tumor  or  swelling 
accompanied  by  a  greater  or  less  amount  of  pus  intimately  intermixed 
with  the  urine  as  it  is  passed,  separating  when  the  urine  is  allowed  to 
stand,  is  sufficiently  diagnostic  of  suppurative  renal  disease.  When  the 
inflammation  and  suppuration  occur  exterior  to  the  kidney  as  in  peri- 
nephritic  suppuration,  the  general  course  of  the  symptoms  is  very  nearly 
the  same,  and  may  present  more  or  less  of  a  tumor  locally,  but  it  will  dif- 
fer in  the  fact  that  tiiere  will  be  little  or  no  appearance  of  pus  in  the  urine 
unless  there  be  coincident  suppuration  in  the  kidney  at  the  same  time, 
as  sometimes  happens.  In  a  case  that  came  under  my  own  observation 
not  very  long  since,  in  which  all  the  symptoms  of  suppurative  nephritis  of 
an  acute  and  severe  character  were  present,  the  post-mortem  revealed  the 
fact,  not  only  that  the  parenchyma  of  the  kidney  in  the  left  side  was 
almost  entirely  disorganized,  and  converted  into  pus,  but  a  considerable 
collection  of  pus  also  existed  exterior  to  the  kidney  constituting  an  abscess 
between  it  and  the  lumbar  muscles.  In  this  same  case  there  were  one  or 
two  small  collections  of  pus  in  the  parenchyma  of  the  opposite  kidney. 
The  primary  disease  was  dependent  on  inflammation  and  suppuration  in  the 
prostate  arising  from  a  contusion  in  the  perinseum.  When  the  suppura- 
tive inflammation  attacks  simply  the  mucous  membrane  lining  the  pelvis 
of  the  kidney  constituting  pyelitis,  the  general  symptoms  are  less  severe. 
Indeed,  there  is  generally  little  or  no  febrile  disturbance  or  increased 
temperature,  and  but  little  acceleration  of  the  pulse,  but  there  is  in  most 
instances  dull,  aching  pains  in  the  loins,  generally  increased  by  standing 
or  walking,  some  degree  of  tenierness  to  pressure  underneath  the  margin 
of  the  ribs  in  the  lumbar  and  lateral  spaces  in  the  direction  of  the  kid- 
neys. And  after  the  disease  has  advanced  a  short  time  there  is  more  or 
less  distension  of  the  pelvis  of  the  kidneys  which  may  be  felt  as  a  tumor 
or  swelling  projecting  below  the  margin  of  the  ribs,  or  between  the  mar- 
gin and  the  anterior  crest  of  the  ilium,  coincident  with  decided  increased 
fullness  or  tumefaction  posteriorly  in  the  lumbar  region.  Pyelitis  exist- 
ing alone  without  involving  the  structure  of  the  kidney  is  manifest,  how- 
ever, more  by  the  condition  of  the  urine,  than  by  either  general  or  local 
symptoms.  In  nearly  all  such  cases  the  urine,  though  showing  but  little 
alteration  from  its  natural  appearance  when  voided,  yet  when  allowed  to 
stand  will  generally  deposit  more  or  less  mucus  in  the  early  stage,  subse- 
quently muco-purulent  material,  and  in  the  later  stages  much  pure  pus. 
When  the  pelvis  of  one  kidney  is  affected  there  will  be  frequently  days 
and  parts  of  days  when  the  urine  that  is  voided  will  appear  perfectly  nat- 
ural, neither  depositing  muco-purulent  material  nor  exhibiting  any  devia- 
tion from  the  natural  condition.  And  if  attention  is  given  closely  to  the 
patient  it  will  be  found  that  at  such  times  the  tumefaction  and  swellino- 
on  the  affected  side  has  steadily  increased,  and  is  usually  accoiiipanied  by 
increased  heaviness  or  weight  and  dull  pain  in  the  lumbar  and  iliac  regions, 
and  in  one  or  two  days,  sometimes  three,  the  urine  will  become  suddenly 
more  copious,  looking  a  little  turbid  when  passed,  and  depositing,  on 
standing,  large  quantities  of  pus  and  muco-puiulent  material  with  dimi- 
nution in  the  fullness  of  the  side,  and  more  or  less  relief  to  the  dull  pain 
and  sense  of  weight  that  had  previously  existed.  The  explanation  of  this 
occurrence  is,  that  in  pyelitis,  the  thicker  portions  of  the  pus  and 
muco-purulent    material   are    liable    to    lodge    in    the    ureters  and   pro- 


634  SUPPURATIVE    NEPHRITIS. 

duce  temporary  obstructions  to  the  passage  of  urine,  or  of  the  products 
of  the  inflammation,  causing  them  to  accumulate  till  the  pelvis  is  more 
distended,  giving  rise  to  a  greater  amount  of  fullness,  weight,  and  dull 
pain,  and  as  the  urine  is  entirely  obstructed  from  the  diseased  part,  the 
patient  voids  only  the  urine  from  the  healthy  kidney,  and  consequently  it 
presents  the  natural  color  and  appearance,  at  the  same  time  that  the 
symptoms  of  trouble  upon  the  other  side  in  all  other  respects  are  aggravat- 
ed. As  the  pressure  accumulates,  the  obstruction  in  the  ureter  is  forced 
through  into  the  bladder,  allowing  again  a  discharge  of  the  contents  of  the 
pelvis,  consequent  lessening  of  the  tumefaction,  and  more  or  less  relief  to 
the  pain,  while  the  urine  coincidently  becomes  very  much  impregnated 
with  inflammatory  products  consisting  of  mucus,  pus  and  not  infrequent- 
ly red  blood  corpuscles.  When  pyelitis  originates  from  causes  not  in- 
volving the  formation  of  urinary  calculi,  there  may  be  at  no  stage  in  its 
progress,  red  blood  corpuscles  in  the  urine  but  only  mucus  and  pus;  and 
these  will  vary  much  in  their  relative  proportions  as  well  as  in  their  abso- 
lute quantity.  But  when  the  pyelitis  has  been  caused  by  the  prior  for- 
mation of  renal  calculi,  there  are  very  few  instances  in  which  there  is  not 
at  times  hemorrhage  sufficient  to  make  blood  quite  manifest  in  the  urine 
when  voided.  There  are  some  cases,  however,  of  this  variety  in  which  the 
calculi  are  numerous,  varying  much  in  their  size,  one  or  more  of  them  too 
large  to  engage  in  the  ureters  at  all,  but  being  retained  in  the  pelvis  of 
the  kidney,  others  of  such  size  that  they  actually  engage  in  the  ureters 
and  pass  through  it,  producing  during  the  passage  more  or  less  severe 
pain,  sometimes  excruciatingly  severe,  which  ceases  abruptly  as  soon  as 
the  calculus  passes  from  the  ureter  into  the  bladder  constituting  what 
has  been  described  as  nephritic  colic.  At  other  times  the  calculus  after 
passing  into  the  ureter  becomes  arrested  at  some  stage  of  its  progress, 
is  retained  there,  constituting  a  permanent  obstruction  to  the  flow  of  the 
urine  through  that  duct  into  the  bladder.  These  cases  of  accumulation 
of  urine  and  purulent  material  in  the  pelvis  of  the  kidney  and  in  the 
ureter  often  distend  both  so  that  the  ureter  itself  above  the  point  of 
obstruction  becomes  dilated  into  a  sac  presenting  all  the  outlines  of  a 
tumor  of  considerable  size  in  that  part  of  the  abdomen.  When  the  calculi 
thus  become  permanently  lodged  in  any  part  of  the  ureter  from  its  renal 
extremity  to  its  entrance  into  the  bladder  the  resulting  enlargements  may 
be  very  various. 

In  some  instances  it  will  be  limited  almost  entirely  to  dilatation  of  the 
urethra  itself,  which  becomes  dilated  into  a  sac  sometimes  two  or  three 
inches  in  diameter,  while  the  pelvis  of  the  kidney  remains  but  little  dis- 
tended. A  case  of  this  kind  came  under  my  observation  in  the  capacity 
of  consulting  physician  some  years  since,  in  which  an  obscure  urinary  af- 
fection had  existed  a  long  time,  and  a  tumor  had  formed  directly  in  the 
course  of  the  ureter  of  the  right  side.  The  tumor  was  of  an  oblong  form 
commencing  low  enough  to  make  it  difficult  to  get  at  its  lower  extremity 
with  the  ends  of  the  fingers  between  it  and  the  ramus  of  the  pubes;  while 
the  upper  portion  could  be  easily  outlined  with  the  fingers,  showing  an 
enlargement  about  three  or  four  inches  in  length  and  at  least  two  inches 
in  diameter  at  its  largest  part.  This  oblong  tumor  lying  in  the  right  side 
of  the  abdomen  directly  in  the  course  of  the  ureter,  and  equally  in  the 
region  of  the  ascending  colon  led  his  attending  physician  into  much  doubt 
in  regard  to  the  nature  of  the  disease.  The  case  ultimately  terminated 
fatally,  and  in  the  post-mortem  examination  it  was  found  that  a  renal 
calculus  had  become  permanently  arrested  in  the  ureter,  within  one  inch 
and  a  half  of  the  opening  of  that  tube  into  the  bladder,  and  had  appar- 


DIAGNOSIS.  •  635 

ently  produced  complete  obstruction  to  the  passag-e  of  urine  and  all  other 
matters  through  that  duct.  This  obstruction  had  resulted  in  dilatation  of 
the  ureter  into  a  sac  or  tumor  of  the  dimensions  I  have  mentioned,  in  the 
rio-ht  side  of  the  abdomen.  The  pelvis  of  the  kidney  was  somewhat 
dilated  and  contained  several  other  additional  calculi,  the  largest  of 
Avhich  was  the  size  of  a  hickory  nut.  Mostof  these  cases  belong  directly 
within  the  domain  of  surgery,  and  we  need  not  pursue  thern  further  than 
to  give  you  a  general  outline  of  their  progress  and  such  symptoms  as  will 
enable  you  to  diagnosticate  them  from  other  forms  of  disease.  As  I  have 
already  stated,  pyelitis  may  occur  and  continue  an  indefinite  period  of 
time,  as  a  chronic  suppurative  affection  of  the  lining  of  the  pelvis  of  the 
kidney,  without  involving  other  parts.  In  very  many  cases  of  pyelitis, 
there  is  coincident  cystitis.  Inflammation  in  both  pelvis  and  bladder 
arises  from  the  same  causes,  and  leads  to  very  similar  results. 

Anatomical  Changes. — I  have  already  spoken  of  the  anatomical  changes 
which  take  place  in  the  pytemic  collections  of  pus  in  the  kidney,  where 
the  purulent  formations  are  the  result  apparently  of  colonies  of  bacteria 
deposited  in  the  progress  of  general  pyasmic  or  septiccsmic  conditions  of 
the  blood.  Whether  the  bacteria  are  the  real  cause  of  the  inflammation 
and  suppuration  here,  or  whether  they  are  only  coincident,  it  is  not  easy  to 
determine.  The  prevalent  opinion  is  that  they  are  the  special  cause  of 
the  rapid  degeneration  of  tissue,  and  the  formation  of  small  multiple  a,b- 
scesses.  In  the  suppuration  which  takes  places  in  the  kidney  in  the  proo-- 
ress  of  suppurative  pericarditis,  abscesses  in  the  lungs,  or  extensive 
suppurative  conditions  in  other  portions  of  the  system,  it  is  probable  that  the 
renal  affection  originates  directly  from  the  passage  through  the  blood  of  the 
emboli,  or  particles  of  matter  detached  from  the  suppurative  surfaces  just 
named,  and  their  lodgment  in  the  minuter  vessels  of  the  cortical  texture  of 
the  kidney.  Such  emboli  plug  up  the  renal  vessels,  and  create  irritation, 
which  leads  to  rapidly  suppurative  inflammation,  and  consequent  formation 
of  pus.  This  may  be  confined  to  a  limited  space  resulting  in  a  single  abscess, 
or  there  may  be  many  points  of  obstruction  and  suppuration,  and  in  their 
development  they  may  unite  more  or  less  together,  until  a  large  portion 
of  the  renal  substance  becomes  converted  into  pus.  In  most  cases  where 
examinations  have  been  made  with  care,  the  embolic  obstructions  thatoccur 
in  this  clas?,  contain  also,  more  or  less  of  colonies  of  bacteria  or  micrococci, 
which  probably  bear  the  same  relation  to  the  suppurative  processes  here, 
that  those  connected  with  the  septicfemic  cases  to  which  I  have  previously 
alluded,  bear  to  them.  It  is  proper  to  state,  that  in  the  embolic  depos- 
its not  infrequently,  some  degree  of  extravasation  of  blood  or  minute 
hemorrhagic  exudations  take  place,  in  the  early  part  of  all  obstructions; 
and  these  may  sometimes  be  detected  on  examination,  in  the  places  that 
have  undergone  the  least  change,  while  in  others  where  suppuration  is 
more  complete  and  extensive,  these  hemorrhagic  exudations  are  un- 
noticeable. 

DUcf/nosis. — As  I  have  already  remarked  there  are  no  symptoms  notice- 
able during  the  lifetime  of  the  patient  by  which  a  diagnosis  of  the 
cases  connected  with  pyeemia  can  be  made,  or  at  least  a  large  propor- 
tion of  them  ;  while  in  other  cases  to  which  I  have  alluded,  the  more 
extensive  formation  of  pus  causes  early  impregnation  of  the  urine 
with  purulent  material.  In  these,  the  diagnosis  can  almost  always 
be  made  by  noticing,  first,  the  occurrence  of  pain  and  heaviness  in 
the  region  of  one  or  both  kidneys,  followed  by  more  or  less  irregular 
chills  and  sweats,  with  the  formation  of  a  tumor  consisting  of  the  enlarg.;- 
ment  of  one  or   both  kidneys,  and  the  appearance  of  pus  in  the  urine, 


636  SUPPCKATIVE   NEPHRITIS. 

when  examined  under  the  microscope.  The  coincidence  of  these  circum- 
stances render  the  diagnosis  of  this  class  of  cases  sufficiently  certain. 
There  are  some  cases  of  pyelitis  in  which  there  is  more  difficulty  in  arriv- 
ino-  at  a  certain  diagnosis  between  pyelitic  disease  and  cystitis.  You  must 
recollect,  however,  that  in  cystitis  the  muco-purulent  material  is  always 
less  intimately  intermixed  with  the  urine  as  it  is  voided,  and  that 
there  is  an  inclination  to  void  the  urine  much  more  frequently  than  natural 
with  correspondingly  less  at  a  time,  and  micturition  is  accompanied  by  more 
or  less  burning,  smarting  pain,  and  some  degree  of  pressure: — whereas,  in 
pyelitis  uncomplicated  by  cystitis,  the  patient  generally  voids  urine  not 
more  frequently  than  in  the  natural  condition,  and  in  thus  voiding  it,  the 
muco-purulent  material  is  so  intimately  intermixed  with  the  urine  as  to  give 
it  a  more  clouded  appearance  but  is  not  recognizable  as  a  separate  material 
by  the  eye,  until  it  has  been  allowed  to  stand  usually  for  an  hour  or  mor3. 
There  is  also  in  uncomplicated  pyelitis,  absence  of  the  sharp,  smarting 
pain  in  voiding  the  urine,  and  of  the  sensation  of  irritation  in  the  urethra 
or  neck  of  the  bladder.  If  there  are  exceptions  to  this  it  is  when  the 
pyelitis  is  accompanied  by  urinary  calculi,  and  some  of  the  smaller  calculi 
occasionally  passing  into  the  bladder  may  give  rise,  before  they  pass  out 
throuo-h  the  urethra,  to  sufficient  irritation  to  cause  pains  similar  to  those 
of  cvstitis.  But  if  such  pains  occur  from  that  cause  they  will  occur  only 
occasionally,  while  in  the  intermediate  time  urine  passes  without  burning, 
and  without  frequency,  and  yet  contains  an  abundance  of  pus.  Such 
cases  seldom  exist  for  a  length  of  time  without  developing  more  or  less 
enlargement  of  the  pelvis  of  the  kidney  and  consequently  a  perceptible 
tumor  in  that  region  which  serves  to  render  the  diagnosis  also  more  com- 
plete. Many  have  claimed  that  there  is  a  difference  in  the  appearance 
of  the  epithelium  derived  from  the  pelvis  of  the  kidney,  when  in  a  state 
of  chronic  inflammation,  from  that  detached  from  the  surface  of  the  blad- 
der in  cystitis.  It  is  quite  evident,  however,  that  there  is  noi:  such  a  de- 
gree of  real  difference  in  these  cases  as  to  be  of  any  value  in  diagnosis. 
But  as  I  have  previously  remarked,  cystitis  and  pyelitis  frequently  exist 
coincidently,  when  the  symptoms,  phenomena,  and  consequences  of  both 
are  present  at  the  same  time.  In  such  cases  there  will  be  an  intermin- 
glincr  of  the  symptoms  of  both,  and  unless  the  pelvis  of  the  kidney  is  en- 
laro-ed  sufficiently  to  present  a  recogn  zible  tumefaction  to  aid  you,  it 
may  be  impossible  to  decide  positively  whether  you  have  a  case  of  cysti- 
tis alone  or  of  cystitis  and  pyelitis  together.  Practically,  however,  it  is 
unimportant. 

Prog)iosis. — The  prognosis  in  all  cases  of  suppurative  inflammation  in 
the  parenchyma  of  the  kidney  must  be  regarded  as  more  or  less  unfavor- 
able. For  while  it  is  true  that  a  few  instances  are  on  record  in  which 
peri-nephritic  suppuration  has  taken  place,  and  by  freely  opening  the 
abscess  from  behind  the  peritoneum  and  establishing  drainage,  patients 
have  recovered;  and  in  very  rare  instances  when  the  suppuration  has  ex- 
isted in  the  substance  of  the  kidney  and  a  discharge  of  pus  has  taken  place 
with  sufficient  freedom  into  the  pelvis  and  through  the  urinary  passages 
with  the  urine  to  drain  the  abscess  and  lead  co  ultimate  recovery,  or  an  incis- 
ion carried  in  the  same  mxnner  as  for  peri-nephritic  abscess  boldly  into  the 
kidney  itself,  has  resulted  in  the  drainage  of  the  abscess  through  the  ex- 
terior with  favorable  results;  yet  these  are  rare  exceptions  when  com- 
pared with  the  general  rule,  which  is,  that  these  suppurative  conditions 
of  the  kidney  all  end  the  life  of  the  patients.  If  it  be  practicable,  as  I 
have  before  suggested,  that  those  numerous  points  of  suppuration  which 
■  take  place  in  the  kidneys  during  septictemic  and  pyasmic  conditions  of  the 


TREATMENT.  637 

system  should  unJerg-o  such  changes  as  to  ultimately  allow  repair  of  the 
struc;uro  of  the  kidney  and  avoid  death  from  renal  degeneration,  yet  the 
great  majority  of  patients  of  that  class  actually  die  from  the  general 
disease  before  such  reparation  has  had  time  to  take  place  in  the  kidney. 
Treatment. — But  few  words  are  necessary  in  regard  to  the  medical 
treatment  of  all  these  different  varieties  of  suppurative  disease  of  the  kid- 
ney. Those  which  originate  in  connection  with  pyiBuiia  and  septice- 
mia are  to  be  treated  entirely  in  accordance  with  the  indications  afforded 
by  the  general  disease.  The  same  may  be  said  of  those  cases  which  orig- 
inate in  connection  with  abscesses  in  the  lungs,  or  suppurative  pericar- 
ditis, or  extensive  suppurative  processes  in  any  other  parts  of  the  system. 
The  renal  affection  being  secondary  entirely  may  hasten  the  fatal  result, 
but  does  not  alter  the  fact  that  the  indications  for  treatment  are  covered 
by  the  morbid  conditions  and  processes  which  had  existed  prior  to  its  oc- 
currence. If  cases  of  diffuse  suppurative  inflammation  occur  as  the  result 
of  direct  blows,  injuries,  or  from  any  causes  that  render  the  renal  affection 
the  primary  one,  it  is  probable  that  treatment  promptly  resorted  to  of  the 
same  character  which  I  have  mentioned  as  applicable  for  acute  nephritis 
in  its  early  stage,  would  be  most  likely  to  relieve  the  patient,  by  either 
preventing  or  lessening  the  extension  of  the  suppurative  process.  But  in 
these  cases,  the  stage  preceding  the  suppurative  process  is  short;  and  of- 
tentimes is  passed  before  the  attention  of  the  physician  is  attracted  to  the 
case,  or  the  true  diagnosis  has  been  made.  But  when  suppuration  is 
once  established,  the  great  object  of  the  treatment  must  be  to  sustain  the 
patient  by  judicious  use  of  nourishment,  and  when,  as  is  often  the  case 
the  stomach  refuses  to  accept  or  retain  food,  nutritive  enemas  must  be 
substituted.  Such  remedies  as  are  calculated  to  sustain  the  patient  mort 
or  less,  and  can  be  used  hypodermically,  may  be  employed  in  that  manner 
Something  may  be  done  by  inunction  or  the  introduction  of  nutrimen 
through  the  skin.  All  these  modes  may  be  resorted  to  for  the  support  of 
the  patient  and  prolongation  of  life,  in  the  hope  that  the  accumulation  of 
pus  will  either  be  relieved  spontaneously  through  free  discharge  into  the 
pelvis  of  the  kidney  and  through  the  urinary  passages  with  the  urine,  or 
that  it  may  assume  such  a  position  or  relation  as  to  be  reached  by  incis- 
ion from  the  exterior  behind  the  peritoneum,  and  allow  of  drainage  in  that 
way.  But  you  will  perceive  that  these  measures  at  once  bring  the  case 
within  the  domain  of  practical  surgery,  where  you  must  look  for  detailed 
directions  for  such  operative  procedures.  In  cases  of  pyelitis  arising  from 
the  existence  of  calculi  in  the  pelvis  of  the  kidney,  the  treatment  must 
consist  in  the  administration  of  such  remedies  as  are  calculated  to  allay 
irritation  in  the  mucous  membrane  of  the  urinary  passages  generallv; 
such  tonics  and  nutrients  as  promote  the  general  nutrition  and  strength 
of  the  patient,  avoiding  exercise,  especially  upon  the  feet,  or  in  the  up- 
riglit  position,  which  is  calculated  by  the  free  motion  of  the  calculi  to  add 
to  the  irritation  and  often  to  occasion  hemorrhage.  If  in  the  progress  of 
the  case  such  symptoms  are  developed  as  render  the  diagnosis  reason- 
ably certain  that  such  calculi  exist,  and  have  become  too  large  to 
be  voided,  it  brings  the  important  question,  whether  the  operation  of 
nephrotomy,  by  which  the  calculi  may  be  reached  and  removed  shall  be 
ventured  upon  or  not.  ^Yhere  there  is  but  a  single  large  calculus  free  to 
move  in  the  pelvis  of  the  kidney,  and  the  patient  is  of  good  constitution, 
the  surgeon  may  undertake  an  operation  for  its  removal  with  reasonably 
fair  prospect  of  success,  as  it  constitutes  probably  the  only  hope  of  pre- 
serving the  patient  from  a  long,  wasting,  painful  sickness  and  ultimate 
death.     As   there   are   no  remedial  agents  known  that  are  capable  of  dis- 


638  FLUXES. 

solving  these  calculi,  their  continued  presence  sooner  or  later  exhausts  the 
pitieat  and  leads  to  coincident  affections  which  shorten  life. 


LECTUEE  LX. 


Fluxes— Definition  and  Varieties— Cutaneous  Flux,  or  Diaphoresis —Its  Causes,  Pathology  and 
Treatment. 

GENTLEMEN:  In  the  sixth  lecture  of  the  present  course  while  speak- 
ing of  the  classification  of  diseases,  or  their  arrangement  into  con- 
venient groups  to  secure  order  in  their  considerat  on,  I  arranged  those  de- 
nominated local  diseases  in  four  sub-classes  or  orders,  namely:  inflamma- 
tions, fluxes,  neuroses  and  a  group  of  miscellaneous  affections.  Having 
completed  the  consideration  of  those  classes  denominated  local  inflamma- 
tions, so  far  as  they  come  within  the  scope  of  what  is  regarded,  at  the 
present  day,  as  practical  medicine,  I  now  invite  your  attention  to  the  dis- 
eases and  morbid  conditions  included  in  the  second  division  under  the 
designation  of  fluxes.  You  will  remember,  that  in  the  lecture  just  alluded 
to,  I  stated  that  this  term  was  not  an  entirely  satisfactory  one,  having 
relation  only  to  a  symptom  which  mav  be  common  to  all  the  morbid 
conditions  included  under  that  designation,  and  having  no  pathological 
significance  on  the  one  hand,  and  no  indications  as  to  the  particular  or- 
gans or  tissues  that  might  be  involved  in  the  disease  upon  the  other. 
And  yet,  as  all  the  diseases  included  in  the  group  are  characterized  by 
an  unusual  flux  or  floM'  of  fluids,  I  am  not  able  to  select  a  better 
term.  In  the  lecture  to  which  I  have  alluded,  you  will  find  a  table  in 
which  the  diseases  and  morbid  conditions  included  in  this  division  are  ar- 
ranged, first  into  two  groups;  the  one  characterized  by  the  flow  of  serous 
fluids  derived  from  the  blood,  and  hence  called  serous  fluxes;  and  the 
other  characterized  Vjy  the  flow  of  blood  itself,  and  hence  called  sanguin- 
eous fluxes  or  hemorrhages.  (See  page  51).  The  serous  fluxes  were 
again  divided  into  two  groups,  the  one  taking  place  from  the  free  sur- 
faces, and  the  other  into  shut  sacs  or  interstitial  spaces  of  tissue.  As 
the  free  surfaces  of  the  body  are  made  up  or  constituted  mainly  of  the 
cutaneous  tissue  upon  the  exterior  surface  of  the  body,  and  of  the  mucous 
membrane  lining  the  alimentary  canal  and  other  cavities  having  external 
outlets,  the  flow  from  these  surfaces  is  at  once  discharged  instead  of  ac- 
cumulating in  contact  with  any  part  of  the  body.  When  the  flow  is  from 
the  cutaneous  surface  exteriorly,  it  takes  the  name  of  diaphoresis,  or  sweat- 
ing. When  it  takes  place  from  the  internal  Iree  surface  of  the  mucous 
membrane  of  the  alimentary  canal,  it  gives  rise  to  discharges  either  by 
vomiting,  purging,  or  both,  and  is  generally  recognized  as  serous  diar- 
rhoea, cholera  morbus,  cholera  infantum  or  epidemic  cholera,  according  to 
the  rapidity  and  copiousness  of  the  discharge.  When  the  flow  of  serous 
fluid  takes  place  into  the  shut  sacs  like  the  membranes  of  the  brain, 
pleura,  pericardium,  peritoneum,  synovial  membranes,  bursal  sacs,  or  into 
the  parenchyma  of  organs,  it  has  no  way  to  escape  except  by  absorption, 
and  consequently  accumulates,  distending  the  parts,  constituting  what  is 
known  as  dropsical  accumulations.     It  then  takes  various  names,  indicated 


DIAPHORESIS.  639 

in  a  great  measure  by  the  name  of  the  sac  in  which  it  may  accumulate, 
as  hydrocephalus,  hydrothorax,  ascites,  an  J  when  in  the  interstitial 
spaces,  oedema  or  anasarca.  In  the  consideration  of  this  group  of  dis- 
eases, I  shall  follow  the  order  in  wh'ch  they  were  presented  in  the  table 
given  in  the  sixth  lecture  to  which  I  have  already  alluded,  and  will  con- 
sequently direct  your  attention  first  to  the  fluxes  from  the  free  surfaces 
of  the  body. 

Diaphoresis. — The  eliminations  from  the  cutaneon** surface,  pissing  as 
they  leave,  from  the  fluid  to  the  vaporized  form,  accomplish,  in  the  healthy 
condition  of  the  system,  two  important  purposes.  One  is  excretory,  free- 
ing the  blood  from  certain  portions  of  the  waste  materials  that  have  been 
derived  from  the  molecular  processes  in  the  tissues  of  the  body,  and  the 
other  is  to  diminish  the  temperature  by  constantly  converting  a  pirtion  of 
the  free  heat  into  a  latent  condition  in  the  conversion  of  the  fluid  on  the 
surface  into  the  aeriform  state.  Cutaneous  exhalation,  therefore,  consti- 
tutes an  active  cooling  process,  provided  by  nature  for  counterbalancing 
the  tendency  to  accumulate  heat  by  the  constant  conversion  of  latent  into 
free  heat  in  the  different  processes  taking  place  in  the  living  tissues. 
The  quantity  of  exhalation  from  the  cutaneous  surface  varies  much 
within  the  limits  of  health. 

As  a  rule,  it  may  be  said  that  the  amount  of  exhalation  from  the  cu- 
taneous surface,  in  the  healthy  condition,  is  in  direct  ratio  to  the  temper- 
ature of  the  surrounding  atmosphere,  provided  the  hygrometric  condition 
or  that  of  moisture  be  the  same.  But  a  dry  atmosphere  at  the  same 
temperature  invites  a  much  more  rapid  exhalation  than  a  moist  one,  from 
the  simple  physical  fact  that  the  atmosphere  is  capable  of  holding  only  a 
certain  amount  of  aqueous  vapor  in  solution  before  it  reaches  the  point 
of  saturation.  Hence,  an  individual  can  maintain  health  in  a  dry  atmos- 
phere, at  a  much  higher  temperature  than  in  a  moist  one;  as  the  ex- 
perience of  each  one  of  you  has  demonstrated,  if  you  remember  the  dif- 
ference in  the  effects  of  two  summer  days  of  the  same  temperature  as  in- 
dicated by  the  thermometer,  but  in  one  of  which  the  air  is  dry,  in  the  other 
the  air  is  saturated  with  moisture.  The  comfort,  and  even  buoyancy  in  the 
first,  contrasts  strongly  with  the  oppressive  character  of  the  second.  I 
call  your  attention  to  these  circumstances  relating  to  health  and  every- 
day life,  that  you  may  the  better  appreciate  not  only  the  function  of  the 
cutaneous  tissue  so  far  as  relates  to  exhalations  or  fluxes  from  it,  and  the 
natural  effects  which  are  produced,  but  also  the  morbid  conditions  and 
their  remedies.  B"'or  while  the  cutaneous  exhalation  may  vary  much  in 
quantity  in  a  given  time  within  the  limits  of  health,  if  it  is  out  of  correspond- 
ence with  the  relations  of  the  surrounding  atmosphere,  it  is  frequently 
in  icative  of  some  pathological  condition  needing  correction.  Without 
going  minutely  into  details,  in  regard  to  all  the  causes  that  influence  ex- 
halations irom  the  surface  of  a  morbid  character,  we  may  group  them  into 
three  divisions:  First,  those  which  simply  increase  the  temperature  of  the 
surrounding  medium.  Second,  those  that  produce  impairment  of  the  gen- 
eral tonicity  by  lessening  the  vital  affinity  of  the  tissues,  including  the 
cutaneous,  and  thereby  inducing  such  general  relaxation  as  to  favor  ex- 
cessive exhalation  of  tlie  watery  or  serous  element  of  the  blood  through 
any  of  the  free  surfaces  of  the  body.  And,  third,  those  causes  that  act 
more  directly  upon  the  vasomotor  nerves  controlling  the  vessels  of  the 
periphery  or  surface  of  the  body.  In  regard  to  the  cases  that  arise  from 
the  first  of  these  causes,  namely,  the  direct  increase  of  the  temperature  of 
the  surrounding  medium,  or  atmosphere,  I  may  point  you,  as  the  most 
familiar  illustration,  to  the  effects  of  the  high  temperature  of  every   sum- 


640  DIAPHOEESIS. 

mer.  As  I  have  before  stated,  all  other  things  being  equal,  the  higher 
the  temperature  of  the  air  in  which  we  live,  the  greater  is  the  amount  of 
cutaneous  transpiration.  An  excess  of  such  exhalation  rapidly  diminishes 
both  the  saline  and  watery  elements  of  the  blood.  For,  as  you  are  aware, 
the  perspiration  contains  an  important  amount  of  the  saline  constituents, 
especially  chloride  of  sodium,  which  is  an  important  element  in  healthy 
blood.  It  is  a  physiological  law,  that  whenever  from  any  process  the 
watery  element  of  the  blood  escapes  in  too  large  proportion,  it  leads  to  a 
demand  for  drink,  or  thirst  for  fluids  on  the  part  of  the  patient.  Conse- 
quently, the  general  habit  of  the  community  during  the  warm  season  of  the 
year,  while  perspiration  is  going  on  sufficiently  active  to  prove  a  source  of 
exhaustion  of  the  water  and  saline  elements  of  the  blood,  is,  to  take  pro- 
portionately larger  amounts  of  water,  or  of  some  kind  of  diluent  fluid  to 
supply  the  place  of  such  exhalation.  As  a  general  rule,  however,  the 
more  copious  the  supply  of  fluids  by  drink,  the  more  copious  also  will  be 
the  cutaneous  transpiration.  The  result  is,  that  a  large  part  of  the  com- 
munity during  the  highest  temperature  of  summer,  by  the  quantity  of 
water  and  other  fluids  they  drink,  directly  encourage  the  flow  of  the 
cutaneous  exhalation,  which  carries  with  it  a  much  larger  proportion  of  the 
saline  e'ements  of  the  blood,  especially  the  chlorine  salts,  than  are  sup- 
plied by  the  water  and  liquids  that  are  taken;  and  the  consequence  is, 
that  the  blood  is  kept  deficient  in  its  free  salts.  It  was  long  ago  ascertained 
bv  Bernard,  and  since  confirmed  by  many  others,  that  the  capacity  of  the 
blood  to  take  up  oxygen  from  the  air  cells  of  the  lungs  and  hold  it  in  so- 
lution to  be  distributed  through  the  system  with  the  arterial  blood,  de- 
pends in  part,  at  least,  upon  the  saline  constituents  existing  in  the  serum. 
You  can  readily  see,  therefore,  that  whenever  the  saline  elements,  and 
more  especially  "the  chlorine  salts  of  the  blood,  are  diminished  below  their 
natural  proportion,  it  also  diminishes  the  capacity  of  the  blood  for  re- 
ceiving oxygen  from  the  air  cells  of  the  lungs,  and  consequently,  dimin- 
ishes the  efficiency  of  the  process  of  oxygenation  and  decarbonization  of 
that  fluid.  The  result  of  such  deficiency  is,  that  the  nervous  system  feels 
the  depression,  consequent  on  the  presence  of  defectively  arterialized 
blood,  o-iving  rise  to  a  sense  of  weakness,  weariness  and  inability  for  active 
exertion.  At  the  same  time  the  gastric  tubules  and  other  secreting  cell 
structures  in  different  organs,  feel  the  want  of  a  more  fully  arterialized 
blood,  and  consequently  fail  to  maintain  the  healthy  performance  of  their 
natural  functions. 

The  appetite  becomes  impaired,  the  food  digests  less  readily  from  the  di- 
minished amount  of  gastric  secretion,  causing  gastric  and  intestinal  derange- 
ments; and  it  is  in  this  way  that  we  have  a  full  and  satisfactory  explana- 
tion of  the  large  amount  of  minor  ailments  that  are  so  prevalent  in  the 
community  during  the  heat  of  every  summer.  And  in  certain  classes  of 
the  community,  those  especially  who  are  working  at  all  seasons  of  the 
year  in  places  exposed  to  a  very  high  temperature,  as  is  the  case  with 
some  of  the  workmen  in  iron  foundries,  rolling  mills  and  manufacturing 
establishments  requiring  the  presence  of  high  heat,  copious  perspiration 
causing  dryness  of  the  mouth  and  craving  for  drink,  induces  a  very  copious 
supply  of  fluids.  I  have  had  occasion  every  year,  for  many  years,  to  ex- 
amine and  prescribe  for  workmen  from  such  places  in  this  city,  who, 
under  the  circumstances,  had  acquired  the  habit  of  drinking  from  six  to 
twelve  litres  (quarts)  of  water  or  other  diluent  drinks  every  day  during 
the  regular  hours  that  they  were  exposed  to  a  high  temperature;  and  at 
the  same  time  perspired  so  copiously  as  to  fully  counterbalance  the 
amount  of  their  drink.     The  result  has  been  such  as  I  have  mentioned,  a 


TREATMENT.  641 

few  moments  since;  the  exhaustion  of  the  free  salts  of  the  blood,  dimin- 
ished oxygenatiou  and  decarbonization,  leaving  the  skin  clammy  and 
cool,  the  countenance  haggard,  the  lips  a  leaden  hue,  under  the  tinger 
nails  more  or  less  bluish  or  leaden,  extreme  weakness  and  almost  total 
suspension  of  gastric  secretion  and  digestion,  with  marked  diminution  in 
the  quantity  of  urine.  It  is  not  only  this  class,  however,  that  suffer, 
although  they  give  us  the  most  complete  demonstration  of  the  extreme 
derangements  produced  by  this  process,  but  there  are  thousands  engaged 
in  no  work  as  well  as  those  who  are  busy  during  the  summer  season,  that 
follow  the  habit  of  indulging  so  largely  in  drinks  as  to  keep  up  excessive 
exhalations  from  the  surface  with  the  same  consequences  I  have  detailed, 
varying  only  in  their  degree. 

Of  course  the  treatment  which  such  patients  require,  consists  mainly 
in  the  proper  regulation  of  their  diet  and  drinks.  I  have  found  by  an 
abundant  trial,  that  nearly  all  acute  cases  of  the  fluxes  liable  to  result 
from  these  causes,  whether  it  be  from  the  high  heat  of  summer,  or  by  ex- 
posure to  the  high  temperature  of  certain  kinds  of  work,  can  be  avoided 
by  the  simple  rule,  that  the  patient,  after  taking  such  an  amount  of  wa- 
ter, milk  and  water,  or  other  simple  diluents,  as  weak  tea  or  weak  coffee,  at 
the  time  he  takes  his  food  as  he  may  desire,  between  the  meals,  he  shall 
never  take  more  than  thirty  or  sixty  centimeters  (  fl.  31  or  |ii)  at  onetime. 
Such  drink  may  be  either  cold  water,  milk  whey,  buttermilk,  or  water 
slightly  acidulated  with  acetic  acid  and  flavored  with  a  little  syrup.  As 
often  as  the  mouth  becomes  dry  and  uncomfortable,  taking  for  drink 
simply  this  small  quantity  of  cold  water,  or  any  of  the  other  drinks  I 
have  mentioned,  moistens  the  membranes  of  the  mouth,  fauces  and 
oesophagus  and  produces  a  cooling  impression  upon  the  stomach,  which 
continues  just  as  long  as  would  be  the  case,  if  they  took  half  a  litre  (or 
pint)  of  a  similar  fluid  at  once.  The  quantity  taken  does  not  alter  the 
time  at  which  the  feeling  or  desire  for  more  drink  is  reproduced.  But 
by  limiting  the  amount  taken  at  any  one  time,  directly  to  the  quantities 
I  have  specified,  most  individuals  would  consume  no  more  than  half 
a  litre  or  one  pint  in  the  interval  between  breakfast  and  dinner,  and  a 
similar  quantity  between  dinner  and  supper.  The  consequence  is,  that 
under  such  a  rule  in  regard  to  drinks,  the  amount  of  exhalation  from 
the  cutaneous  surface  is  greatly  diminished.  The  free  salts  of  the 
blood  are  consequently  retained,  and  the  blood  maintains  very  nearly  its 
natural  proportion  of  constituents  throughout.  The  strength  of  the  in- 
dividual is  also  conserved,  the  secretions  are  maintained  in  their  natural 
condition.  I  have  given  the  rule  to  a  great  many,  who  had  been  suffer- 
ing from  the  conditions  I  have  mentioned,  and  I  have  yet  to  find  a  single 
individual  practicing  it  faithfully,  who  has  not  thereby  obviated  all  the 
evil  effects  from  which  they  had  previously  suffered.  It  is  now  more  than 
thirty  years  since  my  attention  has  been  directed  to  this  particular  sub- 
ject, and  1  am  satisfied  that  a  very  large  percentage  of  the  minor  ail- 
ments of  every  summer,  and  also  many  of  the  more  severe  attacks  of 
cholera  morbus  and  diarrhoea,  originate  from  the  influences  to  which  I 
have  been  alluding.  It  is  hardly  necessary  for  me  to  say  that  the  evil 
effects  of  drinking  large  quantities  of  water,  and  other  diluent  drinks  in 
the  encouragement  of  perspiration  and  loss  of  a  large  proportion  of  the 
saline  elements  of  the  blood,  are  in  no  wise  lessened  by  the  mixture  of 
alcoholic  beverages  with  the  water  or  other  diluents  that  are  taken.  In 
other  words,  that  a  little  whisky  or  brandy  will  in  no  wise  mitigate  the 
evil,  but  on  the  contrary  the  mixture  of  alcohol  in  any  form,  whether  as 
distilled  or  fermented  liquors,  directly  and  positively  adds  to  the  evil  by 
41 


642  DIAPHORESIS. 

still  furtlier  diminishing  the  oxygenation  and  decarbonization  of  the  blood. 
Indeed,  I  have  never  found  the  water  in  any  part  of  the  world  so  bad,  but 
that    the  addition  of  alcohol  would  make  it  worse  for  drinking    purposes. 

The  second  group  of  causes  to  which  I  have  alluded,  namely,  those  w^hich 
produce  excessive  exhalation  from  the  surface  by  causing  relaxation  or 
impairment  of  the  general  tonicity  of  the  tissues  are  chiefly  connected 
with,  or  dependent  upon,  previously  existing  diseases,  such  as  the  ex- 
treme impoverishment  of  the  tissues  in  the  progress  of  consumption, 
chronic  diarrhoea,  chronic  dysentery,  the  collapsing  stage  of  acute  gen- 
eral diseases,  and  of  choleraic  affections.  You  will  learn  as  you  watch  at 
the  bedside,  that  the  last  stages  of  almost  all  general  diseases  of  an  acute 
character,  and  of  those  local  aff"ections  that  cause  death  by  asthenia  or 
exhaustion,  that  the  patient  reaches  a  stage  before  actual  dissolution  in 
vphich  the  tissues  become  so  impaired  by  the  predominance  of  waste  over 
that  of  nutrition,  that  there  is  an  almost  constant  tendency  to  exces- 
sive exhalation  from  the  whole  cutaneous  surface,  usually  giving  it  a 
cold,  clammy  feeling,  at  the  same  time  it  is  bathed  with  an  exudation  of 
the  watery  element  of  the  blood  standing  in  drops  upon  the  surface. 
This  is  well  known  as  the  colliquative  or  cold  perspiration  that  beto- 
'kens  the  speedy  coming  of  death,  and  yet,  it  sometimes  exists  for  days 
before  the  final  cessation  of  life.  However,  in  many  of  these  cases  coinci- 
dently  with  the  relaxation  of  the  surface  and  excessive  exhalation,  the  free 
surface  of  the,  internal  mvicous  membrane  becomes  similarly  relaxed,  and 
a  colliquative  diarrhoea  goes  on  parri-passu  with  the  excessive  diaphoresis 
until  the  muscular  structures,  no  longer  controlled  by  the  involuntary  nerve 
force,  relax  as  indicated  by  the  failure  of  the  sphincters,  and'  the  appearance 
of  the  involuntary  discharges  that  precede  death.  How  far  the  serous 
diarrhoeas  that  take  place  in  young  children  so  generally,  especially  in  the 
more  densely  populated  districts  and  cities  during  the  highest  heat  of  every 
summer  and  the  more  severe,  attacks  of  cholera  morbus  are  dependent 
directly  upon  the  relaxing  influence  of  continuous  high  temperature,  is 
perhaps  difficult  to  determine.  That  it  is  this  influence  of  high  temper- 
ature continuing  day  and  night  for  a  succession  of  days,  that  exerts  a  very 
important  influence,  I  shall  have  occasion  to  demonstrate  to  you  by  an 
abundant  array  of  facts  when  I  come  to  consider  more  in  detail  these 
•diseases. 

The  third  group  of  causes  to  which  T  alluded  as  capable  of  producing 
excessive  diaphoresis,  were  those  which  operate  through  the  vasomotor  ner- 
vous system  chiefly,  if  not  exclusively.  That  there  are  agents  which  may 
thus  act  is  easily  demonstrated  by  watching  the  operation  of  certain  medi- 
cines. The  prompt  effect  of  pilocarpine  in  so  modifying  the  condition  of 
the  cutaneous  vessels  and  the  salivary  glands  as  to  cause  copious  exuda- 
tion of  fluid  from  both,  giving  free  diaphoresis  and  excessive  flow  of 
saliva,  and  the  almost  equally  prompt  manner  in  which  belladonna  and 
various  other  agents  are  capable  of  producing  exactly  the  reverse  effect, 
so  altering  the  cutaneous  capillaries  and  those  of  the  mucous  membrane 
and  glandular  structures  belonging  to  the  mouth,  as  to  arrest  transpiration 
from  the  one  and  secretion  from  the  other  almost  totally,  show  that  thee 
functions  are  capable  of  being  acted  upon  by  special  agents,  both  in  the 
direction  of  inducing  excessive  diaphoresis  on  the  one  hand,  and  of 
'almost  entirely  arresting  exhalations  on  the  other.  And  it  is  probable 
that  a  large  number  of  cases  are  met  with  in  practice,  characterized 
by  excessive  sweating,  whether  in  the  sweating  stage  of  periodical  fevers, 
■or  the  copious  sweats  of  hectic  fever,  or  the  almost  hourly  vacillations 
from  chilliness,  dryness  and  free  sweating  that  we  see  in  some  patients  in 


TREATMENT.  643 

particular  periods  of  life,  more  especially  in  the  female  during  transition 
from  the  continuance  of  the  menstrual  flow  to  that  of  their  final  cessa- 
tion, and  sometimes  for  a  year  following  its  final  discontinuance,  and 
of  some  others  that  might  be  named,  which  are  specimens  of  excessive  cuta- 
neous transpiration,  undoubtedly  directly  dependent  upon  modifications 
of  the  vasomotor  influence  over  the  cutaneous  vessels.  It  is  true,  that 
in  all  those  cases  which  occur  in  connection  with  general  fevers,  or  with 
hectic,  septictemic  or  pytemic  conditions,  the  treatment  must  be  prin- 
cipally that  which  is  necessary  and  proper  for  the  existing  disease  on 
which  the  cutaneous  transpiration  depends,  and  v?ith  which  it  is  con- 
nected as  an  incident.  You  will  meet  with  numerous  cases,  especially 
those  which  occur  in  connection  with  wasting  disease  of  the  hectic  type 
inducing  exhaustive  night  sweats,  as  well  as  those  less  important  but 
much  more  numerous,  occurring  at  the  period  of  change  of  life,  as  it  is 
termed,  in  which  you  will  find  it  necessary  to  prescribe  not  only  for  the 
general  condition,  but  for  the  purpose  of  directly  influencing  this  partic- 
ular symptom. 

In  all  cases,  attention  should  be  given  fully  and  carefully  to  the  condi- 
tion of  all  the  functions  of  the  patient,  and  in  directing  treatment,  such 
directions  should  be  given  as  are  calculated  to  correct  whatever  is  mani- 
festly out  of  order.  In  those  cases  which  occur  at  the  period  of  change  of 
life  in  females,  the  remedies  that  I  have  found  most  efficient  for  remov- 
ing the  cutaneous  relaxation  and  sweats,  which  so  inconvenience  many  of 
these  patients,  by  causing  alternate  chills  and  sweating  at  short  intervals, 
many  times  every  day,  are,  a  combination  in  the  form  of  pill  or  capsule,  of 
the  oxide  of  zinc,  ergotin,  and  extract  of  scutilaria,  in  the  proportion  of 
two  decigrams  ( gr.  iii )  of  the  oxide  of  zinc,  and  six  centigrams  (gr.  i) 
each,  of  the  ergotin  and  extract  of  scutilaria,  in  a  capsule;  one  of  which 
may  be  given  each  morning,  noon  and  night.  If  the  bowels  are  habitually 
inclined  to  be  costive,  as  is  often  the  case  in  these  patients,  the  ad- 
dition of  two  centigrams  (gr  ^)  of  pulverized  aloes  or  extract  of  col- 
ocynth  to  each  capsule,  will  usually  obviate  this  difficulty,  without  inter- 
fering with  the  beneficial  influence  of  the  other  constituents  in  any  de- 
gree. For  the  excessive  diaphoresis  usually  indicated  by  the  frequent 
'night  sweats  existing  in  connection  with  suppurative  conditi(jns  in  the 
lungs,  or  any  other  parts  of  the  body,  we  may  use  with  advantage  often- 
times three  classes  of  remedies,  namely:  those  which  are  calculated  to 
lessen  the  suppurative  process,  and  thereby  retard  the  progress  of  the 
primary  disease  and  its  consequences;  such  tonics  as  increase  the  general 
tonicity  of  the  tissues,  thereby  lessening  the  relaxation  of  the  surface;  and 
such  direct  vasomotor  tonics  as  increase  the  tone  of  the  vessels  of  the 
periphery,  and  more  directly  and  immediately  prevent  the  occurrence  of 
the  periodical  sweats.  Among  the  first  of  these  remedies  I  have  found 
none  more  efficient  than  a  combination  of  pure  glycerine  and  the  svrup 
of  iodide  of  iron  for  lessening  suppuration  in  the  advanced  stage  of 
phthisis,  with  profuse  night  sweats,  and  in  many  other  internal  suppura- 
tions. 

I  have  usually  mixed  these  constituents  in  the  proportion  of  four  parts 
of  pure  glycerine,  with  one  of  the  syrup  of  the  iodide  of  iron,  giving  to 
adults  from  two  to  four  cubic  centimeters  (fl.  3ss  to  3i)  of  the  mixture, 
largely  diluted  with  water,  from  three  to  four  times  in  the  twenty-four 
hours.  I  have  seen  many  cases  in  which  the  amount  of  pus  formed  was 
much  diminished  during  the  use  of  this  combination,  and  coincidently  the 
night  sweats  were  also  correspondingly  mitigated.  Another  combination, 
wliich   produces  a    similar    though    not    quite   as    active    an    effect   in 


644  SEEOUS    DIAEEHGEA,    ETC. 

these  suppurative  conditions,  is  that  of  sub-nitrate  of  bismuth,  sub- 
carbonate  of  iron,  and  minute  doses  of  morphine  or  codeine.  This  is 
particularly  applicable  to  the  suppurative  stag-e  of  tuberculosis,  after  the 
patient  has  become  exhausted  to  such  a  degree  as  to  induce  more  or  less 
irritability  of  the  stomach  and  diarrhoea  as  well  as  night  sweats.  But  for 
the  immediate  control  of  the  copious  sweats  of  all  forms  of  hectic  as  well  as 
many  of  the  more  important  toxic  conditions  that  are  accompanied  by 
profuse  perspiration,  I  have  found  no  remedies  that  were  equal  to  ergotin 
when  given  in  doses  of  two  decigrams  (gr.  iii)  three  times  a  day;  or  the 
extract  of  belladonna,  given  in  just  such  doses  as  the  patient  will  bear  with- 
out producing  uncomfortable  dryness  of  the  mouth  and  fauces,  or  impair- 
ment of  vision  by  dilatation  of  the  pupil  of  the  eye.  But  the  ergotin  has 
succeeded  in  my  hands  more  satisfactorily,  for  this  particular  purpose  than 
any  other  remedy  that  I  have  used.  It  is  unnecessary,  however,  to  con- 
sume your  time  by  further  details  in  regard  to  the  etiology  and  treatment 
of  excessive  fluxes  from  the  cutaneous  surface,  because  the  remarks  which 
I  have  already  made,  concerning  the  modus  operandi  by  which  remedies 
act  in  the  production  of  excessive  diaphoresis,  and  the  different  modes 
by  which  remedies  may  be  brought  to  bear,  either  as  tonics  upon  the 
general  system,  or  as  special  agents  for  improving  particular  functions, 
and  still  more  particularly  as  vasomotor  agents  in  acting  directly,  at  such 
times  as  we  may  use  them,  upon  the  condition  of  the  circulation  in  the 
periphery,  you  will  see  clearly  the  principle  on  which  you  can  act  in  any 
and  all  cases  that  may  come  before  you  for  consideration.  I  will  conse- 
quently leave  this  class  of  cases  and  next  direct  your  attention  to  the 
fluxes  from  the  free  surfaces  within,  or  more  particularly  from  the  mucous 
membrane  of  the  alimentary  canal,  considering  them  under  the  names  of 
serous  diarrhoea,  cholera  morbus,  including  the  cholera  morbus  of  chil- 
dren, which  is  more  generally  styled  cholera  infantum  and  epidemic 
cholera. 


LECTURE    LXI. 


Serous  Fluxes  from  ihe  Mucous  Membrane  of  the  Alimentary  Canal— Serous  Diarrhoea— Cholera 
Morbus,  and  Epidemic  Cholera;  their  General  History  and  Etiological  Relations. 

GENTLEMEN:  The  group  of  affections  included  under  the  heads  of 
serous  diarrhoea  or  "  summer  complaint " — and  cholera  morbus — pre- 
vail most  in  the  middle  part  of  the  temperate  zone.  In  this  country  that 
part  lying  between  the  31°  and  43°  parallels  of  latitude  and  east  of  the 
Rocky  Mountains,  gives  a  much  higher  ratio  of  their  prevalence,  than  the 
parts  further  north  or  south  or  on  the  Pacific  coast.  It  is  within  the  belt 
first  named  that  we  have  the  greatest  range  of  temperature,  the  difference 
between  the  coldest  days  of  winter  and  the  highest  heat  of  summer  being 
from  'ZA°  to  60°  C.  (75°  to  140°  F.)  with  an  average  high  range  of  sum- 
mer heat  for,  at  least,  two  consecutive  months.  It  is  in  the  large  cities 
and  more  densely  populated  towns  within  this  territory  that  the  intesti- 
nal affections  under  consideration  are  so  prevalent,  especially  among  young 
children  that  they  regularly'-  add  from  50  to  75  per  cent  to  the  gross  mortal- 
ity during  the  months  of  July,  August  and  September  of  each  year.     It  is 


ETIOLOGY  AND  PROPHYLAXIS.  645 

directly  upon  the  southern  border  of  this  same  belt  or  zone  of  the  earth's 
surface,  as  it  extends  through  the  southern  part  of  Europe  and  Asia  that 
epidemic  cholera  most  frequently  makes  its  appearance,  and  from  which 
it  has  apparently  spread  at  different  times  over  a  large  part  of  the  civil- 
ized w^orld.  Without  further  general  remarks  I  wish  to  limit  your  atten- 
tion during  the  remainder  of  the  present  hour,  to  the  causes  and  clinical 
history  of  serous  diarrhoea  and  cholera  morbus  as  they  occur  in  both  chil- 
dren and  adults.  In  doing  so  I  shall  make  use  of  the  same  facts  and 
much  of  the  same  language,  that  I  incorporated  in  a  brief  paper  on  the 
"efTiciont  causes"  of  these  affections,  read  to  the  Section  on  Diseases  of 
Children,  at  the  meeting  of  the  American  Medical  Association  in  June, 
1882. 

Etiology  and  Proiyhylaxis. — When  it  is  remembered  that  one  third  oi 
the  human  race  perish  before  they  reach  five  years  of  age,  and  that  a 
large  percentage  of  these  early  deaths  are  the  direct  result  of  attacks  of 
serous  diarrhoea  and  cholera  morbus  in  infancy,  it  will  be  conceded  that 
no  subject  is  more  worthy  of  careful  study  than  the  etiology  and  prophy- 
laxis of  these  affections.  I  mention  etiology  and  prophylaxis  together, 
because  all  measures  designed  to  prevent  diseases  must  be  intelligently 
adjusted  either  to  the  removal  of  the  efficient  causes  or  to  a  neutraliza- 
tion of  their  effects,  else  they  will  fail  to  accomplish  any  useful  purpose. 
Nearly  all  the  public  sanitary  and  hygienic  measures  which  characterize 
the  present  stage  of  civilization,  are  aimed  at  the  removal  or  prevention 
of  the  causes  of  disease,- both  predisposing  and  exciting.  But  there  are 
many  etiological  influences  of  great  potency  in  either  predisposing  to  or 
exciting  attacks  of  disease,  which  are  not  under  human  control.  The 
problem  presented  for  consideration  concerning  these,  is  not  how  to  pre- 
vent or  destroy  them,  but  how  best  to  shield  the  human  system  from 
their  injurious  effects.  For  instance,  bad  food  may  be  destroyed  and  that 
which  is  good  substituted  in  its  place;  bad  and  impure  air  in  dwellings 
may  be  displaced  by  ventilation;  soils  wet  and  impregnated  with  decom- 
posable vegetable  and  animal  matter  may  be  improved  by  drainage  and 
cultivation;  but  the  meteorological  conditions  of  the  atmosphere,  whether 
they  relate  to  impurities,  sudden  and  extreme  changes,  or  waves  of  con- 
tinuous high  or  low  temperature,  are  not  subject  to  our  control,  and 
yet  much  can  be  done  to  mitigate  or  prevent  their  injurious  effects. 
Nearly  all  the  recent  writers  on  practical  medicine  and  on  diseases  of 
children  class  the  cases  of  serous  diarrhoea  and  cholera  morbus  in  children 
under  two  years  of  age,  usually  called  "  summer  complaint  "  and  "  cholera 
infantum,"  with  the  local  inflammations  under  the  general  name  of  catar- 
rhal gastro-enteritis.  And  while  they  all  assert  that  these  forms  of  dis- 
ease are  most  prevalent  and  fatal  during  the  warmest  months  of  summer, 
they  set  forth  as  the  chief  causes  improper  feeding,  impure  and  changed 
milk,  impure  and  confined  air,  the  progress  of  dentition  or  "teeth- 
ing," and  overworked,  badly  fed,  and  unhealthy  mothers  and  nurses. 
All  these  causes  are  represented  as  producing  either  gastric  or  intes- 
tinal indigestion  or  both,  which  so  increases  the  irritation  of  the  mucous 
m3mbranes  as  to  cause  a  more  or  less  rapid  serous  exudation  into  the  gas- 
tric and  intestinal  canal  with  excessive  evacuations.  It  will  be  noted 
that  indigestion  is  very  generally  alleged  as  the  immediate  cause  of  the 
so-called  catarrhal  irritation  and  excessive  discharges;  while  the  indiges- 
tion is  in  turn  regarded  as  the  result  of  bad  feeding,  impure  air,  teething, 
and  unhealth}'  mothers  or  nurses.  Dr.  Flint  and  others  have  placed 
much  emphasis  on  the  influence  of  the  adulterated  and  poor  quality  of 
milk  distributed  in  our  laro;e  cities.     That  the  milk  so  distributed  is  often 


646  DIAEP.PICEA    AND    CHOLEEA    MOEBUS. 

of  poor  quality,  and  is  productive  of  gastric  and  intestinal  deranp;c- 
ments,  and  that  all  the  other  causes  enumerated  are  often  the  occasion  of 
similar  derangements,  I  freely  admit.  But  I  am  quite  certain  that  a 
more  careful  and  extended  clinical  study  will  show  that  none  of  the  causes 
usually  enumerated  really  exert  more  than  a  minor  influence  over  the 
production  of  the  so-called  summer  complaint  and  cholera  infantum  that 
prove  so  destructive  to  infantile  life  in  many  of  our  cities  and  populous 
towns  every  summer.  For  instance,  a  moderate  degree  of  attention  will 
show  that  the  errors  in  feeding  infants,  the  adulterations  of  milk  and  im- 
purities of  other  food,  and  the  unsanitary  condition  of  dwellings,  are  quite 
as  prevalent  in  all  communities  during  the  winter  as  the  summer.  It  is 
quite  certain  that  in  every  community  there  are,  on  the  average,  as  many 
children  cutting  their  teeth  in  December  and  January  as  in  July  and  Au- 
gust; and  I  have  been  wholly  unable  to  find  any  larger  proportion  of  un- 
healthy, badly  fed,  or  overworked  mothers  or  nurses  at  one  part  of  the 
year  than  another.  It  is  quite  certain  that  if  any  one  or  all  of  these  agen- 
cies exerted  a  prominent  or  controlling  influence  in  determining  attacks 
of  serous  diarrhoea  and  cholera  infantum,  such  attacks  would  be  niet  with 
frequently  at  all  seasons  of  the  year.  Yet,  both  the  records  of  the  com- 
mencement of  attacks  and  the  statistics  of  mortality  show  that  the  prev- 
alence of  all  grades  of  these  two  forms  of  disease  is  restricted  almost  en- 
tirely to  the  ninety  days  intervening  between  the  last  week  in  June  and 
the  last  in  September. 

Thus,  in  Chicago,  in  1877,  only  2  deaths  from  cholera  infantum  are 
reported  in  the  statistics  of  the  Health  Department  during  the  months  of 
November,  December,  January,  February  and  March;  8  in  April;  6  in 
May;  23  in  June;  246  in  July;  163  in  August;  69  in  September;  and  13 
in  October.  Again,  in  1875  and  1876,  I  obtained  the  date  of  the  com- 
mencement of  351  cases  of  serous  diarrhoea  and  cholera  infantum,  of 
which  61  commenced  in  June,  197  in  July,  66  in  August,  and  27  in  Sep- 
teinber,  and  none  during  the  remaining  months  of  those  years.  The 
ratio  of  prevalence  thus  found  to  exist  in  the  various  months  of  1875-6-7, 
in  Chicago,  will  be  found  to  fairly  represent  the  ratio  every  year,  and  in 
all  the  Northern  and  Eastern  cities  of  our  country.  If  we  turn  our  atten- 
tion in  another  direction,  we  will  be  met  by  still  greater  difficulties  in 
accounting  for  the  prevalence  of  these  bowel  affections  on  the  supposition 
that  they  are  produced  by  the  causes  to  which  they  have  usually  been 
attributed.  For  instance,  the  mortuary  statistics  show  that  the  diseases 
under  consideration  prevail  but  little  in  cities  so  located  that  there  is  only 
a  short  range  of  temperature  between  the  warmest  days  of  summer  and 
the  coldest  days  of  winter,  and  where,  from  sea  breezes  or  otherwise,  the 
summer  nights  are  cool. 

There  is  no  evidence  within  our  knowledge  which  shows  that  the  milk 
distributed  in  San  Francisco  and  New  Orleans  is  any  purer  or  of  better 
quality  than  in  Boston  and  Chicago.  Neither  are  the  nursing  mothers  any 
more  free  from  mental  and  physical  infirmities,  nor  the  sanitary  conditions 
of  the  dwellings,  sewers,  etc.,  more  perfect  in  the  two  former  than  in  the 
two  last-named  cities.  Yet  an  examination  of  the  mortality  statistics  of 
these  several  cities  shows  a  ratio  of  only  about  five  deaths  from  cholera 
infantum  annually  for  every  10,000  inhabitants  in  San  Francisco,  and  7 
in  New  Orleans,  while  Boston  gives  about  25  and  Chicago  30  deaths 
from  the  same  disease  for  every  10,000  of  their  inhabitants.  The  fore- 
going facts  show  conclusively  that  there  must  be  some  efficient  cause  or 
causes  which  determine  the  prevalence  and  fatality  of  the  diseases  under 
consideration  that  are  not  common  to  all  large  cities  and  all  aggregations 
of  civilized  people. 


ETIOLOGY.  647 

Their  prevalence  at  certain  seasons  of  the  year  only,  and  chiefly  in  cer- 
tain climatic  regions,  shows  conclusively  that  they  are  dependent  on 
causes  which  are  operative  under  some  circumstances  not  common  to  all 
civilized  communities. 

To  determine  what  these  circumstances  are,  I  commenced,  many  years 
since,  to  keep  a  record  of  the  date  of  beginning  of  all  attacks  of  serous 
diarrhoea  and  cholera  infantum  coming  under  my  observation,  in  connec- 
tion with  the  coincident  meteorological  conditions  of  the  atmosphere,  and 
for  three  years  coincident  records  of  a  similar  character  were  kept  by 
active  practitioners  in  Cairo,  Illinois;  Davenport,  Iowa;  and  Omaha, 
Nebraska.  Reports  giving  the  results  of  these  investigations  were  made 
in  the  Medical  Section  of  the  American  Medical  Association,  and  pub- 
lished in  the  Transactions  for  1875,  1877  and  1879,  to  which  I  must  refer 
you  for  details.  Those  investigations  were  sufficient  to  establish  the  fol- 
lowing important  conclusions: 

First. — That  the  prevalence  of  the  affections  under  consideration  is 
limited  principally  to  the  months  of  July,  August  and  September,  com- 
mencing with  the  first  wave  of  high  atmospheric  heat  that  continues  day 
and  night  for  more  than  five  days,  which  in  the  latitude  and  altitude  of 
Chicago  is  sometimes  the  last  week  in  June,  but  more  frequently  the 
first  week  in  July,  and  continuing  more  or  less  during  the  succeeding 
ninety  days. 

Second. — That  while  the  number  of  deaths  from  these  affections  in 
any  city  or  given  community  Vv'ill  be  nearly  the  same  in  the  two  first 
months  after  they  begin — that  is,  Julj'  and  August — the  date  of  the 
initial  symptoms,  or  beginning  of  the  disease  in  three  fourths  of  all 
the  cases  will  be  in  July,  very  few  originating  after  the  first  of  August. 
Many  cases  that  commence  in  July,  and  partially  recover,  are  found  to 
relapse  or  become  worse  during  certain  waves  of  high  temperature  in 
August;  and  a  large  percentage  of  those  attacked  in  July  continue  wast- 
ing with  the  disease  until  relieved  by  death  throughout  the  months  of 
August  and  September. 

Third. — That  it  is  not  simply  high  or  extreme  heat  of  temporary  dura- 
tion, such  as  that  of  a  single  da^-  or  of  any  number  of  days  with  cool 
nights,  which  favors  the  development  of  serous  diarrhoea  and  cholera  infan- 
tum, but  continuous  high  temperature  day  and  night  through  several  days 
in  succession. 

And  if,  in  addition  to  the  high  heat,  the  air  be  stagnant,  as  from  lack  of 
winds,  or  from  obstructions,  as  in  large  and  compactly  built  cities,  or 
from  defective  ventilation  of  dwellings,  the  morbific  effects  are  greatly  in- 
creased. This  explains  why  these  affections  are  more  numerous  and  fatal 
in  cities  than  in  rural  districts,  and  why  they  prevail  so  little  in  large 
cities  located  in  warm  climates,  provided  the  location  be  such  as  to  afford 
cool  breezes  at  night,  as  is  the  case  in  San  Francisco  and  New  Orleans, 
already  alluded  to. 

Fourth. — That  while  the  great  majority  of  attacks  which  occur  in  any 
given  summer  are  found  to  have  their  beginning  in  July,  or  during  the 
first  thirty  or  forty  days  after  the  first  wave  of  protracted  high  tempera- 
ture for  the  season,  they  are  not  equally  distributed  over  the  whole  of  the 
month,  but  are  almost  all  traceable  to  a  limited  number  of  days  and 
nights  coincident  with  the  waves  or  periods  of  continuous  high  tempera- 
ture. From  observations  extending  over  twenty  years  in  Chicago  and 
three  years  in  Cairo,  Davenport,  and  Omaha,  I  have  found  that  the  special 
waves  or  periods  of  high  temperature  day  and  night  vary  in  duration 
from  three  to  fourteen  days.     When  they  do   not    extend    beyond    three 


648  DIARRHCEA    AND    CHOLERA    MORBUS. 

days,  the  effect  on  the  number  of  attacks  of  serous  diarrhoe  i  and  cliolera 
infantum  is  slight.  In  Chicago,  many  summers  have  passed  without  a 
single  period  of  continuous  high  heat  of  more  than  three  or  four  days' 
duration,  and  such  have  uniformly  been  accompanied  by  a  low  ratio  of 
infant  mortality  from  bowel  affections.  In  a  majority  of  the  seasons, 
however,  there  have  been  found  three  of  those  periods  of  continuous  high 
temperature  between  the  25th  of  June  and  the  31st  of  July,  each  from 
five  to  seven  days  in  duration.  And  the  attacks  of  serous  diarrhoea  and 
cholera  infantum  have  increased  so  rapidly  that  the  number  of  deaths 
from  these  alone  has  caused  the  aggregate  mortality  of  July  to  be  more 
than  double  that  of  June.  Much  more  rarely  a  season  has  occurred  in 
which  one  of  these  periods  of  continuous  heat  day  and  night  has  com- 
menced during  the  last  week  in  June  or  first  week  in  July,  and  continued 
with  but  little  variation  for  two  or  three  weeks.  Such  seasons  have  uni- 
formly been  characterized  either  by  a  prevalance  of  epidemic  cholera  or 
an  extraordinary  mortality  from  the  serous  fluxes  in  children. 

Having  thus  traced  the  origin  of  that  part  of  infantile  mortality  caused 
by  the  affections  just  named  to  the  coincidence  of  continuous  high  atmos- 
pheric heat  with  a  minimum  of  atmospheric  currents,  let  us  inquire,  for 
a  moment,  how  this  combination  of  circumstances  can  affect  the  living 
human  body. 

First. — You  have  the  physical  law  that  the  higher  the  temperature  of 
the  air  the  rarer  it  becomes,  and  the  less  oxygen  is  contained  in  each 
cubic  inch.  Consequently  an  individual  breathing  a  given  number  of 
times  per  minute,  and  a  given  number  of  cubic  inches  of  air  at  27°  C  (81° 
F.)  would  receive  into  the  air  cells  of  his  lungs  much  less  oxygen  per  hour 
than  one  breathing  the  same  number  of  times  and  the  same  number  of 
cubic  inches  of  air  at  18°  C.  (65°  F.) 

Again,  a  still  or  stagnant  atmosphere,  whether  from  the  absence  of 
winds  or  currents  without,  or  of  ventilation  within,  becomes  more  rapidly 
exhausted  of  its  oxygen  and  impregnated  with  impurities  from  the 
breathing  of  living  beings  than  one  actively  changed  by  currents  and  free 
ventilation. 

Second. — The  physical  law  of  expansion  by  increase  of  temperature 
applies  to  living  as  well  as  to  dead  matter.  Consequently  continuous  high 
heat,  acting  on  the  living  human  body,  tends  to  increase  the  distance  of 
the  atoms  or  molecules  from  each  other,  and  thereby  lessen  the  force  of 
vital  affinity  or  general  tonicity  of  the  tissues,  while  it  increases  the  ex- 
citability or  susceptibility  to  impressions. 

Third. — The  capacity  of  the  blood  for  taking  up  oxygen  or  holding  it 
in  suspension,  depends  much  on  the  proportion  of  saline  elements  it  con- 
tains, and  under  a  continuous  high  temperature  the  increase  of  cutaneous 
exhalation  rapidly  diminishes  the  free  salts  of  the  blood,  especially  the 
chloride  of  sodium,  and  thereby  directly  lessens  its  capacitv  to  receive  the 
oxygen  from  the  air-cells  of  the  lungs  in  exchange  for  its  carbonic  acid 
gas.  It  is  hardly  necessary  to  add,  that  on  the  degree  of  oxygenation  and 
decarbonization  of  the  blood  depends  the  sensibility  and  natural  action 
of  the  vasomotor  and  all  other  portions  of  the  nervous  structure  of  the 
body.  Here,  then,  you  have  in  these  waves  or  periods  of  high  summer 
heat  the  coincidence  of  less  oxygen  to  the  cubic  inch  of  inspired  air;  less 
capacity  of  the  blood  to  take  up  and  hold  it  in  solution;  less  general  tonic- 
ity of  the  textures  of  the  body,  with  increased  excitability  of  the  mucous 
membranes  and  cutaneous  surfaces  from  the  direct  stimulus  of  external 
heat.  The  two  first  of  these  conditions,  by  lessening  the  oxygenation  and 
decarbonization    of  the   blood,   directly   diminishes   the  influence   of  the 


PATHOLOGY.  649 

vasomotor  nerves  over  the  tone  of  the  vessels  of  the  morbidly  excitable 
mucous  surfaces  of  the  alimentary  canal,  and  thereby  favors  serous  exuda- 
tion instead  of  either  natural  secretion  or  absorption.  Thus,  Vjy  first  es- 
tablishing the  coincident  conditions  under  which  serous  diarrhoeas  and 
cholera  infantum  actually  occur,  and,  second,  by  analyzing  these  condi- 
tions by  the  application  of  known  laws  of  physics  and  physiology,  you  are 
enabled  to  see  clearly  the  exact  pathological  conditions  induced — namely, 
a  morbidly  sensitive  condition  of  the  mucous  membrane  of  the  alimentary 
canal,  in  conjunction  with  such  a  diminution  of  general  tonicity  and 
special  impairment  of  vasomotor  nerve  influence  as  to  impair  the  natural 
secretory  actions,  and  directly  establish  more  or  less  exudation  of  the  se- 
rous elements  of  the  blood.  In  a  large  proportion  of  these  cases  the  re- 
sulting serous  exudation  is  only  sufficient  to  render  the  natural  evacuations 
thinner  and  more  abundant,  constituting  the  mildest  form  of  "  summer 
complaint."  From  this  you  have  all  grades  of  severity  up  to  an  entire 
suspension  of  secretory  action,  and  so  rapid  an  exudation  as  to  cause 
the  copious  vomiting  and  purging  of  an  active  cholera  morbus;  so  copious 
indeed,  sometimes,  as  to  exhaust  the  water  and  salts  of  the  blood,  and  in- 
duce fatal  collapse  in  a  few  hours.  The  essential  pathologncal  conditions 
are,  general  impairment  of  tonicity  of  the  tissues  with  deficient  oxygena- 
tion of  the  blood,  and  special  impairment  of  the  vasomotor  nervous  in- 
fluence over  the  vessels  of  the  mucous  membranes  of  the  stomach  and  in- 
testines. The  exudation  constituting  the  discharges  results  from  these 
pathological  conditions  and  has  no  necessary  connection  with  any  grade 
of  inflammation,  catarrhal  or  otherwise.  Inflammation  of  portions  of  the 
mucous  membrane  often  supervenes  as  a  complication  during  the  progress 
of  protracted  cases. 

But  iiio-colitis  and  recto-colitis  or  dysentery  seldom  occur  until  later 
in  the  season,  when  warm  days  are  followed  by  cool  nights,  and  frequent 
changes  to  wet  and  cold.  And  even  the  indigestion  which  has  been  so 
generally  suggested  as  a  cause  of  "  summer  complaint  "  is  itself  the  result 
of  the  impairment  of  natural  gastric  and  intestinal  secretions  and  the  in- 
crease of  mere  serous  exudation;  the  primary  fault  not  being  so  much  in 
the  quality  and  quantity  of  the  food,  as  in  the  morbidly  sensitive  and 
relaxed  condition  of  the  whole  inner  surface  of  the  digestive  canal.  The 
reasons  why  the  children  under  two  years  are  aff"ected  so  much  more  severely 
than  older  persons,  are,  the  less  mature  development  and  greater  sensi- 
tiveness of  their  gastric  and  intestinal  mucous  membranes  and  glandular 
structures,  and  their  much  more  constant  confinement  indoors. 

If  the  foregoing  views  are  correct,  they  indicate  clearly  that  our  efi'orts 
to  lessen  infant  mortality  from  serous  diarrhoea  and  cholera  morbus  must 
embrace  such  measures  as  will  secure  for  young  children  a  better  supply 
of  fresh,  pure  air  for  increasing  the  oxygenation  and  decarbonization  of  the 
blood  and  maintaining  the  activity  of  the  vasomotor  nervous  system,  and 
as  will  counteract  the  efi'ects  of  high  temperature  by  increasii  g  the  general 
tonicity  and  lessening  the  excitability  of  the  tissues  generally.  Measures 
for  the  first  object  must  consist  in  securing  better  ventilation  of  dwell- 
ings, and  especially  of  nurseries  and  sleeping-rooms  during  the  warmest 
part  of  the  summer;  the  sending  of  young  children,  with  their  mothers 
and  nurses,  from  cities  and  densely  populated  districts,  to  moderately  ele- 
vated healthy  locations,  or  to  floating  hospitals  or  receiving  ships  on  large 
bodies  of  water  during  the  special  periods  of  continuous  high  temperature. 
For  accomplishing  the  second  purpose,  I  know  of  no  measures  that  are  so 
efficient,  and,  at  the  same  time,  within  the  i-each  of  the  poorest  part  of  the 
population,  as  the  judicious  use  of  the  sponge  bath.     Whenever  the  hu- 


650  DIAKEHCEA    AND    CHOLERA     MOEBUS. 

man  system  is  relaxed,  and  rendered  morbidly  sensitive  by  oontinuous 
high  heat,  causing  the  infant  to  be  languid,  restless,  and  sometimes  pale, 
a  free  bathing  or  sponging  of  the  whole  surface  with  water  simply,  as 
cool  as  is  comfortable,  alvv<iys  produces  a  refreshing  and  invigorating  in- 
fluence, which  continues  from  six  to  twelve  hours.  Consequently,  if 
mothers  and  nurses  could  be  so  instructed  by  their  family  physician  that 
during  every  wave  or  period  of  high  atmospheric  temperature,  in  which 
tiie  mercury  did  not  fall  below  21°  C.  (7(3°  F.)  during  the  nights,  they 
regularly  gave  each  child  under  two  years  of  age  a  full  sponge  bath  in 
the  evening  as  well  as  in  the  morning,  and  kept  their  sleeping-rooms  as 
well  ventilated  as  possible,  it  would  diminish  the  number  of  attacks  of 
serous  diarrhoea  and  cholera  infantum  one  half,  and  consequently  very 
greatly  lessen  the  infant  mortality  from  these  affections. 

It  is  well  known  to  every  careful  observer,  that  a  large  majority  of  all 
the  attacks  of  this  form  of  disease  show  their  first  beginning  during  the 
last  half  of  the  night  or  early  in  the  morning,  owing  to  the  long  continu- 
ance of  the  high  temperature,  coupled  with  the  more  still  and  confined 
air  of  the  night.  The  increased  tone  of  the  whole  vascular  system  pro- 
duced by  the  stimulant  and  tonic  effect  of  a  comfortably  cool  sponge  bath 
on  the  function  of  the  vasomotor  nerves,  applied  in  the  evening,  would 
enable  thousands  of  these  little,  restless  sufferers  to  pass  the  whole  night 
unharmed,  when  without  it  the  dreaded  sickness  would  begin. 

Symptoms  or  Clinical  History. — Both  for  convenience  and  accuracy 
of  description,  I  shall  divide  the  intestinal  summer  complaints  or  fluxes  of 
both  children  and  adults  into  three  groups.  In  the  first  group  I  shall  em- 
brace those  cases  in  which  the  patient  is  suddenly  attacked  with  copious 
vomiting  and  purging  of  serous  fluid,  which,  after  the  first  two  or  three 
evacuations  becomes  very  thin,  sometimes  tinged  yellow  or  green  from  the 
presence  of  the  coloring  matter  of  bile,  and  in  other  cases  hardly  staining 
the  napkin. 

Under  the  depleting  influence  of  these  evacuations  the  countenance 
becomes  pale,  the  eyes  sunken,  the  pulse  small  and  frequent,  the  extrem- 
ities cold  and  shrunken,  the  urine  scanty  or  entirely  suppressed,  and  the 
mind  dull  or  inactive,  with  brief  spells  of  great  restlessness.  In  the  more 
severe  attacks  these  results  follow  so  rapidly  that  fatal  collapse  is  reached 
in  from  six  to  twenty-four  hours. 

In  most  cases,  however,  after  the  first  eight  or  ten  hours  the  discharges 
become  less  frequent  anJ  copious,  the  vomiting  being  limited  to  the  re- 
jection of  drinks,  whenever  too  much  is  allowed  to  accumulate  in  the 
stomach;  and  the  passages  from  the  bowels  to  from  one  to  four  or  five  in 
the  twenty-four  hours.  As  very  little  nourishment  is  either  retained  or 
assimilated,  the  patients  continue  to  emaciate,  and  if  not  relieved  hy 
app:opriate  treatment,  will  usually  reach  the  stage  of  fatal  exhaustion 
in  from  one  to  three  weeks.  In  the  advanced  stage  of  some  of  the  cases 
there  occurs  a  constant  wakefulness  or  morbid  vigilance,  with  rolling  of 
the  head,  tossing  of  the  hands,  and  frequent  moaning. 

Such  symptoms  are  apt  to  induce  the  parents  and  nurses  to  think  that 
the  disease  has  "gone  to  the  head."  And  I  have  known  several  cases 
presenting  these  symptoms,  in  which  the  attending  physician  had  made 
cold  applications  to  the  head,  blisters  behind  the  ears;  and  in  three  cases, 
even  leeches  and  a  cathartic  of  calomel  were  resorted  to  under  the  im- 
pression that  the  symptoms  indicated  the  supervention  of  inflammation  in 
the  brain  or  its  membranes.  It  is  hardly  necessary  for  me  to  remind  you 
that  the  symptoms  mentioned  were  the  result  of  cerebral  ansemia  or  defi- 
cient supply  of  blood  to  the  brain  instead  of  inflammatory  action. 


i 
SYMPTOMS.  G51 

Excessive  losses  of  blood  will  often  produce  much  discomfort  in  the 
head,  accompanied  by  wakefulness,  frequent  turning  of  the  head  from  side 
to  side,  and  sometimes  delirium.  This  anaemic  condition  of  the  brain, 
from  whatever  cause,  may  be  distinguished  from  inflammation  or  active 
hyueraemia  by  noting  the  size  of  the  pupils  of  the  eyes,  the  tension  of  the 
carotid  arteries,  and  in  infants  the  condition  of  the  anterior  fontanelle. 
All  grades  of  cerebral  inflammation  are  accompanied  at  first  by  contrac- 
tion of  the  pupils,  fullness  and  hardness  of  the  carotids,  and  convexity  or 
bulging  of  the  f Jiitanelle;  and  it  is  not  until  the  inflammation  has  termi- 
nated in  effusion  sufficient  to  cause  compression  that  the  pupils  become 
dilated.  But  you  must  remember  that  the  same  amount  of  effusion  which 
would  produce  compression  and  dilatation  of  the  pupil,  wouhl  also  pro- 
duce stupor  or  coma  and  still  more  fullness  of  the  fontanelle;  while  in 
the  anaeuiic  condition  of  the  brain,  the  dilated  pupils  and  staring  expres- 
sion of  the  countenance  are  accompanied  by  sleeplessness  instead  of 
stupor  by  softness  of  the  carotids,  and  by  a  sunken  or  concave  fontanelle. 

A  large  proportion  of  the  cases  I  have  included  in  this  first  group,  after 
presenting  the  active  symptoms  of  cholera  morbus  for  the  first  few  hours, 
instead  of  proceeding  to  a  dangerous  or  fatal  degree  of  exhaustion,  un- 
dergo a  different  change.  The  vomiting  ceases  and  the  intestinal  dis- 
charges become  less  frequent,  smaller  in  quantity,  contain  some  mucus  and 
are  sometimes  streaked  with  blood.  At  the  same  time  more  or  less  febrile 
reaction  comes  on,  causing  the  skin  to  become  dry  and  warmer  than 
natural,  especially  over  the  trunk  of  the  body  and  in  the  palms  of  the 
hands;  the  pulse  to  be  more  full  and  frequent;  and  indications  of  abdom- 
inal pains  just  before  and  during  the  evacuations. 

These  are  cases  in  which  the  rapid  exudation  from  the  ilio-colic  mem- 
brane furnishing  the  material  so  actively  vomited  and  purged  during  the 
first  stage,  so  far  detaches  the  epithelial  layer  as  to  favor  true  inflamma- 
tory congestion  before  the  stage  of  extreme  or  fatal  exhaustion,  which 
converts  them  into  cases  of  true  ilio-colitis  with  secondary  fever,  as  I  point- 
ed out  to  you  when  speaking  of  the  various  grades  of  inflammation  in 
the  alimentary  canal. 

Tn  the  second  group  of  cases  I  include  all  th  se  that  commence  with 
mere  thin  or  serous  evacuations  from  the  bowels,  with  little  or  no  pain  or 
vomiting,  and  without  pyrexia;  and  this  embraces  much  the  larger  num- 
ber of  all  the  bowel  affections  that  occur  during  the  summer  months. 
The  intestinal  evacuations  in  the  cases  belonging  to  this  group  vary  much 
in  frequency,  color,  and  consistence. 

In  some  cases  they  are  from  the  beginning  so  thin  and  colorless  as 
to  look  like  turbid  water  in  the  vessel,  and  to  leave  hardly  a  stain  on  the 
napkin  in  young  children.  Yet  the  quantity  voided  is  so  large  as  to  pros- 
trate the  patient  very  rapidly,  causing  the  skin  to  become  blanched  and 
cool,  the  eyes  sunken,  the  pulse  small  and  weak,  with  all  the  indications 
of  approaching  collapse  within  a  few  days.  In  many  of  these  cases  the 
discharges  after  continuing  long  enough  to  induce  a  decided  deficiency 
in  the  watery  and  saline  constituents  of  the  blood,  and  much  general 
weakness,  become  smaller  in  quantity,  less  frequent,  and  mixed  with 
some  mucus.  At  the  same  time  slight  febrile  symptoms  supervene,  caus- 
ing increased  heat  in  the  abdomen,  and  if  the  patient  be  a  child,  it  be- 
comes more  fretful  and  peevish.  The  intestinal  discharges  in  different 
cases  vary  much  in  color,  being  in  some  cases  green,  in  others  pale  yellow, 
and  in  stdl  others  a  little  turbid  like  rice  water.  They  vary  also  much 
in  consistency  and  odor,  being  in  some  cases  thin  as  water  and  nearly 
odorless,  and  in  others  only  semi-fluid,  frothy,  and  extremely  offensive.     In 


652  CHOLERA  MORBUS. 

most  casos  some  of  the  food  or  drink  taken  by  the  patient  can  be  identi- 
fied in  the  evacuations,  together  with  numerous  epithelial  cells  from  the 
surface  of  the  raucous  membrane. 

The  urine  is  generally  scanty  in  proportion  to  the  copiousness  of  the 
intestinal  evacuations.  In  many  cases  if  the  disease  is  not  interfered 
with  by  treatment,  the  patients  continue  steadily  to  lose  flesh  until  the 
emaciation  is  as  complete  as  in  the  last  stage  of  pulmonary  tuberculosis,  and 
death  supervenes  from  simple  asthenia  or  inanition,  at  periods  varying 
from  one  to  three  months  from  the  commencement  of  the  attack.  In 
nearly  all  the  adults  and  in  a  large  proportion  of  the  children,  however, 
after  the  disease  has  continued  from  one  to  four  weeks,  the  discharges  be- 
gin to  improve  both  in  number  and  quality,  digestion  and  nutrition  be- 
come more  active,  and  in  a  few  weeks  the  patients  regain  a  fair  degree  of 
health.  In  a  small  proportion  of  cases,  especially  of  young  children,  the 
recovery  is  only  partial. 

The  stomach  and  duodenum  apparently  regain  their  natural  condition; 
the  child  takes  food  well,  and  appears  cheerful,  but  the  intestinal  dis- 
charges continue  more  frequent  than  natural,  are  semi-fluid  or  frothy, 
light  yellow  or  grayish  color,  and  usually  very  offensive. 

They,  also,  often  contain  curds  of  milk  or  coagulated  casein  and  par- 
ticles of  other  undigested  food.  The  urine,  though  generally  less  than 
natural,  often  contains  an  excess  of  the  phosphates  and  lithates,  which  af- 
ford an  abundant  white  or  milky  looking  deposit  when  the  urine  stands 
until  cold.  With  the  foregoing  symptoms  the  patient  may  continue  sev- 
eral months,  with  a  good  appetite  and  an  abundance  of  nourishment,  and 
yet  he  loses  flesh  or  becomes  more  emaciated  everyday.  But  the  abdo- 
men gradually  increases  in  size,  partly  from  flatulency  and  partly  from 
hypertrophjr  of  the  mesenteric  glands,  until  its  prominence  makes  a 
strong  contrast  with  the  emaciated  extremities.  The  cases  that  assumed 
this  form  were  formerly  called  cases  of  tabes-mesenterica  or  marasmus, 
and  sometimes  continued  one  or  two  years  before  ending  in  death  or  re- 
covery. 

The  third  group  of  cases  generally  included  under  the  head  of  "  sum- 
mer complaint"  or  intestinal  flux,  are  distinguished  from  the  two  preced- 
ing groups  by  the  presence  of  distinct  febrile  action  at  the  beginning  of 
the  attack.  With  the  first  occurrence  of  vomiting  or  purging,  or  both, 
the  skin  is  warmer  and  dryer  than  natural,  the  lips  are  parched,  the  pulse  in- 
creased in  frequency,  and  the  patient  more  fretful  with  indications  of  more 
or  less  griping  pains  in  the  abdomen.  If  vomiting  exists  it  is  generally  a 
retching  or  straining  to  vomit,  with  only  a  slight  discharge  of  thin  mucus, 
sometimes  colorless  but  frequently  tinged  yellow  or  green  from  the 
coloring  matter  of  bile.  Of  course  much  of  whatever  food  or  drink  is 
taken  is  directly  ejected  by  vomiting.  The  intestinal  evacuations  are 
generally  small  in  quantity  containing  some  mucus,  frequent,  and  imme- 
diately preceded  or  accompanied  by  indications  of  griping  pains  in  some 
parts  of  the  abdomen.  You  will  not  fail  to  recognize  these  symptoms  as 
indicating  an  inflammatory  condition  of  the  intestinal  mucous  membrane, 
identical  with  what  I  have  already  described  under  the  class  of  local  in- 
flammations. When  the  disease  is  limited  to  the  ilium  and  upper  part  of 
the  colon,  the  discharges  are  usually  thin  or  serous  with  some  inter- 
mixture of  mucus,  and  of  a  green  or  yellow  color.  When  the  lining  of 
the  lower  part  of  the  colon  and  rectum  is  the  part  chiefly  aff"ected,  the 
evacuations  are  small,  mucous,  sometimes  mixed  with  blood  and  accom- 
panied by  tenesmus  or  straining.  But  the  symptoms,  progress,  prognosis 
and    treatment    of    this    class    of    cases  I  have    already    fully  discussed 


ANATOMICAL    CHANGES.  653 

in  the  lectura  on  ilio-colitis,  etc.,  and  only  give  this  hrief  description 
again  because  they  are  so  frequently  met  with  in  the  latter  part  of  the 
summer  and  early  part  of  autumn  intermingled  with  the  true  serous 
intestinal  fluxes  and  not  always  differentiated  from  them. 

Anatomical  Changes. — The  visible  structural  changes  found  on  the 
post-mortem  examination  of  those  who  have  died  during  the  progress  of 
gastro-intestinal  fluxes  will  vary  much  in  accordance  with  the  duration  of 
the  disease  before  the  fatal  termination. 

When  death  has  taken  place  from  collapse  during  the  active  stage 
of  copious  sjrous  discharges,  the  mucous  membrane  is  found  extensively 
denuded  of  its  epithelial  layer,  with  here  and  there  patches  of  redness 
which  more  resemble  ecchymosis  than  inflammatory  changes,  and  in  some 
parts  a  degree  of  softening  of  the  texture  is  easily  recognized. 

When  death  has  resulted  from  asthenia  after  several  weeks  of  exhausting 
discharges  without  febrile  action,  the  mucous  membrane  of  the  intestines, 
like  the  other  tissues  of  the  body,  is  paler  and  more  attenuated  than  natural 
with  many  superficial  abrasions,  more  particularly  throughout  the  ilium  and 
colon.  In  the  case  of  a  child  eighteen  months  old  who  died  in  the  thi».-d 
month  of  a  wasting  serous  diarrhoea  which  had  commenced  early  in  July, 
I  found  on  making  a  careful  post-mortem  examination,  in  addition  to  the 
generally  pale  and  shrunken  condition  of  the  tissues  a  remarkably  atten- 
uated and  bloodless  condition  of  the  whole  alimentary  canal,  including  the 
mucous  membrane,  which  was  carefully  examined  throughout  its  whole  ex- 
tent. Only  slight  abrasions  were  found  in  portions  of  the  membrane  lining 
the  ilium  and  colon.  Many  of  the  mesenteric  glands  were  moderately  en- 
larged. 

When  death  has  taken  place  at  any  time  after  the  occurrence  of  the 
febrile  reaction  and  the  change  in  the  discharges  to  a  more  mucous  char- 
acter, as  I  have  already  described,  the  post-mortem  examination  will  re- 
veal more  distinct  inflammatory  changes  in  different  parts  of  the  intestinal 
mucous  lining. 

Prognosis. — In  adults  and  in  children  over  five  years  of  age  attacks 
of  serous  diarrhoea  and  cholera  morbus  rarely  terminate  fatally.  Oc- 
casionally, however,  cases  occur  in  the  vigorous  period  of  adult  life  in 
which  the  copiousness  of  the  discharges,  both  from  the  stomach  and 
bowels,  is  such  as  to  produce  all  the  phenomena  attributed  to  well  marked 
cases  of  epidemic  cholera,  ending  in  profound  collapse  and  death  in  less 
than  forty-eight  hours.  But  they  are  rare  exceptions  to  the  general  rule 
of  recovery.  In  infants  or  children  under  three  years  of  age  the  results 
are  widely  different,  the  mortality  being  so  great  as  to  add  more  than  fifty 
per  cent,  to  the  gross  mortality  of  the  months  of  July,  August  and  Sep- 
tember, in  all  the  large  cities  and  populous  towns  in  the  middle  and  north- 
ern part  of  the  United  States.  But  the  prevalence  of  the  disease  is  limited 
mostly  to  the  months  just  named,  and  the  mortality  to  children  under  three 
years  of  age. 


65i  SEEOUS    DIAKRHG2A. 


LECTURE    LXII. 


Serous  Diarrhoea  and  Cholera  Morbus,  continued— Then*  Pathology  and  Treatment, 

GENTLEMEN:  In  the  preceding  lecture  I  directed  your  attention  to 
the  general  history  and  etiology  of  the  diarrhoeal  affections,  more 
frequently  called  "  Summer  Complaints,"  which  constitute  so  important 
a  part  of  the  sickness  of  every  summer,  especially  in  young  children. 
From  a  careful  review  of  the  causes  set  forth  as  most  efficient  in  deter- 
mining the  prevalence  of  this  class  of  diseases  and  their  modus  operandi^ 
as  then  explained,  you  have  probably  already  inferred  the  most  important 
items  of  their  pathology.  In  that  lecture  I  endeavored  to  show  that  all 
the  causes  and  circumstances  which  favored  the  production  of  serous  diar- 
rhoea and  cholera  morbus,  whether  in  children  or  adults,  co-operated  to 
produce  an  increase  of  the  susceptibility  or  irritability  of  the  mucous 
membrane  of  the  alimentary  canal,  and  at  the  same  time  to  diminish  the 
vital  affinity,  and  consequently  the  tonicity  of  the  whole  vascular  system. 

This  morbid  excitability,  coupled  with  impaired  tonicity  of  the  mucous 
membrane,  constitutes  the  primary  pathological  condition  in  all  the  first 
and  second  groups  of  cases  mentioned  in  the  preceding  lecture.  The 
morbid  excitability  of  the  membrane  invites  a  rapid  influx  of  blood  into 
it,  while  the  diminished  vital  affinity  and  consequent  relaxation  of  texture 
admit  of  equally  rapid  effusion  or  exudation  of  the  serum  or  watery  ele- 
ments of  the  blood,  thus  furnishing  the  material  for  the  copious  and  thin 
discharges.  The  rapid  diminution  of  the  watery  element  of  the  blood, 
carrying  with  it  more  or  less  of  the  saline  constituents,  in  such  discharges, 
speedily  diminishes  also  all  the  glandular  secretions  such  as  urine,  bile, 
gastric  and  salivary  juices,  etc.,  and  retards  the  molecular  changes  in  all 
the  tissues  which  involves  both  diminution  of  temperature  and  notable 
shrinking  of  the  whole  body.  The  morbid  sensibility  of  the  nervous  fila- 
ments involved  in  the  mucous  membrane,  acted  upon  by  the  effused  fluid, 
calls  into  action  a  reflex  influence  upon  the  muscular  coat,  thereby  increas- 
ing the  peristaltic  motion  and  the  frequency  of  the  evacuitions. 

Such  are  the  pathological  conditions  which  constitute  the  active  stage 
of  the  affections  now  under  consideration.  These  morbid  conditions  can 
not  exist  long,  however,  without  inducing  other  pathological  changes  of 
equal  importance.  For  instance,  the  rapid  exhaustion  of  the  water  and  salts 
of  the  blood  from  a  continuance  of  the  discharges,  soon  renders  that  fluid 
too  viscid  to  circulate  freely  through  the  capillary  system  or  vessels,  while 
the  copious  exudation  carries  with  it  a  large  amount  of  the  epithelial  cells 
of  that  membrane. 

If  the  vomiting  persists  to  such  an  extent  as  to  prevent  the  retention  of 
drinks  long  enough  to  afford  any  replenishment  of  the  water  in  the  blood, 
there  will  be  danger  of  an  entire  suspension  of  the  capillary  circulation 
and  a  speedily  fatal  collapse.  In  a  very  large  majority  of  the  cases,  how- 
ever, the  increased  viscidity  of  the  blood  so  alters  its  relations  to  the 
capillary  vessels  of  the  mucous  membrane  as  to  stop  the  effusive  or  serous 
exudation  spontaneously,  before  the  stage  of  collapse  is  reached.  .  When 
the  discharges  thus  cease  before  collapse  ensued,  rest  and  a  careful  replen- 
ishment of  the  blood  by  liquid  nourishment  soon  establishes  natural 
molecular  and  secretory  actions,  and  health  is  restored  in  a  large  propor- 
tion of  cases.     But  in  a  smaller  number  of  cases,  it  happens  that  when  the 


TEEATMENT.  655 

discharges  have  ceased,  and  a  healthy  reaction  has  taken  place  in  the  tis- 
sues generally,  there  remain  patches  of  the  mucous  membrane  from  which 
the  epithelium  has  been  detached  so  completely  as  to  materially  impede 
the  capillary  circulation  in  them. 

In  other  words,  to  cause  passive  congestion  first  and  subsequently  a  low 
gride  of  inflammatory  action  accompanied  by  moderate  febrile  reaction, 
which  may  continue  from  one  to  three  or  four  weeks. 

If  the  congested  and  inflamed  patches  are  located  chiefly  in  the  mem- 
brane lining  the  ilium,  the  general  symptoms  will  strongly  resemble  those 
of  enteric  or  typhoid  fever;  if  in  the  colon,  both  thj  intestinal  discharges 
md  the  grade  of  fever  will  more  closely  resemble  those  of  dysentery,  as 
'described  when  giving  the  clinical  progress  of  the  different  groups  of 
cases  yesterday.  But  the  mucous  membrane  is  not  the  only  structure  in 
which  the  capillaries  miy  fail  to  resume  their  functions  when  the  active 
discharges  have  ceased,  and  the  stige  of  reaction  his  come.  When  the 
attack  of  cholera  morbus  has  been  severe,  and  the  amount  of  serous  dis- 
charge by  vomiting  and  diarrhoea  so  great  as  to  Jproduce  a  very  marked 
deficiency  of  water  in  the  blood,  the  latter  may  become  so  altered  in  rela- 
tion to  the  capillaries  of  the  brain,  that  the  circulation  becomes  too  feeble 
to  sustain  the  function  of  the  cerebral  hemisphere.  In  such  cases,  though 
the  intestinal  discharges  may  cease,  the  circulation  and  warmth  be  restored 
in  the  extremities,  and  a  general  appearance  of  healthy  reaction  be  estab- 
lished, yet  the  patients  pass  into  a  state  of  partial  or  complete  coma  from 
which  the}''  seldom  recover. 

Another,  and  p3rhap3  more  frequent  local  failure  in  the  resumption  of 
capillary  and  molecular  actions,  is  in  the  kidneys.  In  the  preceding  lect- 
ure I  stated  that  one  of  the  early  effects  of  copious  serous  or  thin  dis- 
charges from  the  lining  of  the  alimentary  canal,  was  a  partial  or  complete 
suppression  of  urine.  Clinical  observations  show  that  such  suppression 
of  urine  continues  after  a  fair  re-establishment  of  natural  action  through- 
out the  rest  of  the  system,  in  some  cases.  The  consequence  is  that  symp- 
toms of  urc'emic  poisoning  soon  supervene.  Such  are  the  chief  pathological 
conditions  presented  in  the  development  and  progress  of  the  first  and  second 
groups  of  cases  described  in  the  preceding  lecture. 

The  mildest  class  of  cases  of  simple  looseness  of  the  bowels  or  slight 
"summer  complaint"  present  only  the  two  primary  morbid  conditions 
consisting  of  increased  susceptibility  and  diminished  tonicity  sufficient  to 
cause  a  moderate  excess  of  serous  exudation  into  the  intestinal  canal. 
But  the  protracted  continuance  of  even  this  moderate  drain  may  produce 
any  or  all  of  the  subsequent  pathological  conditions  I  have  described,  as 
fully  as  the  more  severe  and  rapidly  exhausting  attacks  of  cholera  morbus 
or  cholera  infantum. 

Treatment. — What  I  have  said  in  regard  to  the  pathology  of  the  impor- 
tant class  of  diseases  under  consideration,  points  directly  to  the  following 
plain  indications  for  fulfillment  in  their  therapeutic  management: 

a.  To  allay  the  morbid  sensitiveness  or  irritability  of  the  mucous  mem- 
brane of  the  alimentary  canal. 

h.  To  restore  the  general  tonicity  of  the  tissues  and  of  the  vaso-motor 
nervous  system. 

c.  To  properly  regulate  the  diet,  drinks  and  general  hygienic  surround- 
ings of  the  patient. 

To  fulfill  the  first  two  indications  named  you  need  the  combined  influ- 
ence of  an  anodyne  and  tonic;  the  first  to  allay  the  morbid  sensitiveness, 
the  second  to  increase  the  general  tonicity  of  the  tissues.  \x\  the  early 
stage    of    mild   cases,    characterized  by  mere   thinning    of  the  intestinal 


656  SEROUS    DIARRHCEA. 

discharges  and  a  feeling  of  lassitude  with  a  little  paleness,  I  have  Ions 
been  in  the  habit  of  using  small  doses  of  some  preparation  of  opi^in  it 
combination  with  a  mineral  acid,  as  in  the  following  formula: 


Acidi  Sulphurici  Aromatici 

10 

c.  c. 

3iiss 

Tincturse  Opii 

10 

(( 

3iiss 

Syrupi  Simplicis 

15 

u 

3iv 

Aqu£e 

60 

u 

!ii 

Mix.  Of  this,  four  cubic  centimeters  (fl.  3i)  may  be  given  to  an  adult 
in  a  little  sweetened  water,  two,  three  or  four  times  a  day,  according  tc 
the  effect  desired.  To  an  infant  from  eight  to  sixteen  months  old  the 
dose  should  not  be  more  than  from  six  to  ten  minims  at  the  same  intervals 
of  time.  Or  the  following,  which  is  milder  and  perhaps  preferable  foi 
young  children: 

]J      Acidi  Hydrobromici  30    c.  c.       |i 

Elixer  Simplicis  30       "         §i 

Tincturae  Opii  Camphoratae        30       "  §i 

Mix.  This  may  be  given  in  the  same  doses  both  to  adults  and  children 
as  directed  of  the  preceding  formula,  and  diluted  also  with  water  when 
given. 

If  in  addition  to  the  moderate  diarrhoea,  the  more  important  secretions 
are  checked  as  shown  by  the  absence  of  the  coloring  matter  of  bile  from 
the  intestinal  discharges,  and  the  scanty  amount  of  urine,  one  of  the  fol- 
lowing powders  may  be  given  each  morning  and  evening  in  addition  tc 
one  of  the  liquid  prescriptions: 


Hydrargyri  Ohloridi  Mitis 

0.30  grams 

gr.  iii 

Sodii  Bicarbonatis 

OAO      » 

gr.  vi 

Sacchari  Albi 

2.00      « 

gr.  XXX 

Mix.  For  an  adult  divide  into  four  powders,  and  for  a  child  twelve 
months  old,  divide  into  twelve  or  fifteen  powders.  The  use  of  these 
should  be  discontinued  as  soon  as  the  intestinal  evacuations  become  yel- 
low or  green  from  the  presence  of  bile. 

In  young  children,  when  the  disease  has  already  continued  in  a  mild 
form  for  one  or  two  weeks,  and  the  discharges  give  an  offensive  or  sour 
smell  and  contain  undigested  casein  or  curds  of  milk,  or  items  of  other 
nourishment,  the  anodyne  and  acid  formula  may  give  place  to  the  fol- 
lowing: 

5.     Acidi  Carbolici  0.20  grams  gr.  iii 

Glycerins©  10.00    c.  c.  3iiss 

Tincturae  Opii  Camphoratae  30.00       "  f  i 

Aquae  Cinnamomi  45.00       "  |iss 

Mix.  To  children  from  eight  to  sixteen  months  old,  from  ten  to  twelve 
minims  may  be  given  in  half  a  teaspoon ful  of  sweetened  water  every 
four,  six  or  eight  hours  according  to  the  frequency  and  quantity  of  the 
discharges. 

In  nearly  all  the  mild  cases  the  judicious  use  of  some  one  of  the  fore- 
going formulae,  with  a  proper  regulation  of  the  nourishment  and  the  daily 


TREATMENT.  657 

access  to  fresh,  pure  air,  will  be  sufficient  to  speedily  restore  the  patients 
to  health.  But  when  the  attacks  are  more  severe,  constituting  what  I 
described  in  the  precedino-  lecture  as  cholera  morbus  or  cholera  infan- 
tum, and  the  matter  vomited  yields  a  sour  odor,  I  order  a  solution  of 
bicarbonate  of  sodium  four  grams  (3i),  and  sulphate  of  morphia  six  centi- 
grams (gr.  i)  in  sixty  cubic  centimeters  (3ii)  of  water;  of  which  I  give 
from  six  to  fifteen  minims,  according  to  the  age  of  the  child,  immediately 
after  each  paroxysm  of  vomiting.  At  the  same  time,  if  the  discharges 
from  the  bowels  are  frequent  and  very  thin  like  water,  I  give  one  of  the 
following  powders  every  three  or  four  hours  until  they  are  diminished: 

i^      Hydragyri  Chloridi  Mitis  0.20  grams  gr.  iii 

Plumbi  Acetatis  0.30      "  gr.  iii 

Pulveris  Opii  0.06      "  gr.  i 

Sacchari  Albi  2.00      "  gr.  xxx 

Mix.  For  a  child  aged  six  months,  divide  into  twelve  powders;  twelve 
months  eight  powders;  eighteen  months  six  powders. 

The  rule  to  give  whatever  medicine  is  designed  for  the  direct  suppres- 
sion of  vomiting  in  small  doses  iinmediately  after  each  paroxysm  of  vom- 
iting is  one  of  unich  practical  importance.  Vomiting  is  an  act  that  can 
not  be  performed  continuously,  but  must  always  occur  in  paroxysm,  with 
an  interval  of  greater  or  less  length  between  them.  Therefore,  if  you 
give  a  dose  of  medicine  immediately  after  a  paroxysm  of  vomiting,  it  will 
remain  in  contact  with  the  lining  membrane  of  the  stomach  a  few  minutes, 
at  least,  before  another  effort  to  vomit  can  be  made.  During  these  few 
minutes,  if  the  medicine  is  soluble,  or  already  in  solution,  it  will  make 
some  impression  both  on  the  nervous  filaments  and  on  the  capillaries  of 
the  mucous  membrane;  and  a  prompt  repetition  of  the  dose  after  each 
paroxysm  of  vomiting  will  soon  accumulate  an  effect  sufficient  to  destroy 
the  morbid  sensibility  and  thereby  stop  the  vomiting.  But  if  you  follow 
the  wishes  of  the  patient  and  the  inclination  of  almost  all  nurses,  by  waiting 
for  the  former  to  "  rest  a  little,"  or  for  the  stomach  to  get  "  settled,"  that  lit- 
tle period  of  rest  will  be  sufficient  for  the  muscular  coat  of  the  stomach  to 
have  regained  its  contractility,  and  the  mucous  membrane  to  have  poured 
out  a  new  supply  of  serous  fluid,  and  consequently  the  patient  is  ready 
for  another  paroxysm  of  vomiting.  Now  if  you  administer  the  dose 
of  medicine  it  is  almost  certain  to  be  rejected  as  soon  as  it  is  swallowed, 
and  you  gain  no  influence  over  the  morbid  conditions.  The  same  rule  is 
important  in  reference  to  the  use  of  enemas  for  aiding  in  the  suppression 
of  diarrhoea  or  dysentery.  They  should  be  administered,  as  soon  after  an 
evacuation  as  possible,  for  the  longer  they  are  delayed  the  more  will  the 
mucus  or  serum  and  other  contents  of  the  bowels  have  accumulated  in  the 
rectum  and  the  more  readdy  will  the  introduction  of  an  eneina  be  followed 
immediately  by  its  expulsion.  These  details  are  given  you,  because  suc- 
cess in  the  treatment  of  the  more  active  gastric  and  intestinal  affections 
of  a  choleraic  nature,  depends  quite  as  much  on  the  time  and  manner  of 
administering  the  medicine,  as  upon  the  kind  of  medicine  used. 

Some  cases,  both  of  serous  diarrhoea  and  cholera  morbus  are  met  with 
every  summer,  in  which  the  discharges,  instead  of  being  sour  and  destitute 
of  the  coloring  matter  of  bile,  are  bitter  and  highly  colored  with  the  latter 
jGluid,  thereby  showing  a  superabundance  instead  of  deficiency  of  the  biliary 
secretion.  In  such  cases,  instead  of  giving  alkalies  or  alkaline  salts  and 
mercurials,  all  of  which  increase  more  or  less  the  glandular  secretions,  I 
resort  directly  to  small  and  frequently  repeated  doses    of  anodynes    and 

42 


658  SEEOUS  DIARRHCEA  AND  CHOLERA  MORBUS. 

astrino-ents,  of  which  the  combination  of  acetate  of  morphia  and  acetate  of 
lead  are  the  most  efficient,  or  more  frequently  to  the  following  anodyne 
and  antiseptic  formula: 

]^     Acidi  Carbolici  0.20  grams  gr,  iii 

Glyeerinae  15.00  c.  c.  3iv 

Tincturge  Opii  Camphoratge  30.00  c.  c.  31 

AqutB  Cinnamomi  45.00  c.  c.  §iss 

Mix.  Give  to  children  between  six  and  eighteen  months  old  from'  ten 
to  twenty  minims  every  one  or  two  hours  in  active  serous  diarrhoea,  and 
after  every  paroxysm  of  vomiting  in  the  active  stage  of  cholera  infantum. 

You  must  keep  constantly  in  mind  the  important  clinical  fact,  that  in 
all  cases  of  copious  intestinal  evacuations,  the  urine  is  liable  to  become 
scanty,  and  that  the  suppression  of  such  evacuations  by  opium  and  astrin- 
gents often  leaves  the  secretory  action  of  the  kidneys  very  defective  and 
sometimes  entirely  suppressed.  This  result  can  be  very  generally  avoid- 
ed by  giving  the  following  prescription  in  doses  suited  to  the  age  of  the 
patient: 


Spiritus  Etheris  Nitrosi 

15.00      0.  c. 

3iv 

Tincturas  Digitalis 

4.00      0.  0. 

3i 

Syrupi  Simplicis 

15.00      c.  c. 

3iv 

AquEe 

60.00      c.  c. 

!i.i 

Potassii  Acetatis 

12.00  grams 

3iii 

Mix.  To  an  adult  four  cubic  centimeters  (fl.  3i),  and  to  a  child  twelve 
months  old  ten  or  fifteen  minims  may  be  given  every  two,  three  or  four 
hours,  according  to  the  effect  desired. 

In  some  of  the  more  active  cases  of  summer  diarrhoea  and  cholera  mor- 
bus, after  the  first  stage  has  passed,  the  vomiting  ceased,  and  the  intesti- 
nal discharges  reduced  to  one  in  from  two  to  four  hours,  a  low  grade  of 
febrile  action  is  set  up  causing  dryness  of  the  mouth,  much  thirst,  restless- 
ness, considerable  griping  pains  before  each  evacuation,  and  more  or  less 
mucus  mixed  with  the  thin  fsei-es;  thus  bringing  them  fairly  within  what 
I  described  yesterday  as  the  third  or  more  inflammatory  group  of  in'o.ti- 
nal  affections.  In  nearly  all  of  such  cases  the  following  emulsion  will  be 
found  one  of  the  most  efficient  that  can  be  used: 


5.      Olii  Terebinthinse 

8.00  c.  c. 

3ij 

Olii  Gaultherjge 

2.00  c.  c. 

3ss 

Tincturfe  Opii 

8.00  c.  c. 

3ij 

Mucilaginis  Acacias 

15.00  grams 

3iv 

Sacchari  Albi 

15.00  grams 

3iv 

Rub  together  thoroughly  and 

add: 

Aquae 

90.00  c.  c. 

fill 

Mix.  Direct  the  nurse  to  shake  the  vial,  and  give  to  children  between 
eight  and  eighteen  months  old  from  eight  to  twelve  minims,  every  three, 
four  or  six  hours,  according  to  the  frequency  of  the  discharges,  until  the 
latter  become  consistent  and  natural. 

When  cases  of  serous  diarrhoea  or  summer  complaint  have  become 
chronic  and  accompanied  by  much  emaciation,  with  coolness  of  the  sur- 
face and  extremities,  the    intestinal  discharges  continuing   thin    and    too 


TEEATMENT.  659 

irequent,  but  without  dysenteric  straining  or  any  notable  intermixture  of 
mucus,  the  remedies  should  contain  some  element  of  a  more  tonic  charac- 
ter. 

In  such  cases  I  have  often  directed  the  following  formula,  with  much 
bemfit  to  the  infantile  class  of  patients: 

^      Phloridzinse  2.00  grams  gr.  xxx 

Spiritus   Ammonii  Aromatic!     4.00  c.  c.  3i 

Tincturae  Opii  Camphoratae      30.00  c.  c.  |i 

Syrupi  Simplicis  15.00  c.  c.  §ss 

Aquae  45.00  c.  c.  f  iss 

Mix.  To  children  under  two  years  of  age  give  from  ten  to  twenty 
minims  three  or  four  times  a  day.  The  phloridzine  is  derived  from  the 
bark  of  apple-tree  root,  and  is  a  mild  tonic  not  unpleasant  to  the  taste 
and  agreeable  to  the  stomach,  while  the  camphorated  tincture  of  opium 
supplies  the  necessary  anodyne  influence.  Another  formula  which  I  have 
occasionally  used  in  the  same  class  of  cases  is  as  follows: 

jj      Erigerontis  Canadensis  15.000   grams       Z'w 
Quiniae  Tannatis  1.300  grams       gr.  xx 

Morphias  Sulphatis  0.066  grams       gr.  i 

Mix.  Pour  on  the  whole,  half  a  liter  or  one  pint  of  boiling  water  to 
make  an  infusion.  When  it  is  cold  you  can  give  to  a  child  one  year  old 
four  cubic  centimeters  or  one  teaspoonful,  to  which  a  little  sugar  may 
be  added,  every  three,  four  or  six  hours.  This  combination  has  the  ad- 
vantage of  being  moderately  diuretic  and  tonic  while  it  is  efficiently 
anodyne  and  astringent.  In  some  very  protracted  cases,  accompanied  by 
an  anaemic  condition  of  the  blood,  I  have  seen  very  good  results  obtained 
by  giving  suitable  doses  of  the  liquor  ferri  nitratis,  morning,  noon  and  tea- 
time,  and  one  of  the  following  powders  at  bed-time: 

]^      Quiniae  Tannatis  0.200  grams  gr.  iii 

Pulveris  Opii  0.065  grams  gr.  i 

Hydrargyri  cum  Cretae  0.200  grams  gr.  iii 

Sacchari  Albi  1.500  grams  gr.  xx 

Mix.     Make  into  six  powders. 

In  the  treatment  of  this  important  class  of  bowel  affections  I  have  thus 
'given  you  an  unusual  number  of  prescriptions  or  combinations,  not  for 
the  purpose  of  encouraging  either  polyphamary  or  over  medication,  but 
rather  for  the  purpose  of  enabling  you  to  select  from  the  variety  some 
one  calculated  to  meet  the  indications  in  each  individual  case  ; 
and  at  the  same  time  to  illustrate  the  value  of  combining  agents  to  meet 
more  perfectly  the  coincident  indications  presented  in  different  stages  of  the 
progress  of  the  same  case.  The  maxim  that  a  thorough  knowledge  of  the 
nature  and  capabilities  of  a  few  remedies  is  better  for  the  practitioner  than 
an  imperfect  knowledge  of  many,  is  doubtless  true.  But  it  is  equally  true 
that  a  thorough  knowledge  of  many  remedies,  even  of  the  same  class,  is 
much  better  than  such  knowledge  of  only  a  few.  For  nothing  is  more 
certain  than  that  every  active  practitioner  who  relies  on  treating  almost 
all  cases  of  disease  with  some  one  of  half  a  dozen  remedies  with 'which  he 
has  become  clinically  familiar  will  every  now  and  then  find  himself  cor- 
nered at  the  bed-side,  or  at  the  end  of  his  therapeutic  resources,  by  some 


660  SEROUS  DIAREHCEA  AND  CHOLERA  MORBUS. 

unusual  feature  of  the  disease  or  idiosyncracy  of  the  patient.  And  this  will 
happen  in  tlie  management  of  no  class  of  diseases  more  frequently  than  in 
those  classed  as  bowel  affections  of  children. 

Thus  far  I  have  said  little  or  nothing  in  regard  to  the  nourishment  for 
this  class  of  patients,  and  yet  it  is  a  matter  of  the  highest  importance.  In 
all  cases  occurring  in  infancy,  if  the  child  can  have  good  breast  milk, 
either  from  the  mother  or  a  healthy  wet  nurse,  it  is  preferable  to  any  or 
all  other  articles  that  have  been  devised. 

But  if  artificial  food  must  be  provided  for  these  little  sufferers,  I  am 
satisfied  from  many  years  of  observation  that  there  is  nothing  better 
than  good,  fresh  cow's  milk,  to  which  may  be  added  lime  water,  in  the 
proportion  of  four  parts  of  the  milk  to  one  of  the  lime  water.  If  this 
combination  is  sweetened  a  little,  either  with  white  sugar  or  sugar  of 
milk,  it  will  possess  as  near  the  properties  of  the  mother's  milk  as  anything 
that  can  be  used.  One  of  the  most  common  errors  in  the  feeding  of  very 
young  children  consists  in  diluting  the  milk,  or  whatever  else  may  be 
used,  too  much.  Nothing  is  more  common  than  to  give  infants,  under 
six  or  eight  months  old,  simple  bread  or  cracker  water,  or  a  mixture  of 
one  part  of  cow's  milk  with  two  or  three  parts  of  water,  slightly  sweet- 
ened with  sugar.  Of  course  the  more  nourishment  is  diluted  with  water 
the  larger  must  be  the  quantity  taken  to  afford  a  given  amount  of  material 
capable  of  being  converted  into  elements  for  the  growth  and  repair  of  the 
tissues  of  the  body.  And  I  have  seen  many  an  infant  worrying  day  and 
night  from  the  combined  sensations  of  hunger  and  colic,  while  its  stomach 
and  bowels  were  filled  to  repletion  with  hread-tea^  toast  water  or  a  mixt- 
ure of  one  part  of  milk  with  three  of  water.  The  correct  rule  for  our 
guidance  in  selecting  food  for  j^oung  children,  especially  when  they  are 
suffering  from  morbid  sensitiveness  of  the  mucous  membrane  of  the 
alimentary  canal,  is  to  get  as  much  of  tho  elements  capable  of  being  con- 
verted into  nutritious  material  as  possible  into  a  small  compass  or  bulk, 
and  yet  have  it  bland  and  easy  of  absorption  by  the  vessels  of  the  stom- 
ach. There  is  no  substance  that  fulfills  these  requirements  better  than  a 
thin,  well  boiled  gruel  of  pure  sweet  milk  and  wheat  flour. 

One  teaspoonful  of  such  gruel  contains  more  material  capable  of  be- 
ing converted  into  flesh  and  blood  than  two  tablespoonsful  of  a  mixture 
of  one  part  milk  and  three  parts  of  water  and  is  far  more  likely  to  be  re- 
tained and  absorbed  by  the  stomach. 

Another  object  of  great  importance  in  the  management  of  the  class  of 
diseases  now  under  consideration,  especially  as  they  affect  young  children, 
is  to  obtain  for  them  access  to  fresh  and  pure  air.  Their  confinement  in 
small,  overheated  and  badly  ventilated  rooms  is  one  of  the  most  efficient 
causes  of  their  sickness  and  mortality. 

Consequently,  so  far  as  possible,  all  chronic  cases  should  be  removed  to 
hilly  and  healthy  districts  of  country,  or  to  boats  or  ships  floating  on  large 
bodies  of  water.  When  neither  of  these  is  practicable  a  short  ride  in  an 
open  carriage  or  buggy,  every  day,  and  the  maintenance  of  thorough  ven- 
tilation and  cleanliness  in  the  rooms  they  occupy,  will  constitute  the  best 
substitute. 


EPIDEMIC    CHOLEEA.  661 


LECTURE    LXIIL 


Epidemic  Cholera— Its  History,  Causes,  Symptoms,  Pathological  Changes,  Diagnosis,  Progii  sis 
and  Treatment. 

GENTLEMEN:  The  subject  which  will  occupy  our  attention  the 
present  hour  is  one  of  much  interest,  and  on  which  volumes  have 
been  written,  both  in  this  country  and  Europe.  I  allude  to  epidemic 
cliolera,  which  has  also  received  the  names  of  cholera  asphyxia,  cholera 
algida,  spasmodic,  malignant,  Asiatic,  and  Indian  cholera. 

I  prefer  to  call  the  disease  epidemic  cholera,  simply  because  it  serves 
to  distinguish  it  from  common  sporadic  or  endemic  cholera  morbus,  with- 
out implying  any  theory  of  either  its  nature  or  origin. 

History. — Some  descriptions  in  the  writings  of  Areteus  have  been  sup- 
posed to  apply  to  this  disease,  and  Professor  Martin  Hoag  has  claimed  to 
have  found  some  distinct  references  to  it  in  the  ancient  Sanscrit  writings; 
but  the  earliest  reliable  accounts  we  have  of  its  prevalence  are  by  D'Orta, 
in  15G3,  at  Goa,  and  during  the  seventeenth  century  by  Bontius  of  Ba- 
tavia,  and  Willis,  Morton  and  others  in  England.  In  1733,  Morgagni  in 
Italy,  and  in  1736,  Degner  in  the  Netherlands,  described  the  prevalence 
of  epidemics  having  much  resemblance,  at  least,  to  the  genuine  epidemic 
cholera.  In  1781-2,  the  disease  prevailed  and  proved  very  fatal  in  Cal- 
cutta, Madras,  and  Ceylon.  The  first  great  migratory  epidemic  of  which 
we  have  any  account,  commenced  at  jassore,  in  August,  1817,  and  soon 
after  at  Calcutta.  During  the  next  five  years  its  ravages  were  extended 
to  almost  every  populous  town  in  China,  the  south  of  Asia,  the  East  In- 
dia Islands,  and  as  far  westward  as  the  eastern  border  of  the  Mediterra- 
nean sea.  In  1831  it  made  its  appearance  in  Europe,  and  prevailed  destruc- 
tively in  many  of  the  more  populous  districts  and  cities,  from  Archangel, 
in  64°  north  latitude,  to  the  borders  of  the  Mediterranean  south,  before 
the  end  of  the  year.  The  following  year  it  became  almost  equally  preva- 
lent for  the  first  time  on  this  continent. 

It  was  first  recognized  in  Quebec  on  the  8th  of  June,  1832.  A  few  days 
later  it  was  also  prevailing  in  Montreal,  New  York  and  Albany,  and  before 
the  end  of  the  summer  months  't  had  manifested  its  destructive  presence 
in  the  principal  cities  of  twelve  States,  extending  from  Boston  to  New 
Orleans.  During  the  two  following  years  it  visited  prominent  places  in 
Mexico,  the  West  India  Islands,  and  from  1834  to  1837,  it  again  severely 
scourged  nearly  all  the  countries  in  the  South  of  Europe  and  in  Central 
America.  During  the  next  decade  nothing  was  seen  or  heard  of  its  prev- 
alence in  any  part  of  Europe  or  America.  In  1847,  however,  it  severely 
attacked  a  Russian  army  west  of  the  Caucasus,  and  during  the  year  1848  it 
revisited  almost  every  country  in  Europe.  Late  in  the  autumn  of  that  year 
the  disease  developed  on  board  of  two  emigrant  ships  in  mid-ocean,  the 
one  sixteen  and  the  other  twenty-seven  days  out  from  Havre.  They  were 
nearly  one  thousand  miles  apa-t  at  the  time  the  disease  appeared  on 
board,  the  one  being  bound  for  the  port  of  New  York,  the  other  that  of 
New  Orleans.  In  the  latter  city  the  disease  developed  into  a  very  se- 
vere and  fatal  epidemic  aln:iost  immediately  after  the  arrival  of  the  vessel 
in  the  month  of  December.  But  it  showed  no  signs  of  prevalence  in  the 
city  of  New  York  until  the  latter  part  of  April,  1849,  and  did  not  reach 
decided  epidemic    prevalence    until    the    latter   part   of  June,  July  and 


662  EPIDEMIC    CHOLERA. 

August.  During  these  months,  however,  it  prevailed  more  or  less  in 
nearly  all  the  more  populous  cities  and  in  many  of  the  country  districts 
throughout  the  United  States  and  Canada.  From  1849  to  1854,  the  disease 
reappeared  each  summer  in  many  of  our  cities,  more  especially  those 
on  the  great  interior  lakes  and  in  the  lower  part  of  the  valley  of  the 
Mississippi;  but  in  the  summer  of  the  last  named  year  it  became  more 
generally  prevalent  and  was  more  fatal. 

During  the  years  1854  and  1855,  it  revisited  many  parts  of  Europe,  after 
which  it  disappeared  from  the  countries  on  both  sides  of  the  Atlantic  until 
1865,  when  it  again  became  prevalent,  first  in  Egypt  and  Arabia,  and 
later  in  several  places  in  Europe.  During  the  follovving  year,  18G6,  the 
disease  visited  the  more  prominent  places  in  the  southern  and  central  parts 
of  Europe  and  reappeared  also  in  many  cities  in  this  country.  In  1867-8, 
its  chief  prevalence  was  in  Central  and  South  America,  and  in  some  of 
the  West  India  Islands.  During  the  summers  of  1871-2,  it  was 
again  quite  prevalent  in  Europe;  and  in  the  summer  of  1873  it  manifested 
a  remarkable  prevalence  in  some  of  the  cities  and  purely  agricultural  dis- 
tricts in  the  States  of  Tennessee,  Kentucky,  Ohio,  Indiana,  and  Illinois. 
During  this  and  the  following  year  the  disease  was  also  prevalent  in  some 
parts  of  South  America,  more  especially  in  Buenos  Ayres,  where  it  proved 
very  fatal.  Since  that  date,  1874,  the  disease  has  prevailed  in  variable  de- 
grees of  severity  in  some  parts  of  India,  or  the  south  of  Asia,  almost  every 
year;  and  during  the  past  summer,  1883,  it  has  manifested  an  extraordi- 
nary prevalence  in  Egypt,  but  has  not  noticeably  prevailed  in  any  part  of 
Europe  or  America.  From  this  very  brief  historical  sketch,  you  will  see 
that  thus  far  during  the  century,  there  have  been  three  extraordinary 
periods  of  epidemic  prevalence  of  the  cholera  in  Europe  and  America. 
The  first  commenced  in  1831  and  continued  until  1837;  the  second  ex- 
tended from  1847  to  1855;  and  the  third  from  1855  to  1874.  A  less  no- 
ticeable period  of  epidemic  prevalence  commenced  in  1817  and  continued 
until  1822,  but  was  confined  mostly  to  Asia  and  the  countries  and  islands 
east  of  the  Mediterranean.  Confining  our  attention  to  this  country  and 
Europe,  it  would  appear  that  durijig  this  century,  the  epidemic  periods  of 
cholera  prevalence  have  varied  from  five  to  nine  years,  while  the  interval 
or  period  of  exemption  has  not  varied  much  from  ten  years.  If  this  gen- 
eral rule  is  to  continue,  we  may  expect  the  commencement  of  another 
epidemic  period  for  Europe  and  America  next  summer,  or  at  the  longest, 
the  summer  following.  Both  in  regard  to  the  number  of  persons  attacked 
and  the  ratio  of  mortnlity  during  the  prevalence  of  an  epidemic,  the 
cholera  must  rank  among  the  most  severe  scourges  of  the  human  race. 
Like  all  the  more  important  acute  non-contagious  diseases  capable  of 
periods  of  wide-spread  epidemic  prevalence,  the  epidemic  cholera  appears 
to  have  a  permanent  habUat,  or  natural  home,  where  it  is  more  or  less  prev- 
alent every  year.  This  home  is  in  India,  where  it  is  as  much  an  endemic 
as  the  yellow  fever  is  in  the  West  Indies. 

Causes  of  Epidemic  Cholera. — All  the  causes  or  influences  that  I 
enumerated  in  the  two  preceding  lectures,  as  favoring  the  production  of 
attacks  of  serous  diarrhoea  and  cholera  morbus,  also  act  as  predisposing 
influences  favoring  the  prevalence  of  epidemic  cholera.  The  chief  of 
these  influences  are  continuous  high  temperature,  still,  or  stagnant  and 
damp  air,  with  such  atmospheric  impurities  as  arise  from  badly  ventilatod 
rooms,  and  from  the  presence  of  the  products  of  decomposing  organic 
matter  either  in  the  soil  or  water,  or  both. 

That  local  conditions  pertaining  to  organic  impurities  in  the  soil,  water 
and  atmosphere,  have  an  important  causative  influence  in  the   production 


ETIOLOGY.  663 

and  spread  of  epidemic  cholera,  is  clearly  apparent  from  the  facts  ac- 
companying* every  epidemic.  A  detail  of  these  facts  would  occupy  too 
much  of  your  time  in  the  lecture  room,  consequently  I  will  refer  only  to 
some  of  tlie  more  prominent,  which  may  guide  you  in  studying  them  fur- 
ther at  vour  convenience.  First,  the  disease  has  never,  in  this  country 
at  least,  been  known  to  prevail  as  an  epidemic  in  elevated  country  dis- 
tricts, presenting  primitive  geological  strata,  with  uneven  surfaces,  rapid 
streams,  and  pure  water.  For  instance,  during  the  epidemic  of  IS-iO,  in 
New  York  City,  hundreds  and  thousands  fled  from  direct  contact  with 
the  disease  in  the  city  to  the  highlands  up  the  Hudson  river,  and  to  the 
mountains  of  Vermont  and  New  Hampshire,  and  though  some  sickened 
and  died  on  the  way,  in  none  of  these  regions  did  the  disease  manifest 
any  disposition  to  prevail.  But  along  water  courses  skirted  by  alluvial 
deposits,  and  over  comparatively  level  and  especially  malarious  districts, 
the  disease  has  spread,  and  often  proved  as  fatal  in  proportion  to  the  num- 
ber of  inhabitants  as  in  the  most  populous  cities.  See  History  of  its 
Prevalence  in  the  Mississippi  Valley  in  1873.  Second,  in  all  the  cities 
and  districts  where  it  prevails,  the  attacks  are  much  more  numerous  and 
severe  in  the  low,  damp,  and  uncleanly  streets  and  neighborhoods,  than 
in  those  presenting  the  opposite  sanitary  conditions.* 

Third,  in  every  epidemic  of  cholera,  the  ratio  of  attacks  and  of  mor- 
tality has  been  much  greater  in  that  part  of  the  population  characterized 
by  uncleanly  and  intemperate  habits,  and  those  of  foreign  birth,  than  in 
any  other  classes.  This  was  strikingly  illustrated  in  the  prevalence  of  chol- 
era in  this  city  (Chicago)  in  the  summer  of  1873.  In  that  season,  al- 
though a  few  well  marked  cases  occurred  in  other  parts  of  the  city,  its 
prevalence  was  limited  almost  entirely  to  a  single  neighborhood  on  the 
southern  border  of  the  city,  occupied  by  an  unsanitary  foreign  population, 
whose  water  supply  was  from  shallow  wells,  containing  only  water  that 
had  filtered  from  the  surface  soil. 

Another  important  predisposing  influence  is  high  temperature.  With 
the  exception  of  the  epidemic  in  New  Orleans,  vv^hich  commenced  in  De- 
cember, 1818,  and  prevailed  very  severely  through  that  and  the  next  suc- 
ceeding month,  all  the  cholera  epidemics  in  this  country  of  which  I  have 
any  knowledge,  have  occurred  not  only  in  the  warm  season  of  the  year, 
but  in  seasons  the  average  temperature  of  which  was  above  the  mean  for 
a  series  of  years.  But  the  occurrence  of  the  disease  in  New  Orleans  in 
December,  1818,  constituted  no  exception  to  its  prevalence  during  high 
temperature,  for  the  records  show  that  at  the  time,  the  temperature  rano-ed 
from  24°  to  29°  C.  (75°  to  85°  F.)  coincident  with  a  still,  damp,  and  \^ry 
impure  atmosphere. 

As  further  illustrating  the  effects  of  temperature,  I  may  remind  you 
that  the  cholera  was  brought  on  board  of  an  emigrant  ship,  into  the  har- 
bor of  New  York,  during  the  same  month  of  December  in  which  it  devel- 
oped so  rapidly  in  New  Orleans,  i^nd  although  the  ship  and  its  living 
cargo  were  detained  in  the  quarantine,  yet  many  of  the  passengers  es- 
caped to  the  city,  and  a  few  of  the  number  were  found  sick  with  the  dis- 
ease in  the  city.  But  in  New  York,  at  that  time,  the  temperature  was  as 
low  as  the  average  for  winter  in  that  latitude,  and  became  still  colder 
during  the  succeeding  month.  Consequently  the  disease  wholly  failed  to 
develop  in  the  city,  and  in  a  few  weeks  disappeared  from  the    quarantine 

*  For  details  concerning  the  epidemics  from  1848-9  to  1854,  see  reports  in  the  Transactions  of  the 
American  Medical  Associaiioii.  Volumes  II,  III,  IV.  V,  VI.  Also  a  volume  on  Epidemic  Cholera, 
by  D.  Mereiith  Reese,  M.  D.,  of  New  York.  For  the  influence  of  local  causes  on  the  epidemic 
ot  1866  in  Chicago,  see  Chicago  Medical  Examiner,  Volume  VIII,  p.  637  to  858. 


664  EPIDEMIC    CHOLERA. 

Again,  the  development  and  severe  prevalence  of  the  disease  in  Egypt 
during  the  past  summer  (1883),  occurred  directly  under  the  coincident 
influence  of  high  temperature,  w^ith  extreme  contamination  of  both  air  and 
water  from  decomposing  animal  matter,  constituting  a  combination  of 
local  circumstances  closely  analogous  to  those  accompanying  the  gathering 
of  pilgrims  at  Mecca  and  other  places  in  India.  These  considerations  lead 
directly  to  the  important  etiological  question,  whether  any  combination  of 
the  predisposing  influences  I  have  named,  is  capable  of  giving  rise  to  the 
disease,  or  must  there  be  present  in  addition  a  specific  cholera  poison,  or 
organic  germ,  derived  from  some  other  source,  while  the  predisposing  in- 
fluences only  serve  to  increase  its  development  or  propagation  and  inten- 
sify its  activity?  The  latter  has  been  the  popular  doctrine  in  the  profes- 
sion for  the  last  twenty  years.  A  large  proportion  of  the  more  recent 
writers  not  only  claim  that  the  disease  arises  from  a  specific  poison  or 
infection,  but  also  that  such  infection  consists  of  organic  germs  or  micro- 
phytes, developed  in  the  blood  and  intestinal  discharges  of  those  suffering 
from  the  active  symptoms  of  the  disease. 

Those  who  advocate  this  view  of  the  efficient  cause  of  cholera  pretty 
generally  regard  the  same  as  originating  in  the  valley  of  the  Ganges,  and 
as  extending  to  other  countries  only  by  the  transportation  of  the  infectious 
microphyte  from  its  native  place  in  Asia.  It  was  this  idea  that  caused  the 
disease  to  be  so  generally  called  Asiatic  cholera.  Of  those  who  regard 
the  disease  as  originating  solely  in  Asia,  one  part  regard  the  cause  as  a 
true  contagiutn  vivum  capable  of  propagating  the  disease  from  person  to 
person,  like  that  of  variola,  while  a  much  greater  number  regard  the 
active  cause  as  an  infectious  microphyte  generated  outside  of  the  human 
system,  but  capable  of  propagation  in  the  alimentary  canal  and  the  serous 
discharges  therefrom.  And  by  many  it  is  supposed  that  the  spread  of  the 
disease  from  place  to  place,  or  from  one  country  to  another,  is  effected 
chiefly  through  the  agency  of  the  cholera  dejections  in  communicating 
the  infectious  principle  or  agent  to  the  soil,  water  and  atmosphere  where- 
ever  such  dejections  are  carried.  Many  microscopic  investigitions  have 
resulted  in  discovering  bacteria  or  microphytes  in  the  evacuations  during 
the  progress  of  cases  of  epidemic  cholera,  more  especially  when  the  exam- 
inations are  made  after  the  discharges  have  been  kept  in  a  warm  atmos- 
phere from  eighteen  to  twenty-four  hours. 

But  hardly  any  two  of  the  investigators  agree  as  to  the  special  micro- 
phytes peculiar  to  the  cholera  cases,  and  none  of  them  have  satisfactorily 
demonstrated  their  causative  influence.  During  the  prevalence  of  the 
disease  in  this  city  in  1866  and  again  in  1873,  I  subjected  many  speci- 
mens of  cholera  discharges  to  careful  microscopic  examinations  both  imme- 
diately after  they  were  voided  and  at  short  intervals  for  three  succeeding 
days.  In  the  examination  of  specimens  just  voided,  very  few  microphytic 
formations  of  any  variety  could  be  detected,  but  after  twelve  or  eighteen 
hours  they  became  more  numerous,  and  they  continued  to  multiply  dur- 
ing the  three  days  they  were  kept  for  observation.  On  extending  my  ex- 
aminations, however,  to  the  thin  or  serous  discharges  of  simple  cholera 
morbus  and  those  of  the  "summer  complaint"  or  common  diarrhoea  of 
young  children,  I  obtained  results  so  nearly  identical  that  I  could  not 
maintain  any  line  of  distinction  between  them.  I  did  not  abandon  the 
search  until  I  became  satisfied  that  there  were  no  organic  germs  or  bac- 
terial forms  in  the  discharges  during  epidemic  cholera,  that  were  not  also 
found  in  the  dejections  of  cholera  morbus,  summer  diarrhoea,  and  all  other 
thin  discharges  from  the  mucous  membranes,  provided  the  specimens  were 
all  treated  alike.     Whether  the  several  commissions  that  were  orfjanized 


CLINICAL    HISTORY.  665 

under  the  directions  of  Koch,  Pasteur  and  others,  and  sent  out  during  the 
past  summer  to  investigate  the  severe  epidemic  of  cholera  in  E^ypt,  have 
made  any  new  or  important  discoveries  can  not  be  known  until  their  re- 
ports are  received  and  critically  examined.  It  must  be  acknowledged, 
therefore,  that  up  to  the  present  time  the  efficient  or  specific  cause  of  epi- 
demic cholera,  if  such  cause  exists,  is  unknown.  That  the  prevalence  of 
the  disease  in  any  given  locality  is  mainly  dependent  upon  the  local 
conditions  of  temperature  and  organic  impurities  present  in  tha  soil,  water, 
and  atmosphere,  coupled  with  the  personal  hygiene  of  the  inhabitants,  is 
proved  by  the  whole  past  history  of  the  disease.  My  own  clinical  obser- 
vations in  seven  seasons  of  cholera  prevalence,  have  afforded  the  strongest 
evidence  that  the  disease  is  not  propagated  by  personal  contagion,  that  is, 
not  directly  communicable  from  person  to  person.  Whether  the  general 
and  local  conditions  to  which  I  have  alluded  as  favoring  the  development 
and  spread  of  cholera,  when  strongly  concentrated,  are  capable  of  directly 
producing  the  disease,  or  whether  this  indirectly  develops  a  specific  infec- 
tious miasm  or  microphyte  that  like  other  infections  is  capable  of  being 
carried  in  clothing,  or  confined  air,  from  one  locality  or  country  to 
another,  and  of  being  propagated  whenever  it  meets  favorable  local  con- 
ditions, are  questions  by  no  means  satisfactorily  settled.  Bv  a  large  ma- 
jority of  writers  of  the  present  day  the  last  question  is  answered  in  the 
affirmative. 

And  some,  like  Dr.  J,  C.  Peters  of  New  York,  have  given  us  elaborate 
and  ingenious  maps,  designed  to  show  the  origin  of  each  epidemic,  in  its 
supposed  Asiatic  home,  and  its  spread  by  transported  infection  from  place 
to  place  on  both  continents.  But  there  are  so  many  gaps  in  the  lines, 
filled  by  suppositions  or  the  imagination  of  the  writers,  as  to  render  them 
of  little  scientific  value. 

Another  circumstance  strongly  supporting  the  idea  that  the  essential 
cause  or  causes  of  the  disease  originate  in  the  locality  where  the  disease 
prevails,  insteaJ  of  having  been  imported  from  some  other  place,  consists 
in  the  fact  that  in  almost  every  epidemic  season,  isolated  cases  of  a 
well  marked  character  occur  in  different  streets  or  neighborhoods,  and 
gradually  increase  in  number  for  some  time  before  the  arrival  of  the  sup- 
posed infection  from  any  other  source.  Thus  Dr.  Fenner  and  others  in 
active  practice  at  the  time,  record  the  fact  that  chole.-a  diarrhoea  and  some 
cases  presenting  all  the  characteristics  of  cholera  occurred  in  New  Orleans, 
in  December,  1848,  before  the  ship  which  is  credited  with  having  brought 
the  infection  had  reached  within  five  hundred  miles  of  that  port.  And 
the  same  has  been  true  in  reference  to  the  first  cases  occurring  at  the  be- 
ginning of  every  cholera  epidemic  inCliicago  since  1850. 

Symptoms  and  Clinical  History. — In  a  very  large  proportion  of  the 
cases  O-  cholera,  the  more  active  symptoms  are  preceded  by  a  moderate  se- 
rous diarrhoea  from  one  to  five  or  six  days.  The  discharges  durino-  this  stage 
usually  average  three  or  four  in  the  twenty-four  hours;  are  very  thin  and 
voided  without  pain  or  effort,  but  are  accompanied  by  a  cool  and  pale 
condition  of  the  cutaneous  surface  and  a  general  feeling  of  weakness. 
After  the  continuance  of  this  apparently  mild  diarrhoea  one  or  more  days, 
the  more  active  symptoms  are  somewhat  suddenly'  ushered  in  by  an  unus- 
ual feeling  of  weakness  coupled  with  an  active  rumbling  or  peristaltic 
motion  of  the  bowels  quickly  followed  by  a  very  copious  watery  evacu- 
ation ;  and  frequently  before  this  is  finished  an  active  paroxysm  of  vomit- 
ing supervenes.  This  finished,  the  patient  lies  down  under  a  feeling  of 
languor  and  exhaustion,  with  general  paleness  of  the  surface,  a  soft,  weak 
and   slightly   accelerated  pulse,   respiration   nearly  natural,   temperature 


66Q  EPIDEMIC   CHOLEKA. 

natural  or  slightly  below,  urinary  secretion  diminished,  and  mouth  deficient 
in  moisture  with  soma  thirst.  In  the  great  majority  of  cases  this  sudden 
development  of  the  active  stage  takes  place  during  the  last  half  of  the 
night  or  before  ten  o'clock  in  the  morning. 

In  cases  of  average  severity,  the  paroxysms  of  active  vomiting  and 
purging  continue  to  recur  at  intervals  varying  from  ten  to  thirty 
minutes,  the  discharges  from  the  bowels  being  copious  in  quantity  and 
having  the  appearance  of  turbid  water,  or  that  in  which  rice  has  been  mac- 
erated. After  the  first  two  or  three  passages  there  is  seldom  any  appear- 
ance of  the  coloring  matter  of  bile  in  the  evacuations  either  from  the  stom- 
ach or  bowels,  and  the  urinary  secretion  is  much  diminished,  and  in  some 
cases,  suppressed. 

Soon  after  the  commencement  of  active  vomiting  and  purging,  severe 
cramps  are  felt,  usually  in  the  muscles  of  the  calf  of  the  leg  first,  and  as 
the  continuance  of  copious  evacuations  rapidly  diminishes  the  relative  pro- 
portion of  the  aqueous  and  saline  elements  of  the  blood,  the  cramps  extend 
to  the  thighs,  arms  and  muscles  of  the  chest  and  abdomen,  adding  very 
much  to  the  suffering  of  the  patient.  In  the  mean  time  the  countenance 
and  whole  surface  has  shrunken,  the  eyes  sunken  in  the  sockets,  the  lips 
pale  and  thin,  the  extremities  cold  and  bluish  from  the  lessening  of  the 
circulation  in  the  capillaries,  the  pulse  frequent  and  weak,  the  mouth  dry 
with  intense  craving  for  cold  water,  and  the  voice  husky  and  feeble. 
After  the  first  hour  the  skin  becomes  bathed  in  perspiration,  which,  added 
to  the  copious  gastric  and  intestinal  discharges,  still  more  rapidly  exhausts 
the  blood  of  its  water,  until  at  the  end  of  from  three  to  six  hours  it  becomes 
too  thick  to  circulate  through  the  smaller  vesse;S,  the  pulse  disappears 
from  the  wrist,  the  intestinal  discharges  become  involuntary,  all  natural 
glandular  secretions  are  suppressed,  and  the  patient  enters  the  stage  of 
complete  collapse.  In  this  stage  he  may  linger  from  one  to  five  or  six 
hours,  presenting  a  cold,  wet  and  shrunken  state  of  the  surface  and 
extremities.  The  mind  is  dull,  the  eyeballs  turned  upward  and  eyelids  only 
partially  closed  and  the  voice  suppressed.  He  no  longer  vomits,  but  still 
has  an  occasional  small  involuntary  discharge  from  the  bowels  with  an 
occasional  muscular  cramp,  and  at  length  the  chin  drops,  the  breathing 
becomes  irregular,  the  heart  beats  unsteadv,  and  finally  all  the  phenomena  of 
life  cease.  Such  are  the  prominent  symptoms,  and  such  the  usual  progress 
of  attacks  of  epidemic  cholera,  when  sufficiently  severe  to  reach  a  direct 
fatal  termination. 

The  time  occupied  by  the  stage  of  active  vomiting,  purging,  and  cramps 
varies  from  three  to  twelve  hours;  that  of  collapse  from  one  to  six  hours, 
in  most  of  the  fatal  cases.  In  the  midst  of  severe  epidemics,  however, 
you  will  meet  with  a  few  cases  in  which  the  violence  of  the  cramps  and 
copiousness  of  the  evacuations  bring  on  collapse  and  death  in  five  or  six 
hours.  In  the  epidemic  of  1854,  in  this  city,  I  saw  a  case  in  the  person 
of  a  Scandinavian  laborer  who  went  to  his  usual  work  in  a  lumber  yard 
after  breakfast  apparently  well.  Affer  continuing  his  work  about  an  hour 
he  became  so  weak  that  he  was  carried  home  on  a  dray,  went  to  the  water- 
closet  and  had  one  very  large  watery  evacuation  from  the  bowels  and  one 
tuxn  of  vomiting;  returned  to  his  room,  sat  long  enough  to  smoke  his  pipe, 
took  to  his  bed,  became  rapidly  cold,  bluish,  shrunken,  and  with  only 
slight  cramps  in  his  legs,  passed  into  complete  collapse  and  died  in  less 
than  six  hours  from  the  time  of  first  complaining.  On  the  other  hand  a 
large  proportion  of  the  cases  of  cholera  in  every  epidemic  run  a  milder 
course  than  I  have  described  and  tend  toward  recovery. 

After  from  one  to  three  or  four  days  of  premonitory  diarrhoea,  the  active 


ANATOMICAL    CHANGES.  667 

stai^e  is  ushered  in  by  vomiting  and  purging  of  a  serous  or  rice  water 
fluid,  soon  followed  by  muscular  cramps,  small  weak  pulse,  cool  and 
shrunken  conditioil  of  the  extremities,  extreme  thirst  and  dryness  of  the 
mouth,  with  weak  or  husky  voice,  and  little  or  no  sweating.  When  these 
active  symptoms  have  continued  from  three  to  six  hours,  greatly  diminish- 
ing the  relative  proportion  of  the  water  in  the  blood  and  bringing  the 
patient  to  the  verge  of  collapse,  they  begin  to  abate.  The  intervals 
between  the  passages  from  the  bowels  and  also  between  the  acts  of  vom- 
iting, become  longer,  the  quantity  passed  at  eacii  time  less,  and  in  two  or 
three  hours  more  the  vomiting  and  cramps  cease,  the  pulse  becomes  slow- 
er and  fuller,  warmth  returns  to  the  extremities,  the  craving  for  drink 
diminishes,  and  the  patient  is  inclined  to  sleep.  In  many  cases  after  a 
few  hours  rest  it  is  found  that  the  renal  secretion  is  more  free,  the  mouth 
moist,  and  when  the  bowels  move  the  passage  is  only  semi-fluid  and  tinged 
with  the  coloring  matter  of  bile;  in  a  word,  that  the  secretory'  functions 
generally  have  been  restored  and  the  patient  fairly  entered  upon  the  stage 
of  convalescence.  Under  rest  and  a  mild  diet,  such  cases  rapidly  recover 
their  usual  health  and  strength.  You  will  meet,  however,  at  the  bedside, 
a  considerable  number  of  cases  one  grade  more  severe  than  those  just 
described.  The'stage  of  active  vomiting,  purging,  cramps,  etc.,  though 
protracted  and  severe,  will  nevertheless  cease  before  inducing  complete 
collapse;  but  instead  of  passing  directly  into  convalescence,  the  mind 
becomas  dull  or  drowsy,  the  face  suffused  with  redness,  the  lips  and  mouth 
remain  dry,  the  urine  scanty,  and  the  extremities  warm  with  more  or  less 
congestion  of  the  skin,  constituting  a  motlerate  general  febrile  reaction. 
This  moderate  grade  of  fever,  accompanied  by  sufficient  irritability  of  the 
stomach  and  bowels  to  cause  an  occasional  vomiting,  and  three  or  four 
thin,  gray  or  reddish  brown  passages  in  the  twenty-four  hours,  may  con- 
tinue from  five  to  nine  days,  during  which  the  assemblage  of  symptoms 
-closely  simulate  those  of  enteric  typhoid  fever.  In  the  majority  of  cases 
this  secondary  fever  terminates  in  the  gradual  establishment  of  conva- 
lescence, but  in  some  a  low  grade  of  inflammatory  action  is  established  in 
the  mucous  membranes,  which  causes  the  evacuations  to  continue  with 
inability  to  retain  and  assimilate  nourishment,  and  a  fatal  degree  of 
exhaustion  supervenes. 

You  have  thus  three  grades  of  active  cholera  attacks;  the  first,  which 
runs  its  course  in  from  six  to  eighteen  hours,  and  ends  in  actual  conva- 
lescence; the  second,  in  which  the  active  stage  is  more  severe,  but  stops 
siiort  of  inducing  full  collapse,  and  is  followed  by  o.ie  or  two  weeks  of 
secondary  fever;  and  third,  those  cases  in  which  the  active  stage  is  so 
severe  and  the  discharges  so  copious  as  to  cause  direct  and  generally  fatal 
collapse. 

Anatomical  Changes. — During  the  epidemic  outbreaks  of  cholera  in 
this  country  in  1849  and  the  five  or  six  succeeding  years,  many  very  thorough 
post-mortem  examinations  were  made,  and  the  changes  in  the  solids  and 
fluids  of  the  body  were  studied  with  much  care.  During  the  epidemic 
of  1849  in  Boston,  thirty-three  autopsies  were  made,  twelve  on  males  and 
twenty-one  on  females.  The  ages  of  those  examined  varied  from  ten  to 
sixty  years,  though  a  large  majority  were  of  adult  age.  The  brain  and  its 
membranes  were  pretty  uniformly  reported  natural.  In  a  few  cases  slight 
serous  effusions  existed  in  the  ventricles  and  on  the  surface  of  the  mem- 
branes, and  in  fifteen  of  the  cases  the  arachnoid  surface  covering  the  pos- 
terior part  of  hemispheres  was  covered  with  a  thin  layer  of  "dark,  thick, 
bloody  fluid,"  which  was  supposed  to  have  transuded  after  death.  The 
only    unnatural    appearances    in    the    chest    were    an  unusually  dry  and 


668  EPIDEMIC    CHOLERA. 

shrunken  condition  of  the  pleura  and  paricardium.  The  lungs  showed 
only  slight  indications  of  congestion  in  a  few  of  the  cases.  The  right 
cavities  of  the  heart  were  not  distended  with  blood,  but'in  fourteen  of  the 
cases  spots  of  ecchymosis  were  found  beneath  the  endocardium  and 
sometimes  in  the  pericardium.  In  the  abdominal  cavity,  the  peritoneum 
was  found  covered  with  a  thin  layer  of  opaline  secretion  or  exudation, 
giving  it  a  moist  and  sticky  feel.  The  liver  and  spleen  were  contracted 
and  contained  less  blood  in  their  vessels  than  natural.  The  kidneys  ap- 
peared nearly  natural,  in  a  few  of  the  cases  a  little  flaccid,  but  the  mucous 
membrane  lining  the  bladder  and  vagina  was,  in  nearly  all  the  cases, 
covered  with  a  thick  layer  of  fluid  of  a  creamy  consistence,  while  the 
bladder  itself  was  contracted  and  empty  of  the  urine.  The  contents  of  the 
alimentary  canal  varied  much  in  consistence  and  color  in  difi'erent  cases, 
but  in  most  of  them  they  were  thin,  yellowish-white  or  like  soapy  water, 
and  contained  both  albumen  and  the  coloring  matter  of  bile.  The  micro- 
scope revealed  an  abundance  of  columnar  epithelium  and  detached  cells. 
The  mucous  membrane  lining  the  stomach  and  intestines  was  generally 
pale,  or  natural  in  color,  with  no  appearance  of  inflammatory  congestion  or 
general  redness  of  the  surface.  The  blood  in  the  cavities  of  the  heart  and 
large  vessels  coagulated  less  readily  and  firmly  than  natural,  and  in  fifteen 
of  the  cases  the  serum  was  distinctly  thicker  or  more  viscid  than  that  of 
healthy  blood.  The  rigor  mortis  and  post-mortem  contractions  existed  in 
all  the  cases.* 

During  the  same  year,  while  the  cholera  was  prevailing  in  Philadelphia, 
a  committee  appointed  by  the  College  of  Physicians  made  still  further 
investigations  concerning  the  condition  of  the  intestines  in  this  disease. 
Dr.  .John  Neill  first  filled  the  vessels  with  a  fine  injection  colored  with 
Vermillion,  and  then  subjected  the  mucous  membrane  to  careful  micro- 
scopic examination.  The  epithelial  layer  of  the  mucous  membrane  was 
found  in  all  the  specimens  examined,  "either  entirely  removed,  or  adher- 
ing loosely,  as  a  pulpy  layer  mixed  with  mucus  or  an  albuminal  substance." 
The  villi  were  also  denuded  of  the  epithelium  but  otherwise  unchanged, 
and  the  capillary  vessels  unbroken. j- 

According  to  the  investigations  of  Dr.  C.  Schmidt,  the  blood  usually 
reaches  its  greatest  degree  of  concentration  from  the  rapid  drain  of  the 
water  in  the  discharges,  during  the  first  twenty-four  to  thirty-six  hours 
after  the  commencement  of  active  symptoms,  when  the  proportion  of  solid 
constituents  was  found  from  one  to  one  and  a  half  times  greater  than 
natural.  The  increase  consists  chiefly  of  the  corpuscular  elements,  extrac- 
tive matter,  and  the  phosphatic  salts. 

You  must  keep  in  mind  the  fact  that  the  changes  I  have  thus  far  de- 
scrii)ed  are  such  as  are  found  in  cases  in  which  death  resulted  during  col- 
lapse from  the  active  stage  of  the  disease. 

When  death  has  been  postponed  until  after  reaction  and  the  secondary 
fever,  the  autopsy  will  generally  show  more  indications  of  inflammatory 
processes,  more  especially  in  the  alimentary  canal. 

In  such  cases  there  is  more  general  redness  of  the  mucous  membrane 
of  the  ilium,  with  an  increase  of  the  lymphoid  cells  and  slight  tumefaction 
of  thb  glands  of  Peyer  and  Brunner.  Numerous  superfi -ial  follicular 
ulcers  are  also  seen  in  parts  that  had  been  most  denuded  of  epithelium  in 
the  past  stage.  In  many  of  these  cases  the  mesenteric  glands  are  mod- 
erately  enlarged    with  some  degeneration  of  structure.     The  kidneys  are 

*  See  "Report  on  the  Cholera  in  Boston  in  1840,"  puWished  b-  the  authorities  of  that  city. 
+  See  'I  raus  letons  of  ihe  Anu'riean  Medical  Association,  Vol  III,  pp.  75-6.    Also  Transactions  of 
the  College  of  Physicians  of  I'liiludelphia,  Dec.  4,  1S49. 


DIAGNOSIS.  669 

found  more  cong'ested  and  tumefied,  with  noticeable  fatty  degeneration  of 
the  tubular  epithelium.  In  these  cases  also,  the  spleen,  liver,  lungs,  and 
serous  membranes  in  the  chest  have  lost  the  shrunken  and  dry  condition 
they  present  when  death  results  directly  from  collapse,  and  may  even 
show  some  degree  of  congestion  and  traces  of  parenchymatous  degener- 
ation. The  only  item  of  importance  which  has  been  added  to  our  knowl- 
edge of  the  anatomical  changes  revealed  by  a  study  of  the  conditions 
found  after  death  from  epidemic  cholera,  since  1849,  relates  to  the  alleged 
finding  of  an  organic  germ  or  micropliyte  in  the  cholera  evacuations 
which  is  represented  as  the  special  infectious  agent  or  cause  of  the  disease. 
Drs.  PettenkofFer,  Snow  of  London,  and  others  adopted  the  theory  that 
the  microphytes  multiplying  in  the  mucous  membrane  of  the  alimentary 
canal  during  the  incubative  stage  of  the  cholera  were  discharged  in  large 
numbers  with  the  evacuations  in  the  subsequent  active  stage  and  were 
capable  of  impregnating  the  water  in  the  soil,  or  adhering  to  damp 
clothing,  and  by  undergoing  further  development  out  of  the  body 
through  the  agency  of  heat,  moisture  and  decomposable  organic  matter, 
they  become  active  and  efficient  agents  in  spreading  the  disease.  That 
there  are  plenty  of  bacterial  forms  in  the  intestinal  discharges  during  the 
active  stage  of  cholera,  is  easily  demonstrated  tjy  microscopic  examination. 
During  the  epidemic  in  this  city,  1866,  I  took  many  specimens  from  the 
discharo;es  of  my  patients  as  so^)n  as  voided,  and  speedily  subjected  them 
to  careful  microscopic  examination.  Several  of  the  specimens  I  kept 
from  three  to  six  days,  repeating  the  examinations  morning  and  evening. 
The  bacterial  formations  were  always  few  and  very  small  at  the  first  ex- 
amination, but  they  developed  rapidly  both  in  size  and  number  by  keep- 
ing. There  were  plainly  several  varieties  of  these  organic  germs,  but  the 
ordinary  spherical  bacteria  and  vibrios  were  much  the  most  numerous. 
After  making  a  thorough  study  of  these  specimens,  I  extended  my  exam- 
inations to  the  thin  evacuations  in  ordinary  cholera  morbus,  cholera  infan- 
tum, and  the  simple  summer  diarrhoea  of  infants.  By  this  means  I  soon 
learned  that  every  variety  of  organic  germ  or  microphyte  that  I  had  seen 
in  the  evacuations  from  my  cholera  patients,  was  equally  visible  in  any 
serous  evacuation  from  the  alimentary  canal  when  treated  and  examined 
in  the  same  manner.  The  correctness  of  the  results  of  these  examinations 
has  been  confirmed  by  the  subsequent  observations  of  many  others.  I  ain 
justified  there-fore  in  stating  that  there  are  no  organic  germs  peculiar  to  the 
intestinal  evacuations  in  epidemic  cholera,  and  consequently  no  founda- 
tion for  the  theory  that  the  disease  is  propagated  by  specific  germs  from 
that  source.* 

Diagnosis. — The  only  diseases  from   which  cases  of   epidemic  cholera 

/ 

*The  latest  information  on  this  subject,  is  from  Dr  Kocb,  chief  of  the  German  Scientific  Commis- 
sion ^sent  to  investig'  ite  th°  na'ure  and  eanse«  of  the  seve-e  epidemic  of  cholera  in  Esypt.  during 
the  past  summer,  1SS3.  He  says  after  examining  the  products  from  twelve  cholera  p  .ti  ntsaud  ten 
cadavers  dead  from  the  disease  in  Alexandria,  that  "no  organized  infective  material  could  be  dem- 
onstrated in  the  blood,  or  in  those  organs  which,  in  the  case  of  other  infective  diseases,  are  usu- 
ally the  seat  of  micro-pa  asites.  viz.:  the  lungs,  spleen,  liver  and  kidneys.  *****  xj^g  Qi^m. 
tents  of  the  bowels  and  the  dejections  of  the  cholera  patients  contained  extraordina-y  quMUtities 
of  micro-organisms  belonging  to  the  most  ditferenc  varieties,  nonj  of  which  appeared  in  prepou- 
d.'rating  proportion.  There  was  also  an  absence  of  other  indications  of  a  relationship  to  the  dis- 
ease-process." See  Maryland  Medical  Journal  for  Nov.  10,  1883.  While  tiius  conceding  that  no 
micro-organisms  peculiar  to  cholera  were  found  eittier  in  the  blood,  the  viscera,  or  the  cholera  de- 
jections, thr  report  from  Dr.  Koch  claims  the  discovery  of  a  bacillus  or  rod-shiped  microphyte  in 
the  mucous  membrane  of  the  lower  half  of  the  ilium,  "which  had  penetrated  the  follicular  glands 
behind  the  epithelium,  and  prolifercated  between  it  and  the  basement  m. mbvane  of  the  gland. 
These  bacilli  were  also  seen  in  the  villi  and  in  .some  deeper  parts  of  the  membrane.  He  acknowl- 
edges, however,  that  "putrefaction  is  able  to  produce  in  the  intestine  exactly  similar  bacterial 
growths."  And  as  all  his  efforts  to  produce  cholera  in  a  variety  of  animals  by  feeding  or  inocula'- 
ing  them  with  these  intestinal  bacilli  afttr  isolation  and  cultivation,  or  by  giving  them  fresh 
specimens  of  the  intes;inj  itself  entirely  failed,  wearj  yet  without  any  p  )sitive  evidence  of  the  ex- 
istence of  a  micro-organism  peculiar  to,  and  causative  of,  epidemic  cholera. 


670  EPIDEMIC    CHOLERA. 

need  to  be  diflPerentiated  are  sporadic  cholera  morbus  and  the  choleraic 
and  algid  varieties  of  pernicious  intermittents.  From  cases  of  cholera 
morbus,  the  epidemic  disease  differs,  first,  in  very  generally  having  a  pre- 
monitory stage  of  painless  diarrhoea  from  one  to  four  or  more  days  before 
the  more  active  cholera  symptoms  commence,  and  second,  in  the  more  gen- 
eral suspension  of  normal  secretory  processes,  and  the  earlier  and  more 
severe  development  of  muscular  cramps  in  a  large  part  of  the  voluntary 
muscles.  The  failure  of  the  voice  and  shrinking  of  the  surface,  is  also 
much  more  marked  than  in  cholera  morbus.  Yet  I  have  repeatedly  seen 
cases  of  sporadic  cholera  morbus,  the  symptoms  of  which  so  closely  simu- 
lated those  of  well  marked  epidemic  cholera,  that  had  they  occurred  during 
the  prevalence  of  an  epidemic,  they  would  have  been  regarded  as  typical 
cases  of  the  last  named  disease.  The  known  presence  or  absence  of  an 
epidemic  influence,  will,  therefore,  aid  you  much  in  determining  your 
diagnosis  in  particular  cases.  From  those  cases  of  pernicious  intermittent 
or  malarious  fever  characterized  by  severe  vomiting,  purging  and  rapid 
prostration  of  all  the  processes  and  functions  of  life,  cases  of  true  cholera 
are  to  be  distinguished  by  the  preceding  stage  of  cholerine  or  simple 
diarrhoea,  the  absence  of  rigors  or  a  distinct  chill  at  the  commencement 
of  active  symptoms,  the  presence  of  more  general  and  severe  muscular 
cramps,  and  the  co-existence  of  a  recognized  epidemic  cholera  influence. 
There  is  sufficient  resemblance,  however,  between  the  active  phenomena 
of  a  paroxysm  of  a  pernicious  choleraic  intermittent  and  the  active  stage 
of  cholera,  to  render  it  difficult  for  a  practitioner  who  may  see  his  patient 
for  the  first  time  in  the  midst  of  the  paroxysm,  to  distinguish  the  one 
from  the  other  by  the  symptoms.  So  true  is  this,  that  whenever  cholera 
epidemics  have  invaded  strongly  malarious  localities,  the  earlier  cases 
have  very  often  been  regarded  as  malignant  attacks  of  malarious  fever; 
and  some  physicians  of  eminence  have  regarded  the  cholera  itself,  as 
only  another  phase  of  the  more  malignant  effects  of  the  same  cause  that 
produces  the  more  common  types  of  periodical  fever.  Some  countenance 
is  given  to  this  idea  by  the  fact  that  cholera  epidemics  have  generally 
extended  much  more  readily  into  malarious  country  districts,  than  into 
those  destitute  of  that  influence.  But  the  differences  in  the  phenomena 
of  the  initial  stages,  and  still  more  in  the  anatomical  changes  as  revealed 
by  autopsies,  as  well  as  in  the  sequelee,  are  sufficient  to  establish  the  essen- 
tially distinct  and  independent  character  of  the  epidemic  cholera. 

Prognosis. — If  you  exclude  from  the  statistics  of  epidemic  cholera  all 
cases  of  cholera  diarrhoea,  and  retain  only  such  cases  as  develop  active 
vomiting,  purging  of  rice  water  character,  and  some  cramps,  you  will 
always  find  a  high  ratio  of  mortality.  Adopting  this  rule,  and  taking 
most  of  their  statistics  from  cholera  hospitals,  nearly  all  recent  writers 
place  the  mortality  from  this  disease  at  from  thirty  to  fifty  per  cent.  This, 
however,  gives  an  exaggerated  idea  of  the  fatality  of  the  disease.  But 
few  cases  of  cholera  are  taken  to  a  hospital  until  after  the  active  symp- 
toms of  the  disease  have  commenced,  and  from  the  rapid  progress  of  the 
disease,  a  large  proportion  of  them  will  have  passed  the  stage  most  favor- 
able for  successful  treatment  before  they  arrive.  To  illustrate  this  fact  I 
need  only  refer  you  to  the  details  of  admission  to  the  special  hospitals  in 
the  large  cities  of  our  country  during  the  epidemic  of  1849.  For  instance 
in  five  hospitals  of  this  class  in  Philadelphia  there  were  admitted  an  ag- 
gregate of  236  cases,  of  whom  forty-nine  or  more  than  one-fifth  were  in 
complete  collapse  at  the  time  of  admission,  and  all  died.  Nineteen  more 
were  in  partial  collapse,  of  whom  six  died.  While  of  the  168  admitted  be- 
fore direct  symptoms  of  collapse  had  supervened  only   eight  died.       The 


PKOGNOSIS.  671 

late  Dr.  D.  Francis  Condie  of  Philadelphia,  who  had  charge  of  the  South- 
wark  cholera  hospital  in  184:9,  and  had  also  had  ample  opportunities  for 
treating  the  disease  during  the  epidemic  of  1832,  makes  the  following 
statement  which  has  an  important  bearing  on  the  question  before  us. 
"  From  the  official  position  which  I  held  in  1832  and  1849,  I  had  a  very- 
large  field  afforded  for  treating  the  disease.  Now,  in  1849,  the  percent- 
age of  mortality  in  all  the  cases  of  cholera  treated  by  me  in  the  Southern 
hospital,  was  ten  per  cent^  and  in  all  the  cases  treated  by  me  in  private 
practice — that  is  in  the  patient's  own  dwelling — rather  more  than  four 
percent.  The  cases  referred  to  were  all  genuine,  fully  formed  attacks  of 
epidemic  cholera.  If  I  had  included  all  cases  treated  by  me  of  cholerine, 
the  percentage  in  hospital  practice  would  have  been  reduced  to  seven,  and 
in  private  practice  to  less  than  two."  * 

My  own  clinical  experience  derived  from  an  active  and  extensive 
practice  in  the  cholera  epidemic  of  1849  in  New  York  City,  and  in  the 
epidemics  of  1850,  '51,  '52,  '54  and  1866  in  Chicago,  fully  confirms  the 
statements  of  Dr.  Condie  in  relation  to  the  ratio  of  mortality,  both  in 
regard  to  the  cholerine  and  the  fully  formed  attacks  of  epidemic  cholera. 
It  will  be  apparent  to  you,  therefore,  that  if  the  cases  of  serous  diarrhoea, 
technically  called  cholerine^  are  to  be  included  in  the  statistics  giving  the 
whole  number  of  cholera  attacks  in  any  given  epidemic,  then  it  must  be 
conceded  that  there  is  a  tendency  in  the  milder  cases  to  spontaneous 
recovery,  and  that  under  good  treatment  in  private  practice  the  per- 
centage of  mortality  resulting  from  all  classes  of  cases  will  not  exceed 
eight  or  ten  per  cent.  But  if  all  the  mild  cases  are  excluded  as  cholerine, 
and  only  such  are  included  in  the  statistics  as  have  taken  on  the  more 
violent  symptoms  of  the  active  stage,  the  mortality  under  the  most  judi- 
cious practice  will  range  from  ten  to  twenty-five  per  cent;  and  in  hospi- 
tals where  from  one-fifth  to  one-third  of  the  whole  number  are  already  in 
complete  collapse  when  admitted,  the  ratio  of  deaths  may  be  increased  to 
fifty  or  sixty  per  cent. 


LECTURE    LXIV. 


Epidemic  Cholera  Continued —Its  Treatment  and  Prophylaxis. 

GENTLEMEN:  Whatever  mav  be  the  specific  or  efficient  cause,  or 
combination  of  causes,  which  produces  epidemic  cholera,  the  symp- 
toms and  clinical  history  show  that  the  prominent  pathological  condi- 
tions are,  a  general  impairment  of  that  elementary  property  of  the 
tissues  called  vital  affinity,  by  which  both  the  tonicity  of  the  tissues  and 
the  natural  molecular  movements  concerned  in  the  processes  of  nutrition 
and  secretion  are  diminished;  an  equal  impairment  of  the  functions  of  the 
vaso-motor  nervous  system,  more  especially  that  part  of  it  connected  with 
the  vessels  of  the  mucous  membrane  of  the  alimentary  canal,  and  coinci- 
de»ntly  an  increased  excitability  of  the  same  membrane.  It  is  this  coin- 
cidence of  impaired  tonicity,  vaso-motor  paralysis,  and  increased  suscepti- 

*See  Report  on  Practical  Medicine  and  Epidemics  in  the  Transactions  of  the  American  Medical 
Association,  Vol.  Ill,  p,  112,  1850. 


672  EPIDEMIC    CHOLEPvA. 

bility,  that  starts  the  undue  exudation  of  the  serous  elements  of  the  blood 
from  the  whole  extent  of  the  alimentary  mucous  membrane,  carrying 
much  of  the  epithelial  layer  with  it,  and  furnishing  the  material  for  the 
copious  discharges  characteristic  of  the  disease.  To  these  primary  and 
essential  pathological  conditions  are  added,  as  the  disease  progresses,  the 
rapid  thickening  of  the  whole  mass  of  the  blood,  the  shrinking  of  the 
tissues,  the  muscular  cramps,  and  finally  the  failure  of  oxygenation,  decar- 
bonization  and  circulation,  constituting  complete  collapse.  Or,  if  the 
morbid  changes  stop  short  of  this,  congestions  take  place  in  those  portions 
of  the  mucous  membrane  most  denuded  of  epithelium,  followed  by  a  low 
grade  of  inflammatory  action,  and  secondary  fever,  of  more  or  less  danger 
to  the  patient.  If  tliese  v.ews  concerning  both  the  primary  and  second- 
ary pathological  conditions  present  in  an  attack  of  cholera  are  correct, 
they  readily  suggest  certain  rational  and  important  objects  to  be  accom- 
plished in  the  treatment  of  each  successive  stage  of  the  disease.  These 
objects  are,  first,  to  restore  the  general  tonicity  of  the  tissues,  to  increase 
the  activity  of  the  internal  vaso-motor  influence,  and  lessen  the  undue 
excitability  of  the  mucous  membranes,  in  the  early  stage  of  the  disease. 
Accomplishing  these  objects  fully  cuts  short  the  disease  and  renders  the 
further  use  of  medicines  unnecessary.  Failing  in  this,  the  next  leading 
object  is  to  limit  the  serous  exudation  to  such  an  extent,  at  least,  as  to 
prevent  extreme  thickening  of  the  blood,  and  to  maintain  the  more 
important  secretory  and  eliminative  functions  in  a  state  of  activity.  Still 
later,  however,  when  the  water  and  saline  elements  of  the  blood  are 
already  greatly  diminished,  the  renal  and  other  secretions  nearly  suppressed 
and  the  thickened  and  imperfectly  oxygenated  blood  fast  stagnating  in 
the  capillaries  of  the  shrunken  tissues,  it  becomes  an  object  of  paramount 
importance  to  replenish  and  dilute  the  blood  b}^  restoring,  as  far  as  possi- 
ble, its  wasted  elements,  and  at  the  same  time,  to  maintain  the  sensibility 
and  action  of  the  nervous  centers  of  organic  life 

Finally,  if  your  patient  passes  by  the  immediate  dangers  of  collapse  and 
a  secondary  fever  is  developed,  you  must  combat  the  local  intestinal, 
renal,  or  other  hyperfemias  and  sustain  general  nutrition  on  the  same 
principles  and  by  substantially  the  same  means  that  I  pointed  out  for  the 
management  of  the  more  advanced  stage  of  enteric  typhoid  fever.  Such, 
gentlemen,  are  the  objects  clearly  before  you  for  accomplishment  in  the 
different  stages  of  a  cholera  attack,  from  the  initial  diarrhoea  to  the  end 
of  the  secondary  fever.  And  I  need  not  add  that  on  the  promptness 
with  which  you  recognize  these  objects,  and  the  skill  you  display  in 
selecting  and  applying  the  proper  means  for  their  accomplishment,  will 
depend  your  success  in  the  treatment  of  the  disease.  Neither  is  it  neces- 
sary for  me  to  assure  you  that  no  one  remedy  is  calculated  to  meet  fully 
the  indications  at  any  stage  of  the  disease,  much  less  at  all  stages.  All 
acute  general  diseases  present  complex  pathological  conditions  which 
change  in  their  relations  as  these  diseases  progress  through  their  successive 
stages  either  to  the  recovery  or  death  of  the  patient.  To  attain  the  high- 
est degree  of  success,  therefore,  you  must  so  combine  remedies  as  to  meet 
the  complex  pathological  elements,  and  so  vary  them  as  the  disease  pro- 
gresses, as  to  preserve  the  accuracy  of  their  adjustment  to  the  changing 
conditions  of  the  disease.  The  numerous  statistics  you  find  in  your  books 
in  regard  to  the  relative  value  of  opium,  alcoholic  liquids,  calomel, 
emetics,  saline  evacuants,  bleeding,  etc.,  are  of  no  actual  value  simply 
because  they  are  not  accompanied  by  an  accurate  statement  of  the  stage 
of  the  disease,  the  condition  of  the  patient,  and  the  coincident  use  of  other 
r.'-medies.  at  thi  time  any  one  of  the  remedies  named  in  the  tables  was 
being  used. 


15.0  c.  c. 

3iv 

15.0  grams 

3iv 

15.0  c.  c. 

3iv 

30.0  c.  c. 

!i 

60.0  c.  c. 

!ii 

TJREATMENT.  673 

The  most  favorable  time  for  accomplishincr  the  first  objects  I  have 
named,  is,  the  stage  of  premonitory  diarrhoea  and  the  first  one  or  two 
hours  after  the  active  cholera  symptoms  have  supervened.  During  the 
first  of  these  periods,  one  of  the  most  reliable  combinations  I  have  used, 
is  the  following: 

^      Acidi  Sulphurici  Aromatici 
Magnesife  Sulphatis 
Tiiicturse  Opii 
Elixer  Simplicis 
Aquae 

Mix.  Give  to  an  adult  four  cubic  centimeters  (fl.  3i)  in  a  little  addi- 
tional water  every  three,  four  or  six  hours  according  to  the  frequency  of 
the  evacuations,  and  keep  the  patient  at  rest.  During  each  of  the  cholera 
epidemics  in  this  city  since  1849  I  have  used  this  prescription  in  a  large 
number  of  cases  of  cholerine  with  the  most  satisfactory  results.  The 
sulphuric  acid  and  aromatics  furnish  the  necessary  tonic  influence  to 
the  tissues  and  a  mildly  stimulant  effect  to  the  vaso-motor  nerves, 
while  the  opiate  efi^ectually  allays  the  morbid  excitability  of  the  mucous 
membranes.  I  usually  repeat  the  dose  at  the  shorter  intervals  until  the 
discharges  have  been  prevented  foi  twenty-four  hours,  and  then  increase 
the  interval  until  the  passages  are  limited  to  one  in  twenty-four  hours, 
and  are  natural  in  color  and  consistence.  If  malarial  influences  were  prev- 
alent at  the  time,  the  intestinal  discharges  light  colored,  and  the  patient's 
tongue  coated,  I  gave  in  addition  to  the  foregoing  prescription  a  pill  or 
capsule  containing-  sulphate  of  quinia,  thirteen  centigrams  (gr.  ii)  and 
six  centigrams  (gr.  i)  of  blue  mass  each  morning  and  noon. 

Another  combination  which  1  have  sometimes  used  as  a  substitute  for 
the  aromatic  sulphuric  acid  mixture,  and  with  good  effect  is  the  following: 

^j^.      Acidi  Sulphurici  Aromatici 
Tincturffi  Cinchonae  Comp. 
Tincturse  Nucis  Vomicae 
Tincturse  Opii  Camphoratae 

Mix.  Give  an  adult  four  cubic  centimeters  (fl.  3i)  in  a  little  sweetened 
water,  every  three,  four  or  six  hours  until  the  bowels  are  regular.  I  might 
multiply  formula  intended  for  the  accomplishment  of  the  same  general 
purposes,  but  the  two  already  given  are  sufficient  to  indicate  the  nature  of 
the  remedies  needed  to  correct  the  morbid  processes  in  the  first  or  prelim- 
inary stage  of  the  disease. 

When  the  active  symptoms,  vomiting,  purging,  and  cramps,  have  com- 
menced, I  direct  the  immediate  application  of  strong  mustard  sinapisms 
over  the  epigastrium  and  nearly  the  whole  length  of  the  spine;  keep  the 
patient  in  a  horizontal  position  with  dry  warmth  to  the  extremities,  and 
give  internally  every  half  hour  three  milligrams  (gr.  1-20)  of  strychnine 
and  eight  or  ten  minims  of  oil  of  turpentine,  rubbed  up  with  gum  arable, 
sugar  and  mint  water,  in  the  form  of  an  emulsion.  Immediately  after 
each  paroxysm  of  vomiting  I  also  give  a  powder  containing  sulphate  of 
morphia  fifteen  milligrams  (gr.  ^),  calomel,  six  centigrams  (gr.  i)  and 
white  sugar  three  decigrams  (gr.  v)  rubbed  together,  and  follow  it  by  a 
small  piece  of  ice  instead  of  water  or  any  other  kind  of  drink.  I  mean  to 
be  understood  literally  when  I  say  hnmediately  after  each  paroxysm  of 
vomiting,  for  the  stomach  cannot  maintain  a  continuous  effort  to  eject  its 
43 


15.0  c.  c. 

3iy 

60.0  c.  c. 

fii 

15.0  c.  c. 

3iv 

60.0  c.  c. 

?ii 

674  EPIDEMIC    CHOLERA. 

contents.  Consequently  if  the  powder  is  swallowed  immediately  after  the 
contractile  power  of  the  stomach  has  been  exhausted  by  a  paroxysm  of 
vomiting,  a  little  time  will  elapse  before  another  paroxysm  can  take  place, 
during  which  the  morphine  will  gain  some  impression  on  the  nervous  sen- 
sibility, and  the  calomel  on  the  capillaries  of  the  mucous  membrane.  If 
you  delay,  however,  as  nearly  all  nurses  and  patients  will  desire  to  do 
after  each  act  of  vomiting,  until  the  patient  has  "rested  a  few  minutes,"  or 
the  "  stomach  has  settled  a  little,"  such  delay  will  usually  he  just  long 
enough  for  the  muscular  coat  of  the  stomach  to  regain  its  contractility 
and  its  cavity  to  have  gathered  a  fresh  accumulation  of  effused  serum,  and 
is,  therefore,  all  ready  for  another  paroxysm.  Then  if  you  give  the 
powder  or  anything  else  it  will  be  promptly  rejected  by  vomiting  as  soon 
as  it  is  swallowed.  At  the  same  time  that  1  direct  the  foregoing  treat- 
ment by  the  mouth,  I  also  direct  three  centigrams  (gr.  -g-)  of  acetate  of  mor- 
phia, and  six  decigrams  (gr.  x)  of  acetate  of  lead,  dissolved  in  about 
sixty  cubic  centimeters  (fl.  |ii)  of  water,  to  be  used  as  a  rectal  enema, 
immediately  after  each  intestinal  evacuation. 

In  a  large  proportion  of  the  cases  that  have  come  under  my  care  very 
soon  after  the  commencement  of  the  active  cholera  symptoms,  the  plan  of 
treatment  just  detailed  has  begun  to  moderate  the  violence  of  the  symp- 
toms in  from  two  to  three  hours,  and  by  continuing  the  same  remedies  at  a 
little  longer  intervals,  all  active  symptoms  have  ceased  before  the  patient 
reached  a  dangerous  degree  of  prostration.  In  the  epidemic  of  1866,  I 
used  in  many  cases  the  ordinary  carbolic  acid  mixture  in  doses  for  adults 
•of  four  cubic  centimeters  (fl.  3')  after  each  act  of  vomiting  instead  of 
the  powder  of  morphine  and  calomel.*  During  all  this  early  part 
of  the  active  stage  of  the  disease,  the  patients  M^ere  kept  as  constantly 
in  the  recumbent  position  as  possible,  their  craving  for  cold  water 
satisfied  by  frequent  small  pieces  of  ice,  held  in  the  mouth  long 
enough  to  smooth  the  edges  and  angles  and  then  swallowed.  But  if, 
either  from  failure  of  the  remedies  or  from  neglect  of  treatment,  the  se- 
rous discharges  have  continued  until  the  surface  is  much  shrunken,  the 
extremities  bluish,  the  pulse  feeble,  and  the  sweating  copious,  indicating 
much  diminution  in  the  relative  proportions  of  the  water  and  salts  of  the 
blood  an:l  consequent  near  approach  of  collapse,  instead  of  continuing 
the  remedies  already  mentioned,  it  is  better  to  give  at  once  a  hypodermic 
injection  of  sulphate  of  morphia  one  centig:ram  (gr.  1-6)  and  atropia 
one  milligram  (gr.  1-60),  and  endeavor  to  replenish  the  exhausted  elements 
of  the  blood  and  maintain  the  susceptibilitj'-  of  the  nervous  and  other 
structures  by  giving  alternately,  every  fifteen  or  twenty  minutes,  fifteen 
cubic  centimeters  or  a  tablespoonful  of  strong  infusion  of  coffee  or  tea, 
and  of  beef  or  chicken  broth  well  salted  with  chloride  of  sodium  or  chlorate 
of  pota'ssiura.  If  the  first  hypodermic  injection  does  not  promptly  check 
the  sweating,  improve  the  pulse,  and  stop  the  vomiting,  it  may  be  repeat- 
ed in  from  half  an  hour  to  an  hour.  At  this  stage,  when  the  blood  has 
become  too  thick  to  circulate  freely,  and  too  imperfectly  oxygenated  to 
sustain  either  nerve  sensibility  or  secretory  action,  the  influence  of  the 
atropia  over  the  vaso-motor  nerves  of  the  periphery  by  which  further  exu- 
dation from  the  skin  may  be  checked,  and  of  the  coflFee  or  tea  (or  their 
active  principles,  caffeine  or  theine)  in  directly  increasing  the  general  sus- 
ceptibilities, make  them  the  most  efficient  agents  we  possess  for.  resisting 
the  further  progress  of  the  patient  toward  complete  and  fatal  collapse. 
And  when  promptly  resorted  to  in  the  stage  indicated,  in  connection  with 

*  See  paje  656. 


TREATMENT.  675 

the  persevering  use  of  small  and  frequently  repeated  doses  of  well  salted 
animal  broths  to  maintain  the  fluidity  and  oxypjenation  of  the  blood,  they 
have  produced  better  results  than  any  other  remedies  I  have  used.  As  a 
rule,  a  strict  horizontal  position  with  dry  warmth  to  the  surface  and  ex- 
tremities should  be  maintained  throughout  the  whole  of  the  active  stage 
of  the  disease.  All  wet  applications,  after  the  first  mustard  sinapisms, 
only  increase  evaporation  and  thereby  help  to  reduce  the  temperature, 
already  too  low,  and  consequently  should  be  avoided.  Active  and  per- 
sistent frictions,  so  frequently  resorted  to,  also  do  more  harm  than  good  by 
the  agitation  and  weariness  induced  by  them.  The  best  way  to  lessen 
the  cramps,  is  simply  to  seiz  ;  the  cramping  muscles  and  hold  them  under 
firm  pressure  a  few  secimds  until  they  relax.  At  the  same  stage  of  the 
disease  in  which  I  have  suggested  the  use  of  hypodermic  injections  of 
morphine  and  atropia,  advantage  has  been  derived  from  two  or  three 
thorouo-h  applications  over  the  whole  cutaneous  surface  of  a  dilute  mercu- 
rial ointment  in  which  was  incorporated  a  liberal  quantity  of  pulverized 
gum  camphor  and  cayenne  pepper.  This  application  was  used  quite  ex- 
tensively in  some  of  the  cholera  hospitals  in  New  York  City,  during  the 
epidemics  of  1849  and  1854,  and  according  to  the  reports  with  good  effect. 

If  the  stage  of  actual  collapse  finally  ensues,  the  chances  of  recovery 
under  any  treatment  will  be  very  small.  They  will  be  best  promoted, 
however,  by  continued  rest  and  the  faithful  administration  in  small  and 
frequent  doses  of  the  coffee,  tea,  and  well  salted  animal  broths,  in  the 
same  manner  as  I  have  already  mentioned.  Under  such  treatment,  I 
have  seen  a  few  cases  of  well  marked  collapse  from  which  the  patients 
recovered. 

If,  either  before  or  after  collapse,  febrile  reaction  comes  on,  and  a 
grade  of  secondary  fever  is  established,  accompanied  by  inflammatory 
congestion  in  the  parts  of  the  mucous  membrane  most  denuded  of  its  epi- 
thelium, it  can  be  most  successfully  treated  on  the  same  principles  and  by 
the  use  of  the  same  remedies,  that  I  recommended  in  detail  when  speaking 
of  the  management  of  the  second  stage  of  enteric  typhoid  fever.  I  have 
now  given  you,  in  as  few  words  as  possible,  the  treatment  for  the  several 
stages  of  cholera,  in  which  I  was  induced  to  place  much  confidence,  from 
an  active  personal  experience  in  several  epidemics.  During  that  expe- 
rience, I  either  tried,  or  saw  others  try,  a  great  variety  of  additional  reme- 
dies. I  have  resorted  to  venesection,  cupping,  emetics  of  chloride  of  so- 
dium and  mustard,  camphor,  saline  evacuants,  and  astringents;  and  I  have 
seen  others  use  ice  and  salt  to  the  surface,  large  doses  of  opium,  quinine, 
calomel,  alcoholic  liquids,  etc.  In  a  few  cases,  characterized  by  unusually 
severe  muscular  cramps  at  the  commencement  of  the  active  stage,  I  thought 
that  thorough  dry  cupping  over  nearly  the  whole  length  of  the  spine  af- 
forded some  relief.  In  three  or  four  similar  cases,  a  moderate  venesection 
afforded  some  temporary  relief,  but  nothing  permanent.  In  three  or  four 
cases  the  local  effects  of  salt  and  mustard  on  the  gastric  membrane, 
coupled  with  the  revulsive  effect  of  free  vomiting,  appeared  to  promptly 
check  the  further  progress  of  the  disease;  but  in  other  cases  it  only  hast- 
ened on  the  stage  of  exhaustion.  In  some  neighborhoods  where  there  was 
a  strong  coincident  prevalence  of  malarious  influence,  the  use  of  moderate 
doses  of  quinine  by  hypodermic  injectioi  produced  some  good.  But  from 
all  my  past  opportunities  for  observation,  I  am  fully  satisfied  that  the 
liberal  use  of  alcohfjlic  liquids,  and  what  are  called  heroic  doses  of  medi- 
cines of  any  kind  are  injudicious  and  productive  of  much  more  harm  than 
good,  in  the  treatment  of  every  stage  of  epidemic  cholera. 

Complications  and  Sequelce. — The  active   stage  of  epidemic  cholera  is 


676  EPIDEMIC   CHOLEEA. 

not  often  complicated  by  the  co-existence  of  any  other  disease.  And  such 
attacks  as  end  in  convalescence  without  the  supervention  of  secondary 
fever,  usually  allow  of  a  rapid  recovery.  But  when  the  active  stage  is 
followed  by  secondary  fever,  the  inflammatory  developments  in  the  mu- 
cous membrane  often  affect  that  part  lining  the  colon  and  rectum,  caus- 
ing decided  symptoms  of  dysentery.  Cases  of  this  kind  are  noticed  more 
frequently  toward  the  close  of  a  summer  epidemic  of  cholera,  than  at  its 
beginning.  When  such  cases  do  occur  they  are  to  be  treated  in  the  same 
manner  as  I  directed  when  speaking  to  you  of  the  asthenic  grade  of  dys- 
entery under  the  head  of  inflammations  of  the  alimentary  canal.  Per- 
haps the  most  important  complication,  which  may  continue  also  as  a  sequel, 
is  such  a  degree  of  renal  congestion  as  to  cause  the  urine  to  be  albumin- 
ous and  very  much  diminished  in  quantity,  or  entirely  suppressed.  The 
secretion  of  urine  is  always  much  diminished  during  the  active  stage  Of 
cholera  when  the  water  of  the  blood  is  being  actively  drained  through  the 
bowels,  but  in  most  cases  of  favorable  tendency,  the  secretion  is  resumed 
as  soon  as  the  intestinal  discharges  cease.  When  it  is  not,  there  soon 
follows  more  or  less  drowsiness,  slight  muscular  twitchings,  a  soft,  weak 
pulse,  and  a  low  temperature.  If  the  suppression  or  extreme  paucity  of 
virine  continues  beyond  twenty-four  hours,  the  drowsiness  generally  deep- 
ens into  unconsciousness  or  coma,  with  slow  and  irregular  respiration,  varia- 
ble pulse,  cold  extremities,  and  sometimes  sweating  with  a  urinous  odor. 
Unless  relief  is  obtained  by  a  resumption  of  secretion  some  time  during 
the  second  or  third  days,  one  or  two  momentary  paroxyms  of  general 
spasm  or  muscular  rigidity  occur,  followed  speedily  by  entire  failure  of 
respiration  and  circulation,  and  consequently  the  death  of  the  patient. 
The  best  way  to  obviate  such  a  result,  to  re-establishing  the  renal  secre- 
tion is  to  re -dilute  the  blood  by  giving  small  and  frequent  doses  of  milk 
whey,  buttermilk  or  animal  broths;  sustain  nerve  sensibility  and  cardiac 
force  by  caffeine,  and  endeavor  to  directly  excite  increased  renal  secretion 
by  giving  as  freely  as  the  stomach  will  bear,  an  infusion  of  juniper  berries, 
uva  ursi  and  galium,  holding  in  solution  the  acetate  or  nitrate  of  potassium. 
In  one  case  that  came  under  my  observation  during  the  cholera  epidemic 
of  1866,  recovery  took  place  after  complete  suppression  had  continued 
three  days,  under  the  treatment  just  indicated.  In  another  case  in  the 
same  epidemic,  complete  suppression  of  urine  took  place  during  the  latter 
part  of  the  active  stage  and  continued  nearly  five  days,  and  yet  recovered, 
the  secretion  being  finally  re-established  while  taking  a  powder  containing 
nitrate  of  potassium,  three  decigrams  (gr.  v),  and  calomel,  thirteen  centi- 
grams (gr.  ii),  every  two  hours.* 

Prophylaxis. — According  to  the  most  generally  accepted  doctrines 
in  regard  to  the  origin,  and  spread  or  propagation  of  epidemic  cholera,  it 
originates  in  some  part  of  India  or  southern  Asia,  and  is  carried  to  other 
countries  by  human  intercourse,  the  infection  being  supposed  capable  of 
adhering  to  clothing  or  merchandise;  of  being  retained  in  the  holds  of 
shins;  and  especially  to  be  propagated  in  the  intestinal  discharges  of 
cholera  patients.  It  is  true,  all  concede  that  there  must  be  a  high  tem- 
perature and  certain  bad  sanitary  conditions  in  the  places  or  countries  to 
which  the  supposed  infection  is  carried,  or  it  will  not  propagate  itself  or 
develop  any  epidemic  of  the  disease.  If  you  accept  the  correctness  of 
these  views,  it  logically  follows  that  your  chief  prophylactic  measures 
must  be  efficient  quarantines,  including  thorough  vessel  and  immigrant 
inspection,  to   prevent  the  importation  of  the  infection;    immediate  and 

*  See  Chicago  Medical  Examiner,  Vol.  VII,  pp.  746-750,  1866. 


PEOPHYLAXIS.  677 

thorouo-b  disinfection  or  destruction  of  all  the  discharges  and  clothing  of 
cholera  patients,  to  arrest  the  progress  of  an  epidemic  after  it  has  com- 
menced; and  the  enforcement  of  local  cleanliness,  ventilation  and  good 
water  supply,  for  the  purpose  of  removing  the  local  conditions  favorable 
for  the  propagation  of  the  supposed  infection.  While  the  facts  connected 
with  the  development  of  every  epidemic  which  has  appeared  in  this  coun- 
try are  not  capable  of  satisfactory  explanation  on  the  theory  of  imported 
infection,  it  is  'nevertheless  a  good  rule  to  keep  always  in  force  such 
measures  of  inspection,  isolation  and  quarantine  as  will  prevent,  as  far  as 
possible,  the  importation  of  all  forms  of  disease  and  unsanitary  materials. 
The  theory  that  there  is  a  specific  cholera  infection  propagated  chiefly  in 
and  by  the  cholera  evacuations,  is  certainly  unsupported  by  an  adequate 
number  of  observed  facts.  Even  the  most  learned  and  well  equipped 
commissioners,  who  have  visited  E^■ypt  for  the  special  purpose  of  investi- 
gating the  nature  and  causes  of  the  severe  cholera  epidemic  in  that  coun- 
try during  the  past  summer,  have  been  wholly  unable  to  propagate  the 
disease  by  usmg  either  the  fresh  dejections  or  the  bacilli  found  in  the 
intestines  after  isolation  and  cultivation.  Yet  as  all  organic  matter,  sep- 
arated from  the  living  body  under  a  summer  temperature,  is  capable  of 
speedily  undergoing  such  degenerative  changes  as  to  evolve  elements  of 
a  hurtful  or  dangerous  quality,  the  serous  discharges  from  cholera  patients 
should  be  at  once  removed  and  so  disinfected  as  to  prevent  further  putre- 
faction or  septic  changes,  as  far  as  possible.  But  of  all  the  prophylactic 
measures  for  preventing  the  spread  of  cholera,  those  which  relate  to  the 
maintenance,  for  the  community  at  large,  of  a  pure  atmosphere,  a  clean 
soil,  and  an  adequate  supply  of  good  water,  and  for  the  individual  or 
family,  cleanliness  of  person  and  premises,  good  ventilation,  wholesome 
food,  and  minds  free  from  unreasonable  fear  and  anxiety,  are  by  far  the 
most  important.  And  there  are  these  important  advantages  in  keeping  the 
minds  of  any  community  strongly  impressed  with  the  protective  value  of 
strict  sanitary  measures  and  with  the  necessity  for  the  removal  or  avoidance 
of  all  sources  of  local  impurities  of  either  air  or  water,  that  they  all  con- 
tribute in  an  equal  degree  to  protect  the  community  from  a  great  variety 
of  other  and  more  common  diseases. 

Of  the  protective  measures  of  a  personal  character  I  enumerated  free- 
dom from  unreasonable  fear  and  anxiety;  to  which  should  also  be  added 
exemption  from  excessive  fatigue,  and  the  avoidance  of  all  alcoholic 
drinks,  whether  fermented  or  distilled;  and  the  adherence  to  a  plain  ordi- 
nary diet,  including  a  fair  variety  of  vegetable  and  animal  substances, 
such  as  agree  best  with  the  individual  when  no  epidemic  exists. 

Such  members  of  the  community  as  can  not  divest  themselves  of  a  cer- 
tain feeling  of  dread,  fear  or  atixiety  about  their  personal  safety  during 
an  epidemic,  had  much  better  go  early  and  directly  to  some  plac3  exempt 
from  any  liability  to  a  prevalence  of  the  disease;  for  all  experience  shows 
that  such  mental  conditions  very  greatly  increase  the  chances  of  being 
attacked.  On  the  contrary,  a  cheerful,  confident  tone  of  mind  resting  on 
clear  convictions  of  duty  and  right,  and  aided  by  habits  of  temperance 
and  virtue,  will  do  very  much  to  shield  the  individual  from  an  attack  of 
cholera  during  an  epidemic,  even  of  the  most  severe  and  protracted  char- 
acter. These  remarks  are  as  applicable  to  physicians  as  to  the  members 
of  any  other  profession  or  calling  in  life. 


678  DROPSIES. 


LECTURE  LXV. 


Aqueous  Fluxes  from  the  Serous  Membraaes  or  Shut  Sacs  and  Areolar  Tissue:  more  generally 
called  Dropsies.  Their  Varieties,  Causes,  Clinical  History,  and  the  General  Principles  governing 
their  Treatment. 

GENTLEMEN:  The  serous  membranes  of  the  body,  unlike  the  cuta- 
neous surface  and  the  mucous  membranes,  are  all  shut  sacs:  and 
consequently,  whenever  serous  fluid,  or  the  watery  element  of  the  blood 
flows  from  these  surfaces  faster  than  it  can  unJergo  natural  absorption 
through  the  blood  vessels,  it  accumulates,  and  causes  more  or  less  disten- 
sion of  the  sac  itself.  The  same  is  true  when  the  efi'usion  or  exudation 
of  fluid  takes  place  from  the  vessels  of  the  areolar  tissue  or  parenchyma 
of  the  organs.  Accumulating  faster  than  it  can  be  absorbed,  it  fills  up 
the  tissue,  causing  it  to  be  tumefied,  or  oeiematous,  by  having  its  inter- 
stitial spaces  distended  with  the  efi"used  fluid.  As  remarked  in  the  pre- 
vious lecture,  when  serous  or  watery  fluid  accumulates  in  any  of  these 
parts,  it  constitutes  some  form  of  what  is  familiarly  styled  dropsy.  Par- 
ticular names  are  applied,  according  to  the  membrane  or  point  of  the  body 
including  the  accumulated  fluid.  In  a  strict  pathological  sense  all  those 
cases  included  under  this  head  of  serous  fluxes  into  the  shut  sacs  of  the 
body  are  symptoms  of  some  co-existing  and  preceding  disense,  and  do 
not  constitute  individual  diseases.  They  are  susceptible  of  division  into 
two  classes:  one,  in  which  the  serous  flow  is  the  result  of  inflammation 
of  some  grade  in  the  membrane  from  which  the  efi'usion  takes  place. 
As  you  have  learned,  when  considering  the  local  inflammations  of  serous 
structures,  one  of  the  almost  constant  results  occurring  in  the  progress 
of  the  inflammation  was  an  efi'usion  in  the  second  stage  of  the  inflam- 
mation. And  in  cases  where  the  inflammatory  action  assumes  more  or 
less  of  a  chronic  form,  the  amount  of  eti"used  fluid  becomes  sufiicient 
to  create  full  distension  of  the  cavity  of  whatever  membrane  is  in- 
volved, and  to  remain  incapable  of  absorption  after  the  inflammition  pro- 
ducing it  had  disappeared.  Aside  from  the  existence  of  inflammation 
as  a  cause  of  serous  flux  from  the  membranes  lining  the  cavities  of  the 
body,  and  the  areolar  or  connective  tissue  of  the  different  structures,  the 
causes,  that  usually  result  in  serous  flux  or  dropsical  accumulations,  may 
be  arranged  into  two  classes:  The  first  class  consists  in  the  obstruction 
of  the  circulation  in  the  vessels  leading  from  the  membrane  from  which 
the  effusion  takes  place;  as  familiarly  illustrated  by  those  diseases  of  the 
liver  which  lead  to  obstruction  of  the  circulation  through  the  portal  vessels 
distributed  in  the  liver,  causing  undue  fullness  of  the  opposite  distribution 
of  the  same  vessel  in  the  abdominal  viscera. 

But  the  same  rule  will  apply  to  all  serous  surfaces,  wherever  the  vessels 
carrying  the  blood  from  the  part  are  such  that  they  are  capable  of  being 
obstructed  in  any  part  of  their  course  so  as  to  increase  the  fullness  of  the 
vessels  of  the  membrane.  This  fullness  causes  the  watery  element  of 
the  blood  to  exosmose  or  transude  through  the  walls  of  the  vessels  to  the 
cavity  formed  by  the  membrane.  The  same  is  true  in  regard  to  dropsi- 
cal accumulations  in  the  connective  tissues  and  parenchymatous  struct- 
ures. Any  obstruction  in  the  course  of  the  vessel,  to  the  return  of  the 
blood  from  the  part  causes  habitual  overfullness  of  the  capillaries,  leads 
to  exudation  of  the  watery  elements,  filling  up  of  the  tissues,  and  consti- 
tutes what  is  usually  called,  oedema  or  anasarca.     This  is  well  illustrated 


VARIETIES.  679 

by  the  pressure  of  the  gravid  uterus  upon  the  iliac  veins  in  advanced 
pregnancy;  often  so  far  obstructing  the  return  of  blood  from  the  lower 
extremities  as  to  cause  them  to  become  largely  infiltrated  with  drop- 
sical fluid,  or  cedematous.  Tumors  in  the  axilla  will  frequently  produce 
the  same  effect,  by  pressure  upon  the  veins  returning  the  blood  from  the 
hand  and  forearm,  causing  more  or  less  serous  infiltration  into  the  tissue, 
making  the  hand  and  arm  throughout  oedematous.  It  is  thus  that  we 
have  a  variety  of  impediments,  which  produce  dropsical  accumulations, 
either  in  the  shut  sacs,  or  in  particular  tissues,  purely  of  a  mechanical 
character,  without  any  ne(^essary  alteration,  eil;her  in  the  composition  of 
the  blood,  or  in  the  special  pathological  condition  of  the  structures  in- 
volved in  the  effusion.  The  other  class  of  causes  which  are  liable  to  pro- 
duce oedematous  infiltration,  or  dropsical  accumulations  in  the  shut  sacs, 
are  such  as  produce  impoverishment  of  the  blood  itself,  causing  the  albu- 
men and  red  corpuscles  of  the  blood,  one  or  both,  to  become  largely  defi- 
cient or  below  the  natural  proportion  in  healthy  blood.  In  proportion  as 
these  constituents  are  diminished  below  the  natural  standard,  the  blood 
becomes  thinner  and  approaches  more  nearly  to  the  consistence  of  water. 
It  is  a  physiological  law,  that  the  smaller  blood  vessels  and  capillaries,  hav- 
ing their  walls  adjusted  to  the  circulation  of  fluid  of  a  given  consistence, 
whenever  the  blood  is  rendered  more  fluid,  beyond  a  given  limit,  its  vessels 
allow  exudation  or  transudation  of  the  watery  element  through  their  walls 
into  the  interstitial  spaces  of  the  tissues,  and  from  the  membranous  sur- 
faces into  the  sacs  of  the  membranes. 

Perhaps  the  most  familiar  illustration  of  this  class  of  cases  is  found  in 
those  diseases  of  the  kidney  which  give  rise  to  the  excretion  of  albumen  of 
the  biood  with  the  urine,  as  in  Bright's  disease  proper,  and  the  different  con- 
ditions grouped  under  the  name  of  albuminuria.  One  of  the  constant 
tendencies  of  such  cases  is,  by  the  progressive  thinning  of  the  blood  from 
the  removal  of  a  large  proporti(jn  of  the  albumen  and  consequent  increase 
in  the  relative  proportion  of  the  water  of  the  blood,  to  induce  general 
exudation  of  that  watery  element  from  the  smaller  blood  vessels  into 
the  areolar  tissues  of  the  body,  first,  and,  as  the  impoverishment  still 
goes  on,  ultimately  into  one  or  more  of  the  serous  sacs  of  the  body. 
The  same  result  may  b3  pro  luce  J  by  excessive  and  repeated  hemorrhages, 
by  which  both  albumen  and  red  corpuscles  are  reduced  below  their  normal 
proportion  in  the  blood.  The  continued  action  of  malaria,  as  is  well 
known,  produces  similar  impairments  particularly  in  reference  to  the  red 
corpuscles,  thereby  greatly  diminishing  the  viscidity  of  the  blood  and 
resulting  in  oedem;i,  or  dropsical  effusion  into  the  areolar  sacs,  in  the 
more  dependent  parts  first;  and,  as  the  impoverishment  of  the  blood  goes 
on,  all  the  structures  throughout  become  subject  to  oedematous  or  drop- 
sical infiltrations.  These  illustrations  are  sufficient  to  show  you,  first, 
that  all  serous  accumulations  in  the  various  shut  sacs  of  the  body  and 
parenchyma  of  organs,  are  not  only  symptoms  but  results,  and  not  dis- 
tinct diseases,  although  they  may  receive  distinct  names.  They  arise 
either  from  inflammation  of  the  texture  from  which  the  effusion  has  taken 
place,  or  from  the  mechanical  impediments  to  the  return  of  blood  through 
the  vessels  from  the  parts  in  which  the  effusion  occurs,  or  third,  from 
absolute  thinning  of  the  whole  mass  of  the  blood  until  it  approximates  in 
its  consistence  that  of  water  itself.  Such  a  condition  is  generally  the 
result  of  the  impoverishment  of  the  red  corpuscles,  or  of  the  albumen,  or 
of  both.  The  two  first  of  these  causes  lead  to  circumscribed  dropsical 
accumulations,  by  which  I  mean  accumulations  directly  limited  to  a  par- 
ticular serous  cavity,  or  to  some  particular  portion  of  the  areolar  tissue. 


680  DROPSIES. 

It  will  require  only  a  moment's  reflection  on  your  part  to  see  why  these 
two  classes  of  causes  necessarily  induce  circumscribed  or  local  dropsy. 
The  first  are  inflammations  directly  of  the  part  from  which  the  efi"used  fluid 
occurs  and  necessarily  must  be  essentially  local.  The  second,  arising 
from  obstruction  to  the  return  of  blood  through  particular  vessels,  will 
afi'ect  only  the  parts  to  which  these  vessels  are  distributed,  and  con- 
sequently must  be,  primarily  at  least,  local  in  the  development  of  the  drop- 
sical result.  The  vena  porta^  having  distribution  only  in  the  abdominal 
viscera,  in  its  obstruction  leads  only,  primarily,  to  abdominal  dropsical 
accumulations.  The  iliac  veins  returning  the  blood  sent  to  the  lower 
extremities  when  obstructed  will  lead  only  to  dropsical  or  oedematous 
infiltration  into  those  extremities  and  so  of  all  other  parts.  But,  on  the 
other  hand,  dropsy  that  arises  from  the  third  class  of  causes,  those  which 
produce  impoverishment  of  the  blood  itself,  rendering  it  too  thin  to 
circulate  freely  through  the  smaller  vessels  without  exosmose  or  trans- 
udation, are  not  local.  Their  first  beginnings  are  always  determined  by 
the  law  of  gravity.  The  dropsical  accumulation  showing  itself  first  in 
the  parts  most  dependent  or  most  distant  from  the  heart  or  central  organ 
of  the  circulation.  Consequently  this  form  of  dropsical  effusion  in  all  the 
earlier  part  of  its  progress  is  changed,  by  change  of  position.  The 
patient  in  the  horizontal  position  during  the  night  presents  in  the  morning 
indications  of  dropsical  infiltration  in  the  bloated  condition  of  the  coun- 
tenance, puffiness  under  the  eyes  and  not  infrequently  pitting  along 
the  surface  of  the  trunk  of  the  body.  But  on  assuming  the  upright 
position  in  the  morning  and  during  the  day,  these  appearances  will  leave 
the  face  and  upper  part  of  the  trunk,  while  the  feet,  ankles  and  limbs, 
will  perhaps  become  filled  up,  so  that  in  the  evening  they  will  be  largely 
swollen  from  the  dropsical  infiltration.  But  placed  on  a  level  with  the 
body,  this  disappears  in  a  great  measure  during  the  night. 

Those  accumulations  that  result  from  alterations  in  the  mass  of  the 
blood,  are  properly  denominated  general  dropsy.  Always  pervading 
the  areolar  tissues  first,  in  the  parts  most  dependent  and  most  remote 
from  the  central  organs  of  the  circulation,  and  as  the  case  progresses, 
capable  of  increasing,  step  by  step,  until  it  permeates  almost  the  en- 
tire structures  of  the  body,  before  death  takes  place.  The  circum- 
stances to  which  I  have  alluded  are  important  in  enabling  you  to 
make  a  correct  diagnosis  in  the  cases  that  may  come  before  you  in  the 
general  field  of  practice.  The  first  step  in  the  diagnosis  of  any  case 
that  may  present  itself,  will  be,  to  determine,  if  possible,  the  morbid 
condition,  or  disease,  which  has  been  the  cause  of  the  dropsy.  A 
simple  examination  of  the  patient  exteriorly,  will  enable  you  to  deter- 
mine readily  whether  the  case  is  one  of  general  dropsy,  pervading  the 
most  dependent  tissue  prominently,  and  changing  more  or  less  by  change 
of  position,  thus  showing  that  it  is  influenced  by  the  law  of  gravity,  or 
whether  it  is  confined  to  some  particular  portion  of  the  body,  or  some 
particular  cavity.  If  the  first,  it  is  general  dropsy;  if  the  second,  it  is 
circumscribed  dropsy.  In  the  first  you  are  to  look  for  the  pathological 
condition  giving  rise  to  the  dropsy,  first,  in  alterations  in  the  mass  of 
the  blood,  and  secondly,  in  the  particular  conditions  which  may  have  pro- 
duced such  alteration  in  the  blood.  In  the  second,  or  cases  of  circum- 
scribed dropsy,  it  is  comparatively  easy  to  determine  the  disease  or  patho- 
logical condition  which  has  given  rise  to  the  dropsical  accumulation,  by 
simply  investigating  as  to  the  symptoms  of  inflammation  in  the  part, 
or  in  the  absence  of  any  such  symptoms,  either  present,  or  in  the  past 
history  of  the  case,  by  searching  for  some  mechanical    impediment  in  the 


PROGNOSIS.  681 

course  of  the  vessels  leading'  from  the  part.  On  the  other  hand,  in  all 
cases  of  general  dropsy  resulting-  from  impoverishment  of  the  blood,  you 
■will  most  readily  arrive  at  a  correct  discovery  of  the  primary  patholog- 
ical condition  bv  examining  carefully  the  physical  signs  connected  with 
the  heart,  having  reference  especially'  to  the  existence  of  structural  or 
valvular  lesions,  capable  of  obstructing  mechanically,  the  flow  of  blood 
through  the  cavities  or  openings  of  that  organ,  and  in  case  no  evidence 
of  disease  is  found  there,  your  attention  should  be  turned  next  to  the 
urine,  examining  it  carefully  b}'  the  proper  tests,  and  if  no  evidence  of 
albumen  is  fou  id,  or  other  condition  of  chat  secretion  which  would  ex- 
plain the  occurrence  of  an  excess  in  the  relative  proportion  of  the  watery 
element  of  the  blood,  then  your  attention  must  be  next  turned  directly 
to  those  causes  of  blood  impoverishment  to  which  I  have  already  alluded; 
such  as  protracted  malarious  influences,  repeated  and  copious  hemor- 
rhages, or  some  one  of  those  peculiar  constitutional  forms  of  disease,  de- 
nominated leucocythremia,  pseudo-leucocythaamia,  and  pernicious  ar)ae- 
mia.  In  at  least  ninety-nine  cases  out  of  every  hundred,  however,  the 
general  dropsy,  or  rather  the  primary  morbid  condition  which  has  led  to 
it,  will  be  found  either  in  cardiac  or  renal  disease,  or  in  the  action  of  ma- 
laria, or  in   copious  and   persistent  losses  of  blood  by  hemorrhages. 

Prognosis. — In  the  management  of  all  cases  of  dro.isy,  the  first  object 
of  importance  is  to  arrive,  as  I  have  just  stated,  at  a  correct  conclusion 
in  regard  to  the  pathological  conditions  which  have  led  to  the  serous  ac- 
cumulations. Having  done  this,  you  are  enabled,  generally,  to  determine 
with  much  accuracy  how  far  the  case  admits  of  a  cure,  and  how  far  th-^ 
patient  can  expect  only  palliation,  or  temporary  relief.  The  dropsical 
difficulty,  being  only  a  symptom  or  result  of  some  one  of  the  pathological 
conditions  to  which  I  have  alluded,  if  such  condition,  in  any  given 
case,  is  itself  capable  of  being  remedied,  the  removal  of  the  dropsical  ac- 
cumulation will  generally  follow.  On  the  other  hand,  if  the  dropsical 
accumulation  is  the  result  of  such  organic  or  structural  diseases  as  are 
themselves  incurable,  the  only  benefit  that  can  be  conferred  upon  the  pa- 
tient will  be  the  adoption  of  such  measures  as  will  temporarily  diminish 
the  dropsical  accumulation,  or  in  some  measure  retard  the  progress  of  the 
primarv  disease.  Unfortunately,  a  large  proportion  of  the  cases  of  gen- 
eral dropsy  depend  upon  organic  disease  of  a  permanent  character,  ei- 
ther in  the  heart  or  in  the  kidneys;  while  those  cases  that  result  from 
malarious  influences,  or  from  hemorrhages,  are  more  frequently  suscepti- 
ble of  permanent  relief.  And  yet  hemorrhages  sometimes  arise  from  in- 
curable pathological  conditions;  such  as  cancerous  or  malignant  growths, 
and  hemorrhagic  diatheses. 

In  the  circumscribed  dropsies,  the  prognosis  will  also  depend  entirely 
upon  the  nature  of  the  local  pathological  conditions  which  have  given  rise 
to  the  serous  accumulations.  The  larger  proportion  of  those  which  have 
resulted  from  direct  inflammation  in  the  part  are  curable,  as  you  have 
already  learned  from  the  discussion  of  the  treatment  of  inflammation  in  the 
different  organs  and  structures  of  the  body.  Those  cases  of  circumscribed 
dropsy  that  arise  from  changes  in  the  important  internal  viscera,  such 
as  cirrhosis  of  the  liver,  being  themselves  permanent  or  incurable,  the 
prognosis  is  necessarily  unfavorable;  although  in  many  of  them  much  can 
be  done,  both  to  palliate  the  patient's  condition,  and  to  prolong  life. 
Where  the  effusion  has  arisen  from  pressure  upon  the  blood  vessels  return- 
ing the  blood  from  the  part  in  which  dropsy  occurs,  relief  may  often  be 
obtained  by  removing  the  cause  of  the  pressure.  A  gravid  uterus  in 
due    time   relieves  itself,   and  removes  pressure  from   the    iliac    vessels. 


6S2 


DROPSIES. 


Tumors,  which  may  press  upon  the  larger  veins,  as  when  developed  in  the 
axilla  or  in  the  groin,  and  sometimes  in  the  abdomen,  in  such  a  way  as  to 
rest  upon  the  iliac  veins,  or  abdominal  aorta,  are  not  infrequently  capa- 
ble of  being  removed  by  surgical  operations. 

Treatment. — It  is  thus  that  treatment  of  all  dropsy  resolves  itself 
primarily  and  largely  into  the  adoption  of  such  measures  as  are  calculated 
to  remove  the  various  pathological  conditions,  which  have  given  rise  to 
the  alterations  in  the  blood,  or  that  mechanically  impede  its  circulation 
through  different  parts.  Yet  there  is  a  large  proportion  of  cases  in  which 
these  pathological  conditions  can  not  be  removed,  and  where  the  work  of 
the  physician  is  restricted  to  the  effort  to  palliate  the  patient's  condition  by 
retarding  the  increase  of  the  dropsical  accumulations  and  sustaining  the 
strength  of  the  patient.  Jt  becom^^s  therefore  an  important  practical 
question  at  the  bedside,  how,  in  the  more  important  cases  that  are 
likely  to  arise,  this  palliation  can  be  most  efficiently  and  properly  accom- 
plished. In  other  words  by  what  moans  can  we 'most  effectually  diminish 
the  amount  of  dropsical  accumulation  or  prevent  its  increase  in  the  various 
forms  of  dropsy  to  which  I  have  alluded.  In  all  those  cases  dependent 
upon  impoverishment  of  the  blood,  there  are  two  rational  principles  to 
guide  our  treatment.  One  is,  to  so  aid  nutrition  by  the  proper  regulation 
of  the  diet  and  other  hvgienic  measures  as  will  improve  the  digestion  and 
assimilation  of  food  and  consequently  increase  the  nutritive  elements  of 
the  blood;  the  other,  to  increase  the  action  of  those  organs  and  struct- 
ures which  eliminate  the  watery  element  of  the  blood,  and  thereby 
diminish  the  relative  proportion  of  that  element,  and  increase  the  viscidity 
of  that  wh.ch  remains  in  the  vessels.  You  are  well  aware  that  the  skin 
and  kidneys  are  the  structures  through  which  the  watery  element  of  the 
blood  is  most  largely  eliminated.  And  whenever  it  is  in  excess,  as  it  is 
relatively  in  all  cases  of  impoverishment,  by  increasing  the  action  of  the 
skin  and  kidneys,  and  at  the  same  time  maintaining  a  reasonable  degree 
of  activity  in  the  nutrition  and  formation  of  new  materials  for  the  blood, 
you  must  efficiently  work  in  the  direction  of  correcting  the  impoverish- 
ment and  restoring  the  proper  relative  ratio  between  the  watery  element, 
and  solid  or  organizable  constituents  of  the  blood,  and  will  thereby 
directly  le.^sen  the  tendency  to  further  effusions  into  the  tissues  and  cavi- 
ties of  the  body.  But  action  upon  the  skin  and  kidneys  in  such  a  way  as 
to  largely  increase  the  elimination  of  water  is  capable  of  producing  effects 
beyond  that  to  which  I  have  just  alluded.  It  may  not  only  restore  the 
natural  ra.io  or  proportion  in  the  different  elements  of  the  blood,  and 
thereby  stop  the  further  effusion,  but  the  watery  element  maybe  reduced, 
at  least  temporarily,  below  its  natural  proportion.  Whenever  such  is  the 
case,  it  is  a  physiological  law  that  more  active  absorption  of  water  takes 
place  from  the  interstitial  spaces,  and  such  serous  cavities  of  the  body  as 
may  contain  it,  to  supply  the  deficiency  of  that  element  in  the  blood. 
Consequently,  whenever  through  diaphoresis,  or  diiiresis  the  water  of  the 
blood  is  reduced  below  the  natural  proportion,  active  absorption  takes 
place  from  the  tissues  and  cavities,  thereby  lessening  the  accumulations 
and  exudations  wherever  they  may  exist.  And  it  is  in  this  way  that  diu- 
retics act  when  they  reduce  the  effused  fluid  in  dropsical  cases.  In  cases 
whore  the  kidneys  are  the  seat  of  disease,  and  perhaps  the  primary  cause 
of  blood  impoverishment  and  dropsical  accumulations,  little  can  be  done 
by  remedies  directed  to  increase  the  action  of  those  organs.  But  dia- 
phoretics, warm  baths  and  such  remedies  as  increase  largely  the  flow  of  the 
watery  element  from  the  cutaneous  surface,  may  be  still  available  and 
productive  of  good.     The   mucous   m3:nbr.iae  of  the   alimentary  canal  is 


TREATMENT.  683 

also  a  very  important  medium  through  which  elimination  of  the  watery 
element  may  be  increased,  by  giving  the  patient  frequent  doses  of  hydra- 
gogue  cathartics,  such  as  elaterium  and  the  saline  cathartics,  sufficient 
to  cause  from  two  to  four  copious  watery  evacuations  in  the  twenty-four 
hours,  and  thereby  rapidly  diminish  the  watery  element  of  the  blood. 
Practically,  however,  there  is  objection  to  the  use  of  hydragogue  Ciithartics 
very  actively  or  during  any  considerable  length  of  time,  on  account  of 
their  tendency  to  cause  loss  of  appetite,  impairment  of  digestion,  and 
ultimately,  p  sitive  irritation  of  the  mucous  membrane,  by  which  more 
injury  is  done  to  the  digestive  organs  than  is  compensated  for  by  the 
increased  discharge  of  water  in  the  evacuations. 

In  all  those  conditions  of  blood  impoverishment  and  general  dropsy 
that  do  not  hinder  the  kidneys  from  being  placed  under  the  influence  of 
diuretics,  you  will  find  it  important  to  have  some  guide  as  to  the  kind  of 
diuretics  you  should  use.  For  instance,  some  cases  of  general  dropsy  are 
accompanied  by  small  secretion  of  urine,  and  an  imperfect  climinaLion  of 
the  saline  elements  of  that  fluid,  leaving  tliem  in  excess  in  the  blood  and 
tissues  of  the  body;  in  other  words,  cases  in  which  there  is  imperfect 
elimination  of  the  products  of  tissue  disintegration.  Such  is  usually  the 
case  with  the  general  dropsies  that  follow  attacks  of  eruptive  fevers,  or 
other  general  acute  diseases.  In  these  cases,  where  diuretics  iire  us?d  it 
is  desirable  to  choose  such  as  will  not  merely  increase  the  excretion  of  the 
watery  element  of  the  blood,  but  will  also  promote  especially  the  elimina- 
tion of  the  products  of  tissue  disintegration.  For  this  purpose  the  saline 
diuretics  are  very  much  more  efficient  and  reliable  than  those  of  vegeta- 
ble origin.  But  in  those  cases  of  dropsy  in  which  there  is  no  retention  of 
the  elements  or  products  of  tissue  disintegration,  but  a  mere  accu- 
mulation of  the  watery  element  of  the  blood,  the  vegetable  diuretics 
and  nitrous  ether  will  be  much  more  suitable  for  the  purpose  than  the 
salines.  The  fluid  extracts  of  galium,  uva  ursi,  and  the  spirits  of  nitrous 
ether,  aided  more  or  less  by  digitalis,  in  many  instances  will  be  found 
more  suitable  in  such  cases  and  much  better  calculated  to  conserve  the 
strength  of  the  patient,  and  allow  the  continuance  of  efficient  digestion, 
than  the  free  use  of  the  saline  diuretics,  such  as  the  bitartrate,  nitrate  and 
acetate  of  potassium  or  the  iodides.  But  in  the  large  proportion  of  the 
cases  of  dropsy,  both  circumscribed,  as  when  it  exists  in  some  one  of  the 
serous  sacs  of  the  body,  and  when  it  pervades  the  areolar  tissue,  your  pa- 
tient will  arrive  at  a  stage  where  your  palliative  measure  will  become 
unavailing;  neither  diuretics,  diaphoretics,  hydragogue  cathartics,  nor 
any  other  measures  that  can  be  devised  relating  to  the  administration  of 
medicine,  will  longer  hold  in  abej^ance  the  accumulation  of  fluid,  and  some 
other  measures  must  be  adopted,  or  tbo  effect  upon  some  one  or  more  of 
the  important  functions  of  the  body  will  cause  a  fatal  termination.  In 
ascites,  the  fullness  will  become  such  as  to  crowd  the  diaphragm  up- 
wards, lessening  the  capacity  of  the  chest,  and  by  direct  pressure  upon 
the  stomach,  preventing  the  taking  of  food  and  its  digestion  to  such  an 
extent  as  to  endanger  the  life  of  the  patient.  In  hydrothorax  a  similar 
danger  will  result  from  a  great  degree  of  compression  of  the  lungs.  Ac- 
cumulations in  the  pericardium,  similarly  endanger  fatal  pressure  upon 
the  walls  of  the  heart.  When  the  dropsy  is  thus  circumscribed,  and  it  can 
not  any  longer  be  either  diminished,  or  the  patient  protected  from  serious 
danger,  the  proper  resort  is,  to  direct  evacuation  of  the  contained  fluid, 
either  by  paracentesis,  with  the  troohar,  or  by  aspiration.  The  latter  in 
the  great  majority  of  cases  is  preferable  for  the  thorax,  pericardium  and 


684  DROPSIES. 

sometimes  the  membranes  of  the  brain,  while   in  the  abdomen    we  may 
more  freely  use  the  ordinary  trochar. 

By  thus  directly  removing  the  accumulated  fluid,  you  will  temporarily 
relieve  the  obstructions  that  had  previously  existed,  and  give  the  patient 
at  least  a  pei'iod  of  comfort,  before  a  re-accumulation  can  take  place. 
Such  re-accumulation,  however,  in  all  cases  where  it  depends  upon  an  in- 
curable pathological  condition,  will  sooner  or  later  occur,  and  usually,  the 
rapidity  of  the  return  will  increase  after  each  tapping  or  aspiration  until, 
eventually,  the  patient  reaches  a  stagi  of  fatal  exhaustion.  Yet,  by  the 
judicious  practice  of  such  removal  life  may  be  prolonged  very  much  be- 
yond what  it  would  be,  if  no  such  resort  was  had.  In  another  class  of 
cases  affected  with  general,  instead  of  circumscribed  dropsy,  the  patient 
may  arrive  at  a  stage  where  life  is  put  directly  in  jeopardy  !)y  the  uni- 
versal infiltration  of  the  connective  tissue  of  the  body  throughout  its 
whole  extent,  and  yet  there  is  liot  such  a  degree  of  accumulation  in  any 
of  the  important  serous  cavities  that  tapping  or  aspiration  from  those 
cavities  would  afford  the  necessary,  though  temporary,  relief.  Generally 
some  other  mode  of  draining  the  connective  tissue  throughout  must  be  re- 
sorted  to,  or  the  patient  must  be  allowed  to  die.  In  such  cases,  during 
the  last  ten  years,  I  have  resorted,  in  a  goodly  number  of  instances,  to  a 
free  incision  on  one  side  of  each  ankle,  or  a  little  above  the  internal  mal- 
leolus; making  the  incision  from  an  inch  to  an  inch  and  a  half  in  length, 
directly  down  through  all  the  tissues  to  the  immediate  vicinity  of  the  peri- 
osteum. By  placing  the  limbs  a  little  dependent,  with  oil  cloth,  or  oil  silk, 
to  conduct  the  draining  fluid  off,  so  as  to  prevent  the  bed  and  clothes  from 
becoming  wet,  and  keep  the  patient  comfortable  in  that  respect,  these 
incisions  very  seldom  fail  to  produce  complete  drainage  of  the  dropsical 
fluid,  from  the  whole  extent  of  the  connective  tissue  of  the  body.  And 
in  some  cases  of  incurable  organic  disease  of  the  heart,  they  have  relieved 
the  patient  almost  entirely  from  four  to  six  months.  And  when  the 
incisions  have  healed,  and  the  tissues  have  become  filled  up  gradually,  » 
repetition  of  the  incisions  has  relieved  the  same  case,  sometimes,  two  or 
three  times,  thereby  not  only  prolonging  life  for  a  whole  year,  or  a  year 
and  a  half  in  some  instances,  but  rendering  the  patient  most  of  the  time 
comparatively  comfortable.  The  same  is  true  in  cases  that  result  from 
renal  disease;  unless  the  incisions  are  postponed  so  long  that  the  elimina- 
tion of  urea  has  ceased,  and  uremic  poisoning  has  already  developed  in 
the  nervous  centers.  In  a  few  instances  where  the  renal  disease  was  sup- 
posed to  -have  been  permanent  and  incurable,  complete  drainage  of  the 
water  from  the  tissues  through  the  incisions  in  the  ankles  has  resulted  in 
the  full  return  of  the  renal  secretion  permanently,  and  the  consequent 
restoration  of  the  patient.  I  have  thus  given  you  this  outline  of  the  va- 
rieties of  dropsical  accumulations,  or  serous  fluxes  into  the  shut  sacs  and 
connective  tissues  of  the  body,  the  different  causes  and  pathological  con- 
ditions that  give  rise  to  them,  and  the  principles  that  should  guide  us  in 
their  treatment,  both  in  reference  to  removal  of  the  original  disease,  and 
in  the  palliation  of  such  cases  as  admit  only  of  this  mode  of  treatment, 
and  the  prolongation  of  life.  I  will  therefore  next  call  your  attention  to 
the  other  division  of  fluxes  which  I  denominate  sanguineous  fluxes  or 
hemorrhages. 


HEMOERHAGES.  685 


LECTURE    LXVI. 


Sanguineous  Fluxes  or  Hemorrhages— Their  Varieties,  Causes,  Consequences,  and  General  Prin- 
ciples of  Treatment. 

GENTLEMEN" :  By  sanguineous  fluxes,  or  hemorrhages,  I  mean  the  flow 
or  exit  of  blood  from  the  vessels  in  which  it  is  naturally  contained. 
The  nost  common  causes  of  hemorrhage,  are,  solutions  of  continuity  or 
rupture  of  the  vessels,  resulting  from  wounds,  or  injuries  produced  by 
mechanical  violence.  But  all  hemorrhages  of  this  class  are  necest-arily 
of  a  surgical  character,  and  involve  surgical  treatment,  consequently  they 
are  excluded  from  our  present  consideration.  Leaving  the  iiemorrhages 
that  thus  result  from  direct  mechanical  violence,  all  others  may  be  divid- 
ed primarily  into  two  classes  :  First,  those  which  result  from  increased 
flow  of  blood  to  some  part,  or  some  particular  vessel,  faster  than  the  cap- 
illaries are  capable  of  allowing  its  transmission.  Second,  such  as  result 
from  some  impairment  in  the  function  or  structure  of  the  vessels  them- 
selves. The  first  may  be  produced,  either  by  severe  exertion,  by  which 
the  force  and  frequency  of  the  action  of  the  heart  is  increased,  as  in 
heavy  lifting  or  any  other  violent  exercise,  or  it  may  arise  from  simple 
increase  of  the  muscular  force  of  the  heart  in  the  systolic  contractions, 
thereby  sending  the  blood  more  forcibly,  and  in  greater  quantities  to  the 
parenchyma  of  organs  and  the  periphery  of  difl"erent  structures  of  the 
body,  than  is  natural.  In  such  cases,  the  organs  which  receive  their 
blood  in  the  most  direct  line  from  the  heart,  will  feel  the  force  of  such 
increased  activity  in  the  greatest  degree.  Hence,  most  of  the  hemor- 
rhages that  occur  from  these  causes  are  from  the  yielding  of  the  walls  of 
vessels  either  in  parts  within  the  cranium,  or  in  the  Schneiderian  mem- 
brane, or  from  the  vessels  of  the  lungs.  Another  less  frequent,  but  yet 
occasional  cause  of  increased  flow  of  blood  into  certain  structures  faster 
than  the  capillaries  and  small  vessels  are  capable  of  conveying  it  through, 
is  an  increased  activity  of  contraction,  and  consequent  tension  of  the 
coats  of  the  larger  arteries  leading  in  any  given  direction,  but  more  fre- 
quently of  the  aorta  itself.  Cases  of  this  kind  I  have  observed,  both  in 
the  thoracic  and  abdominal  sections  of  the  aorta,  and  though  rare,  yet  in  a  few 
instances  they  evidently  caused  hemorrhages  of  much  the  same  character 
as  result  from  hypertrophy  of  the  heart.  All  the  class  of  cases  to  which 
I  have  now  alluded,  whether  arising  from  the  effects  of  protracted  and 
severe  exercise,  or  from  muscular  hypertrophy  of  the  heart,  or  increased 
activity  of  the  muscular  structure  of  the  larger  blood  vessels,  are  properly 
called  active  hemorrhages  ;  indicating  by  that  phrase,  that  they  result 
from  increased  impetus  or  flow  of  blood  to  the  part,  and  not  from  any 
special  fault  in  the  structure  of  the  part  from  which  the  blood  flows.  The 
second  class  of  hemorrhages,  however,  result  from  an  entirely  different 
class  of  causes,  having  no  connection  with  any  increased  flow  of  blood  to 
the  part  or  increased  activity  in  the  mechanism  of  the  circulation,  but  re- 
sulting either  from  mechanical  obstruction,  or  impairment  of  vessels  them- 
selves. The  obstructions  may  vary  widely  in  their  nature  from  each 
other.  Perhaps  those  of  most  frequent  occurrence  are  from  inflammatory 
exudations.  You  have  noted  in  the  descriptions  1  have  given  of  nearly 
all  the  acute  inflammations,  when  speaking  of  the  resulting  anatomical 
changes,  that  among  those  changes  in  the  texture  of  organs  there  was  to 


686  HEMOREHAGES. 

be  observed  in  many  cases  the  appearance  of  red  corpuscles  of  the  blood 
with  the  exudative  material,  constituting  minute  hemorrhages  from  the 
inflamed  and  obstructed  capillaries. 

These,  however,  are  usually  not  included  in  the  class  of  hemorrhages  as 
described  in  your  text  books,  but  are  simply  spoken  of  as  part  of  the  an- 
atomical changes  belonging  to  the  inflammatory  processes.  Another 
class  of  obstructions  in  the  vessels,  however,  that  may  give  rise  to  more 
positive  hemorrhages,  consist  of  emboli  or  fibrinous  clots  and  shreds,  either 
forni3d  in  some  portion  of  the  vessel,  or  carried  into  it  from  the  central 
organs  of  circulation.  Undoubtedly  many  cerebral  hemorrhages  occur  in 
this  way,  and  some  in  the  pulmonary  structures,  and  occasionally  into  the 
parenchyma  of  the  spleen,  kidneys  and  liver.  A  still  more  frequent  cause 
of  hemorrhage  from  direct  o')struction  of  the  vessels  of  the  part  consists 
of  tubercular  deposit.  This  kind  of  deposit,  as  stated  to  you  when  speak- 
ing of  the  subject  of  tuberculosis,  has  been  more  frequently  found  in  the 
lungs  than  any  other  part  of  the  human  body.  The  pulmonary  structure 
being  exceedingly  vascular,  and  its  connective  tissue  distensible  or  elas- 
tic, the  deposit  of  tubercular  matter,  whether  in  small  granules,  or  in  larger 
masses  of  more  friable  or  caseous  material,  is  very  liable  to  be  so  place  i 
as  to  obstruct  completely  the  flovv  of  blood,  through  not  only  the  capil- 
lary vessels,  but  the  smallar  arteries  and  veins.  And  one  of  the  most 
common  incidents  in  the  progress  of  pulmonary  tuberculosis  of  all 
varieties,  is  the  occurrence  of  hemorrhage,  technically  called  hemoptysis. 
Hence,  it  is  often  the  case  that  these  hemorrhages  from  the  lungs  take 
place  early  in  the  progress  of  the  tubercular  affection;  so  early,  indeed,  as 
to  constitute  the  first  thing  to  arrest  the  attention  of  the  patient,  and 
to  impress  upon  him  the  idea  that  some  serious  disease  is  pending. 
Another  mode  of  obstructing  vessels  suffijiently  to  cause  hemorrhage  is 
the  pressure  of  tumors  or  morbid  growths,  or  the  enlargement  of  viscera  in 
any  direction,  by  which  such  enlargements  are  made  to  produce  mechan- 
ical pressure  sufficient  to  obstruct  the  natural  passage  of  blood  through 
the  vessels.  Still  another  class  of  pathological  conditions  which  may 
give  rise  to  hemorrhage,  consist  in  alterations  of  the  texture,  or  walls  of 
the  vessels  of  tlie  part  from  which  the  blood  flows.  Chief  among  these 
alterations  are  fatt}'-  or  caseous  degenerations  in  the  fibres  of  the  muscu- 
lar coat  of  the  vessels.  Such  degeneration  diminishes  the  tonicity  or 
firmness  of  the  texture,  and  allows  the  ordinary  degree  of  blood  pressure 
to  rupture  the  vessel  walls  and  permit  the  flow  of  blood  cither  upon  the 
surface,  or  directly  into  the  parenchyma  of  the  texture.  Familiar  exam- 
ples of  this  kind  of  degeneration  are  found  n^ore  particularly  in  the  brain, 
in  patients  of  sedentary  habits  or  who  have  long  been  addicted  to  the 
moderate  use  of  alcoholic  drinks;  by  which  the  oxygenation  and  decarbon- 
ization  of  the  blood  is  retarded,  thereby  favoring  the  caseous  or  fatty  degen- 
era  ion  of  the  structures  generally.  Similar  degenerations  take  place  some- 
times from  age,  without  being  preceded  by  objectionable  habits  or  modes 
of  life,  but  simply  as  the  result  of  impaired  nutritive  changes  in  old  age. 
A  large  proportion  of  the  attacks  of  paralysis,  especially  of  a  hemiplegic 
character,  that  occur  between  the  ages  of  forty  and  sixty  years,  as  well  as 
those  of  apoplexy,  are  from  this  form  of  degeneration  in  the  structure  of 
the  coats  of  the  cerebral  vessels.  Another  alteration,  or  pathological  con- 
dition of  the  vessels  which  favors  hemorrhage  is  defective  nutrition.  In 
certain  conditions  of  the  blood  and  of  the  properties  of  the  tissues,  such 
as  is  illustrated  in  the  disease  called  scorbutis  or  scurvy;  in  pernicious 
anasmia,  and  other  affections  in  which  the  blood  is  changed  in  its  quality, 
either  by  impairment  of  its  coagulability,  or  by  so  great  impoverishment  of 


CAUSES.  687 

its  nutritive  constituents  as  to  be  incapable  of  affording  the  elements  of 
healthy  nutrition,  or  of  sustaining  the  vital  affinity  governing  molecular 
movements  and  giving  tone  to  the  tissues.  Consequently  the  actual  nu- 
trition of  the  vessel  walls  in  some  organs  becomes  so  impaired,  that  they 
are  incapable  of  resisting  the  pressure  of  blood  in  them;  in  such  cases 
either  a  direct  rupture  of  the  vessel  wall  and  hemorrhage  may  occur,  or  a 
transudation  of  the  blood  by  exosmosis  without  visible  rupture. 

Still  another  condition  of  vessels  is  sometimes  met  with,  that  I  may 
denominate  atrophy  or  wasting  of  the  vessel  walls  with  dilatation.  This 
is  perhaps,  the  condition  existing,  to  some  extent,  in  all  cases  of  varicose 
distension  of  veins;  ordinarily  however,  cases  of  this  kind  do  not  give 
rise  to  actual  hemorrhage.  But  when  the  part  is  so  situated,  that  coinci- 
dent with  diminished  i.utrition  leading  to  atrophy  of  the  vessel  walls, 
there  is  at  the  same  time  diminution  of  the  natural  amount  of  pressure 
from  without  on  the  vessels,  as  seen  in  advanced  life  in  those  instances 
where  the  brain  begins  to  diminish  in  volume,  leaving  less  pressure 
against  the  veins  of  the  dura-mater,  at  the  same  time  that  the  general 
nutrition  of  the  veins  is  less  than  normal,  we  get  that  condition  of  im- 
paired vessel  walls  constituting  a  thinning  with  small  dilatations,  ruptures 
and  hemorrhages  of  a  limited  amount,  constituting  the  disease  which  has 
been  denominated  pachy- meningitis  interri,  and  which  I  have  already 
described  to  you  when  speaking  of  inflammatory  affections  of  the  mem- 
branes of  the  brain.  Although  this  condition  was  then  described  in  the  list 
of  inflammations  of  the  cerebral  membrane,  it  was  made  evident  that  the 
morbid  conditions,  and  especially  the  hemorrhages  which  occur  in  such 
cases  often  leading  to  some  of  the  most  prominent  and  dangerous  symp- 
toms that  accompany  that  form  of  disease,  arise  not  from  inflammatory 
congestion,  but  from  actual  thinning  of  the  walls  of  the  vessels  and  the 
diminished  pressure  produced  by  the  shrinking  of  the  cerebral  mass. 
Consequently  the  haematoma,  as  they  are  called,  accompanying  pachv- 
meningitis,  are  actual  specimens  of  hemorrhage  resulting  from  this 
atrophy  of  vessel  walls  and  diminished  pressure  upon  their  exterior. 
Still  another  morbid  condition  of  the  vessels  favoring  the  occurrence  of 
hemorrhage  is  the  impairment  or  suspension  of  vaso-motor  influence, 
causing  paralysis,  either  complete  or  partial,  in  the  muscular  structure 
entering  into  the  composition  of  the  coats  of  the  vessels.  You  will 
readily  see  how  this  might  favor  such  an  accumulation  of  blood  in  the  part 
as  to  result  in  the  rupture  of  their  walls  and  hemorrhage.  The  blood 
continuing  to  flow  into  the  vessels  by  the  ordinary  force  of  the  heart  and 
receiving  no  additional  impulse  from  contraction  of  the  vessel  walls,  does 
not  pass  through  the  capillaries  with  the  usual  degree  of  rapidity,  and 
consequently  would  tend  directly  to  accumulate  in  the  arterioles  until 
over-distension  might  cause  rupture  and  hemorrhage. 

The  last  class  of  causes  or  pathological  conditions  I  shall  enumerate  re- 
late to  the  quality  of  the  blood.  As  I  remarked  a  few  moments  ago,  when 
the  blood  is  greatly  impoverished  in  its  corpuscles  and  albumen,  render- 
ing it  unnaturally  thin,  it  exhibits  a  tendency  to  permeate  the  vessel 
walls,  producing  petechial  or  hemorraghic  spots.  When  such  a  condition 
of  the  blood  exists  coincidently  with  impairment  of  vaso-motor  influence, 
there  is  decided  danger  of  hemorrhagic  exudation.  Still  more,  however, 
is  this  the  case  when  impairment  of  vaso-motor  influence  in  the  vessel  is 
associated  with  that  disorganized  morbid  condition  of  the  blood  which 
exists  in  well  marked  cases  of  scorbutus,  the  plague  and  other  malignant 
fevers,  and  the  bites  of  serpents.  Such  cases  are  generally  accompanied  by 
hemorrhages,  both  from  the  free  surfaces,  such  as  the  mucous  membrane  of 


688  HEMOERHAGES. 

the  month,  nostrils,  stomach  and  intestines,  and  into  the  parenchyma  of 
organs,  or  the  cutaneovis  or  subcutaneous  tissues.  In  the  latter,  it  gives  rise 
to  the  well  known  appearance  of  patechial,  purpuric  and  hemorrhagic  spots, 
which  often  accompany  the  malignant  types  of  disease.  Hemorrhages, 
when  arising  from  an}-  one  of  the  last  class  of  causes  I  have  enumerated, 
are  called  passive  hemorrhages,  in  contra-distinction  to  those  I  have  enu- 
merated as  active  hemorrhages;  the  latter  being  the  result  of  increased 
active  flow  of  blood  to  the  part,  and  all  the  former,  however  varied  may  be 
the  pathological  condition,  having  resulted  from  passive  accumulation  of 
blood  in  the  part. 

From  this  review,  you  will  perceive  that  hemorrhages,  like  the  serous 
fluxes  of  which  I  have  previously  spoken,  are  all  simply  consequences,  or 
mere  coincidences  of  preceding  disease,  and  are  therefore  symptoms  of  no 
one  morbid  condition.  You  will  also  see  clearly,  from  the  number  of  dif- 
ferent pathological  conditions  that  may  give  rise  to  hemorrhage,  that  it  is 
of  the  utmost  importance,  in  the  management  of  such  cases  as  may  arise 
in  ordinary  practice,  to  so  study  them,  that  the  proper  diagnosis  as  to  the 
actual  causes  and  pathological  conditions  existing  in  any  individual  case 
may  be  duly  appreciated.  For,  the  methods  of  treatment  must,  in  all 
cases,  be  guided  largely  by  the  preceding  and  accompanying  pathological 
conditions  on  which  the  hemorrhage,  as  a  mere  symptom,  may  depend. 
As  I  have  already  intimated,  hemorrhages  may  take  place  either  from  free 
surfaces,  or  into  the  shut  sacs  of  the  body,  or  into  the  parenchyma  of  dif- 
ferent organs  and  textures;  but  the  symptoms  which  will  be  presented, 
will  vary  much  in  accordance  with  this  division.  When  the  flow  takes 
place  from  free  surfaces  the  symptoms  resulting  immediately  from  the 
hemorrhage  will  be  almost  exclusively  such  as  are  produced  by  the  loss 
of  blood,  namely:  paleness  of  the  surface,  softness  and  increased  fre- 
quency of  the  pulse,  diminished  temperature  or  coldness  of  the  extremities 
and  surface  of  the  body,  great  sense  of  weakness,  with  irregular  sighing 
respiration,  relaxation  of  the  skin,  with  increased  exudation  or  sweating, 
thirst,  restlessness,  vertigo,  ringing  in  the  ears,  dimness  of  vision,  and 
finally  syncope  and  death  from  exhaustion.  But  when  the  blood,  instead 
of  flowing  from  the  free  surfaces  makes  its  exit  into  shut  sacs,  or  into  the 
parenchyma  of  any  of  the  organized  structures  of  the  body,  another  class 
of  symptoms  may  be  added  to  those  I  have  already  enumerated. 

It  is  true,  that  if  the  flow  is  into  one  of  the  larger  serous  sacs,  as  into 
the  peritoneal,  or  pleural  cavities,  the  quantity  of  blood  lost  in  filling  up 
either  of  these  cavities  may  produce  all  the  direct  symptoms  that  I 
have  indicated,  even  to  that  of  death  from  direct  syncope.  But  when- 
ever the  hemorrhage  takes  place  into  the  smaller  cavities,  and  especially 
when  it  occurs  in  the  parenchyma  of  organs  it  seldom  produces  its  most 
disastrous  effects  from  the  quantity  of  blood  lost,  but  from  interruption 
of  the  function  of  the  part  immediately  subject  to  the  pre-sure  of  the 
accumulated  blood.  Even  when  the  hemorrhage  is  into  the  cavity  of  the 
pleura  there  is  perhaps  more  danger  to  life  from  the  interference  with 
the  expansion  of  the  lungs,  and  the  carrying  on  of  respiration,  than  from 
the  quantity  of  blood  lost.  Still  more  would  this  be  the  case  when  the 
hemorrhage  is  into  the  pericardium.  That  sac  would  hardly  contain  a 
sufficient  amount  of  blood  to  be  fatal,  merely  from  the  quantity  of  the 
blood  that  would  be  withdrawn  from  the  general  circulation,  but  might 
readily  prove  fatal  from  the  amount  of  pressure  the  accumulated  blood 
would  exert  upon  the  walls  of  the  heart.  And  if  the  hemorrhage  is 
either  upon  the  surface  or  in  the  parenchyma  of  the  brain,  where,  from  the 
bony  encasement,  there  can  be  no  distension  of  the  walls  and  the  pressure 


SYMPTOMS.  689 

of  the  accumulated  blood  must  be  'brought  to  bear  directly  upon  the 
cerebral  substance,  there  is  imminent  danger  of  fatal  consequences  even 
from  a  very  small  amount  of  hemorrhage. 

Hemorrhages  taking  place  into  tlie  cutaneous  and  subcutaneous  areolar 
tissue,  v\hile  they  may  impede  movements  and  interfere  with  the  functions 
of  the  parts  to  some  extent,  and  thereby  cause  the  patient  much  inconven- 
ience, are  rarely  either  sufficient  in  quantity  to  prove  directly  fatal,  or  to 
interfere  sufficiently  with  any  vital  function  to  produce  the  same  result 
indirectly.  From  this  general  review  of  the  pathological  conditions  giv- 
ing rise  to  hemorrhages,  tiie  general  lesions  and  symptoms  which  accom- 
pany them,  both  when  from  free  surfaces,  and  the  parenchyma  of  organs, 
you  will  readily  perceive  that  it  would  be  an  unnecessary  waste  of  time  to 
take  up  the  various  hemorrhages  and  describe  the  phenomena  or  symptoms 
accompanying  each  in  detail.  Of  those  which  flow  from  free  surfaces,  the 
most  common  are  epistaxis  from  the  Schneiderian  membrane,  haemopty- 
sis from  the  lungs,  hajmatemesis  from  the  coats  of  the  stomach,  hgematuria 
from  the  mucous  membrane  of  the  bladder,  menorrhagia.  from  the  uterus, 
and  intestinal  hemori-hage  from  any  part  of  the  mucous  membrane  of  the 
alimentary  canal  below  the  stomach.  When  the  hemorrhages  occur  into 
the  connective  or  areolar  tissue  in  any  part  of  the  body  it  takes  the  name 
of  haematocele  or  blood  tumor. 

From  what  I  have  just  said  in  regard  to  the  symptoms  which  result 
from  hemorrhage,  both  from  free  surfaces  and  into  the  shut  sacs  and 
parenchyma  of  organs,  it  requires  but  a  single  step  of  inductive  reasoning 
to  arrive  at  the  three  leading  objects  to  be  attained  in  their  treatment. 
These  are,  first,  the  adoption  of  such  measures  as  are  calculated  to  ar- 
rest the  further  flow  of  blood;  secondly,  to  mitigate  or  remove  the 
consequences  of  such  flow  as  has  already  taken  place;  and  third,  to  re- 
move as  far  as  practicable  the  pathological  conditions  which  have  been 
the  primary  cause  of  the  hemorrhage.  If  you  see  clearly  the  scope  of 
these  three  objects  in  the  arrest  of  the  further  flow,  the  mitigation  or  re- 
moval of  the  immediate  consequences  of  that  flow  upon  the  functions  that 
may  be  involved,  and  the  removal  of  the  original  pathological  condition 
from  which  the  hemorrhage  has  arisen,  you  will  be  able,  in  any  given 
case,  to  conduct  its  treatment  on  rational  principles.  In  regard  to  the 
first  of  these  objects,  it  will  occur  to  you  at  once  from  what  I  have  said, 
that  the  means  for  arresting  the  further  flow  of  blood  in  any  given  case 
must  depend,  in  part  at  least,  upon  the  immediate  cause  of  such  flow.  If 
the  hemorrhage  be  one  of  the  active  class,  dependent  upon  an  increased 
impetus  or  flow  of  blood  to  the  part,  the  first  step  in  the  treatment  must 
be  to  retard  that  flow.  Where  it  has  arisen  from  some  sudden  or 
violent  exercise,  the  exertion  must  be  stopped,  not  only  for  the  time  be- 
ing, but  permanently.  If  it  originates  from  increased  cardiac  action, 
whether  from  direct  hypertrophy  of  the  muscular  structure,  giving  it  in- 
creased power  to  propel  the  blood  through  the  arterial  system,  or  whether 
it  be  from  temporary  excitation  of  the  cardiac  structure,  the  first  step  in 
the  treatment  must  be  to  moderate  the  cardiac  action  either  by  direct  de- 
pletion (venesection),  or  by  cardiac  sedatives  and  rest.  The  force  and 
frequency  with  which  the  heart  propels  the  blood,  must  be  diminished. 
If  the  patient  is  plethoric,  in  the  middle  period  of  life,  or  in  3'outh,  one 
prompt  venesection  may  be  one  of  the  most  efficient  means  for  dimin- 
ishing the  cardiac  force  and  arterial  tension,  thereby  arresting  the 
hemorrhage.  In  the  great  majority  of  such  cases,  however,  the 
prompt  administration  of  such  cardiac  sedatives  as  directly  diminish  the 
44 


690  HEMOEKHAGES. 

force  and  frequency  of  the  heart's  action,  will  be  sufiGcient  for  arrest- 
ing- the  further  flow  without  venesection.  Among  the  most  efficient  of  such 
agents  are  the  veratrum  viride,  aconite,  gelsemium,  and  perhaps  I  would 
be  justified  in  putting  with  these  the  acetate  of  lead,  particularly 
when  given  in  as  large  doses  as  the  stomach  will  bear.  The  same  rule 
of  treatment  applies  to  those  rare  cases  that  appear  to  depend  on  increased 
arterial  activity,  especially  when  manifest  in  the  coats  of  the  aorta. 

In  all  cases  of  active  hemorrhage  it  is  not  only  of  primary  importance 
to  diminish  the  force  and  frequency  of  the  action  of  the  heart  and  tlie 
larger  arteries,  and  keep  the  patient  at  rest,  but  it  is  also  in  some  of  the 
cases  beneficial  to  moderately  act  upon  the  secretions  by  diaphoretics, 
diuretics  and  mild  laxatives,  thereby  lessening  the  general  fullness  of  the 
vessels.  The  diet  should  be  simple,  unstimulating,  and  moderate  in 
amount.  When  hemorrhage  of  the  second  or  passive  class  occurs,  in  ful- 
filling the  first  indication  I  have  laid  down,  namelj',  to  arrest  the  further 
flow  of  blood,  there  is  often  required  a  very  careful  and  accurate  discrimi- 
nation between  cases  which  may  depend  upon  different  pathological  con- 
ditions of  the  vessels  of  the  part.  In  all  such  as  appear  to  be  dependent 
on  impairment  of  the  vaso-motor  nerve  influence,  inducing  what  might  be 
termed  in  familiar  language,  relaxation  of  the  coats  of  the  vessels,  and 
consequent  retardation  of  the  flow  of  blood  through  the  capillaries,  al- 
lowing it  to  passively  accumulate  without  actual  degeneration  of  struct- 
ure in  the  vessels  themselves,  there  are  no  remedies  more  efficient  in 
directly  arresting  further  flow  of  blood  than  such  as  directly  increase  the 
action  of  the  vaso-motor  nerves  on  the  contractility  of  the  vessels. 
Ergot,  or  its  active  principle,  ergotin,  is  one  of  the  most  efficient  of  this 
class  of  agents.  The  tincture  of  the  chloride  of  iron,  persulphate  of  iron, 
and  most  of  those  remedies  which  are  recognized  as  astringents,  produce 
somewhat  analogous  effects  by  their  presence  in  the  blood,  whether  it  be 
by  acting  on  the  vaso-motor  nerves,  or  directly  on  the  walls  of  the  vessel 
themselves. 

The  first  three  of  the  agents  named  have  been  in  my  hands  most 
efficient:  namely,  ergot  or  ergotin,  the  persulphate,  and  tincture  of  the 
chloride  of  iron.  The  activity  with  which  they  are  administered  must 
depend  upon  the  urgency  of  the  case,  or  the  rapidity  of  the  flow  of  blood. 
In  cases  of  hemorrhage  dependent  on  fatty,  caseous  or  other  forms  of 
degeneration  in  the  coats  of  the  vessels,  if  not  sufficient  to  produce  im- 
mediately fatal  results,  will  be  influenced  more  by  the  use  of  such  agents 
as  improve  nutrition,  and  at  the  same  time  increase  vaso-motor  influence. 
Strychnia  and  the  mineral  acids  often  act  favorably  upon  this  class  of 
cases.  They  should  be  given  in  doses  suited  to  the  age  of  the  patient 
and  the  condition  of  the  digestive  organs;  and  where  there  is  a  decided 
excess  of  fat,  the  administration  of  from  three  to  five  decigrammes  (gr.  v 
to  viii)  of  chlorate  of  potash  in  a  mucilaginous  solution  after  each  meal, 
by  increasing  the  chlorine  salts  in  the  blood,  and  the  consequent  taking  up 
of  an  increased  amount  of  oxygen  from  the  air  cells  of  the  lungs,  will  aid 
in  oxidizing  the  fatty  and  carbonaceous  materials  of  the  blood,  and 
thereby  prevent  further  accumulation  of  these  materials  in  the  tissues. 
It  may  not  aid  in  arresting  hemorrhages  in  this  class  of  patients  but  will 
lessen  the  danger  of  thf  ir  recurrence  alter  they  have  been  arrested. 

The  same  rules  and  class  of  remedies  apply  to  the  accomplishment  of 
the  first  object  in  the  treatment  of  all  the  forms  of  hemorrhage  that  re- 
sult from  impairment  in  the  tone  of  the  vessels.  In  those  cases  arising  from 
toxemic  conditions  of  the  blood,  the  remedies  must  be  principally  such  as 
are  calculated  either  to  neutralize  or  remove  thj  blood  poison,  in  connec- 


PATHOLOGY.  691 

tion  with  such  as  increase  the  general  tonicity  of  the  whole  vascular 
system.  In  other  words  the  hemorrhage  is  but  the  symptom  of  the  general 
disease  and  must  be  treated  accordingly,  that  is,  by  controlling  the  patho- 
logical condition  upon  which  it  depends.  I  will  detain  you  only  to  speak 
a  few  words  in  regard  to  that  form  of  hemorrhage  which  takes  place 
in  connection  with,  or  in  consequence  of  what  has  been  denominated  the 
hemorrhagic  diathesis  or  hasmaphilia.  This  condition  is  met  with  most 
frequently  in  cliildren  under  the  age  of  ten  years,  and  occasionally  at  a 
later  period,  but  very  rarely  in  adult  life. 

There  are  various  degrees  of  this  diathesis,  or  tendency  to  hemorrhage. 
In  the  great  majority  of  cases,  it  is  not  so  strongly  developed  as  to  pro- 
duce spontaneous  hemorrhage  from  any  part  of  the  body.  But  when- 
ever a  solution  of  continuity  has  taken  place  by  any  wound,  however 
trifling  or  small,  there  is  no  tendency  to  stop  the  flow  of  the  blood,  but 
it  oozes  almost  indefinitely.  The  extraction  of  a  tooth  in  such  a 
constitutional  condition  often  incurs  very  dangerous  loss  of  blood. 
The  prick  of  a  pin  or  slight  cut  of  a  knife  in  any  part  of  the 
body  causes  the  blood  to  continue  oozing,  with  no  apparent  spon- 
taneous tendency  to  its  own  arrest.  In  some  of  these  cases,  es- 
pecially in  children  from  two  to  six,  eight  or  ten  years  of  age,  the 
tendency  to  hemorrhage  is  so  strong  that  it  will  occur  spontaneously 
or  without  any  injury  whatever.  I  have  met  with  some  cases  in  which  the 
flow  of  blood  took  place  from  the  gums  and  mouth  without  any  visible 
wound  in  the  membrane  lining  the  parts;  more  frequently  from  the 
Schneiderian  membrane  of  the  nostrils,  slowly  but  continuously,  until  a 
most  dangerous  degree  of  exhaustion  had  occurred.  I  have  met  with 
several  cases  where  the  hemorrhage  occurred  in  the  same  spontaneous 
manner,  without  any  known  provocation  by  wounds  or  bruises,  into  the 
subcutaneous  tissue;  more  frequently  of  the  lower  extremities,  causing 
numerous  accumulations  of  blood  and  consequent  tumefactions.  These 
blood  tumors  are  liable  to  present  all  those  varieties  of  color  that  follow 
extravasations  of  blood  into  the  tissues  from  ordinary  bruises  or  contused 
wounds.  In  one  instance  two  very  large  hemorrhages  took  place  into  the 
areolar  tissue  on  the  back  between  the  scapula,  one  of  which  was  at  least 
15  centimeters  (5  inches)  in  diameter.  The  same  patient  had  seven  small 
ones  in  the  lower  extremities.  It  is  not  often  that  this  class  of  patients 
have  hemorrhages  from  the  lungs,  or  ffom  the  stomach,  unless  there  is  a 
preceding  wound  or  injury;  but  from  the  mucous  membrane  of  the 
mouth,  nostrils,  and  into  the  cutaneous  and  subcutaneous  tissues,  hem- 
orrhages are  frequent  in  their  occurrence  and  are  often  sufficiently  copious 
to  induce  a  very  dangerous  degree  of  exhaustion.  But  it  is  particularly 
when  they  accidentally  meet  with  some  slight  wound,  that  they  are  liable  to 
such  a  flow  of  blood  as  to  endanger  life.  A  few  of  these  patients  I  have 
had  under  observation  for  a  series  of  years.  One  in  the  West 
division  of  the  city  was  under  my  care  at  different  times  as  occa- 
sion might  require  from  the  age  of  two  up  to  that  of  ten  years, 
and  several  have  been  similarly  under  observation  for  two,  three  or 
four  years.  I  do  not  now  remember  any  case  under  my  own  supervision 
that  terminated  fatally  as  the  direct  result  of  hemorrhages.  But  they 
all  present  some  evidence  of  blood  impoverishment,  such  as  paleness 
of  the  lip,  a  sallow  or  cachectic  hue  of  the  surface  and  sometimes  a  puffv 
or  semi-oedematous  appearance  of  the  face  and  extremities.  When  a  con- 
siderable period  has  elapsed  without  hemorrhage  they  are  usually  free 
from  symptoms  of  disease  except  such  as  would  be  common  to  a  moderate 
degree  of  debility  or  lack  of  power  of  endurance. 


692  HEMOEEHAGES. 

Pathology . — The  actual  pathological  conditions  existing  in  these  cases 
of  hemorrhagic  diathesis  have  never  been  reliably  and  accurately  deter- 
mined. Most  of  the  older  writers  expressed  their  opinion  that  the 
essential  defect  was  in  the  coagulability  of  the  blood,  or  in  its  plasticity. 

But  I  have  seen  no  case  in  which  the  blood  escaping  from  the 
vessels  directly  in  the  progress  of  the  hemorrhage,  did  not  coagulate,  or 
in  which  the  solidified  fibrin  did  not  possess  a  fair  degree  of  tenacity. 
Chemical  analysis  has  not  resulted  in  the  discovery  of  sufficient  deficiency 
either  in  the  quantity  of  fibrin,  the  amount  of  albumen,  or  any  other  ele- 
ments that  may  be  supposed  to  be  concerned  in  giving  the  blood  plastic- 
ity to  account  for  the  constitutional  defect.  More  recently,  a  better  ap- 
preciation of  the  influence  of  vaso-motor  nerves  upon  the  blood  vessels, 
and  the  part  that  the  contraction  of  arterioles  and  smaller  veins  have  in 
aiding  the  circulation,  has  led  to  the  supposition  that  the  defect  in  the 
class  of  cases  to  which  I  allude,  was  the  arrest  of  the  vaso-motor  power, 
causing  paralysis  of  the  coats  of  the  smaller  vessels,  thereby  destroying 
their  tendency  to  contract,  and  allowing  passive  exudation  spontaneously; 
and  when  a  vessel  is  severed  leaving  it  without  the  power  to  contract 
sufficiently  to  close  the  orifice. 

Another  theory  or  supposition  is,  that  the  defect  consists  in  the  absence 
of  the  usual  muscular  fibers  naturally  existing  in  the  coats  of  the  arterioles 
and  smaller  veins.  The  absence  of  these  would  render  the  vaso-motor 
influence  of  no  efi'ect,  there  being  no  muscular  structure  on  which  the 
nerves  could  act,  and  the  vessels  themselves  would  be  without  the  ca- 
pacity to  contract.  The  truth  or  falsity  of  this  latter  supposition  ought 
to  be  demonstrable  by  dissection  and  microscopic  study  of  the  composi- 
tion of  the  coats  of  these  smaller  vessels,  I  am  not  aware  that  this  part 
of  the  investigation  has  been  carried  to  the  extent  that  it  ought  to  be, 
and  it  aff"ords  a  field  in  which  some  of  you,  who  are  skilled  both  in  dis- 
sections with  the  scalpel,  and  in  microscopic  observation,  may  do  well  to 
enter  upon  the  first  opportunity  that  may  be  afforded  you  and  study  this 
part  of  the  subject.  My  own  impression  is,  that  there  is  both  a  defect  in 
the  amount  of  muscular  structure  entering  into  the  vessels,  and  in  the 
vaso-motor  nerve  influence.  In  one  case  the  one  predominates,  and  in 
another  case,  the  other.  Whenever  the  cause  depends  upon  a  loss  of  in- 
nervation or  defect  in  the  vaso-motor  nerve  influence  they  are  more 
amenable  to  treatment  and  more  generally  recover  or  arrive  at  an  ultimate 
removal  of  the  diathesis,  and  continue  on  through  the  ordinary  period  of 
life,  while  cases  dependent  on  the  absence  of  muscular  fibers  in  the 
coats  of  the  smaller  vessels,  are  probably  incurable. 

Treatment. — For  arresting  hemorrhage  in  these  cases  when  called  at  the 
time  it  is  in  progress,  whether  spontaneous  or  from  some  wound  orinjurj^ 
I  have  found  no  other  remedies  equal  in  efficiency  to  the  internal  admin- 
istration of  persulphate  of  iron  and  ergot,  not  given  together,  but  alter- 
nately, in  doses  suited  to  the  age  of  the  patient,  each  once  in  from  two  to 
four  hours,  or  from  one  to  two  hours  apart,  according  to  the  gravity  of 
the  case,  and  the  eftect  desirable  to  accomplish.  In  some  of  the 
cases  there  has  been  a  coincident  irritable  and  quick  pulse,  with  slight 
febrile  heat,  in  which  the  use  of  digitalis  in  connection  with  the  ergot,  has 
produced  much  better  effects  than  the  latter  alone.  A  little  boy,  between 
three  and  four  years  of  age,  came  under  my  care  several  years  since,  who 
had  bled  from  the  membrane  lining  the  mouth  and  nostrils,  till  a  dan- 
gerous degree  of  exhaustion  had  supervened.  He  had  been  subjected  to 
treatment  of  some  kind  for  two  weeks  without  arresting  the  hemorrhage. 
On  giving  him  a  mixture  composed  of  equal  parts  of  tincture   of  digitalis 


TREATMENT.  693 

and  fluid  extract  of  ergot  in  doses  often  minims  of  the  mixture  in  plenty 
of  sweetened  water,  every  four  hours,  and  six  centigrammes  (gr.  i)  of  the 
persulphate  of  iron  dissolved  in  water,  between  each  of  the  doses  of  digi- 
talis and  ergot,  the  hemorrhage  was  arrested,  and  then  by  continuing  the 
same  remedies  at  much  longer  intervals  for  two  weeks,  no  return  taking 
place,  the  persulphate  of  iron  was  discontinued,  and  the  digitalis  and  er- 
got given  everv  morning  and  evening  for  six  weeks  longer.  The  child  in 
the  m'^antime  being  kept  chiefly  upon  bread  and  milk  as  a  diet,  and 
though  allowed  to  go  out,  carefully  avoiding  excessive  exercise.  There 
was  not  only  no  relapse  of  hemorrhage  during  that  time,  but  much  im- 
provement in  his  general  appearance;  the  eflects  occasioned  by  the  copious 
loss  of  blood  having  very  much  diminished,  the  treatment  was  then  discon- 
tinued. He  remained  well  for  six  months,  when,  without  any  known 
cause,  the  hemorrhage  again  commenced.  The  same  remedies  were 
again  resorted  to,  arresting  it  in  two  or  three  days,  and  taking  pains  to 
keep  up  a  moderate  amount  of  their  use  for  several  weeks,  he  remained 
exempt  from  further  bleeding  for  one  year.  At  the  end  of  that  time  I 
was  again  summoned,  and  found  him  with  a  return  of  his  old  trouble.  He 
again  recovered,  however,  under  the  treatment  that  had  been  previously 
adopted.  1  then  induced  his  mother  to  continue  the  use  of  two  doses  a 
day  of  the  digitalis  and  ergot  for  nearly  six  months,  and  although  the 
family  continued  to  live  within  my  reach  at  least  spven  or  eight  years,  I 
learned  nothing  of  any  return  of  the  hemorrhage.  In  several  instances  I 
have  known  children  to  recover  from  this  diathesis  when  it  has  been  well 
marked  and  severe,  so  that  spontaneous  hemorrhage  ceased  to  trouble 
them,  but  all  through  life  there  was  great  difficulty  in  arresting  hemorrhage 
on  ocjurrence  of  any  accident  that  produced  severance  of  the  vessels. 
While  I  have  succeeded  better  with  the  remedies  I  have  indicated  in  di- 
rectly arresting  the  flow  of  blood,  and  by  judicious  regulation  of  the  diet, 
hygienic  measures,  and  the  protracted  use  of  one  or  two  doses  a  day  of  the 
digitalis  and  ergot,  occasionally  giving  for  a  week  at  a  time,  the  tincture 
of  chloride  of  iron  in  addition  to  the  other,  still  there  are  cases  in  which 
other  remedial  agents  will  be  required.  You  should  always  make  due 
inquiry  in  regard  to  the  condition  of  the  secretions,  and  remedy  by 
suitable  laxatives  any  constipation  of  the  bowels,  correct  derangements 
of  the  stomach,  taking  care  that  the  urinary  secretion  is  kept  free  and 
natural,  and  the  function  of  the  skin  as  well  performed  as  possible.  All 
these  things  require  attention,  yet  you  must  remember  that  the  leading 
object  of  treatment  for  a  considerable  period  of  time  should  be  to  procure 
greater  efficiency  of  the  vaso-motor  influence  over  the  whole  system  of 
smaller  vessels.  Local  applications  other  than  those  that  are  designed  to 
produce  temporary  obstruction  to  the  flow  of  blood  by  contact  or  pressure, 
appear  to  produce  no  beneficial  result.  The  application  of  surgeon's  lint 
saturated  with  jiersulphate  of  iron,  and  accompanied  by  an)oderate  degree 
of  pressure,  is  practiced,  and  in  some  cases  with  benefit.  When  pressure 
can  be  brought  to  bear  directly  upon  the  open  vessel,  or  vessels,  it  will  tem- 
porarily obstruct  the  flow  of  blood.  And  it  is  possible,  when  the  flow  takes 
place  from  the  mucous  membrane  of  the  mouth  and  nostrils,  that  the  appli- 
cation of  astringents,  such  as  solutions  of  alum,  acetate  of  lead,  gallic 
acid,  etc.,  may  have  some  influence,  although  I  have  never  seen  instances  in 
which  their  effects  were  well  marked.  I  have  seen  the  blood  continue  to 
ooze  from  the  mucous  surface  of  the  gums  and  nostrils,  directly  in  opposi- 
tion to  the  con  tact  of  a  strong  solution  of  persulphate  of  iron  held  in  contact 
by  lint  saturated  with  the  astringent  material.  I  have  seen  it  ooze  with 
equal  freedom  in  opposition  to  tlie  constant  application  of  powdered  mat- 


C94  NEUROSES. 

ico,  powdered  alum  and  tannic  acid.  I  have  consequently  been  induced 
to  attach  little  importance  to  local  applications,  other  than  that  of  simple 
pressure,  where  this  can  be  brought  to  bear  sufficient  to  temporarily  ojd- 
pose  the  flow  of  blood.  Passive  exercise  by  riding  in  the  open  air,  plain, 
nutritious  food,  and  mild  currents  of  electricity  for  a  few  minutes  each 
day,  wili  aid  in  promoting  the  general  health  and  nutrition,  between  the 
periods  of  hemorrhage. 


LECTURE     LXVII. 


Neuroses :    General  Observations  on  the  Physiology  and  Pathology  of  the  Nervous  Structures. 

GENTLEMPJN:  In  the  lecture  on  the  general  arrangement  of  dis- 
eases given  near  the  beginning  of  the  present  course,  I  stated  that 
the  third  division  of  local  diseases  would  include  the  consideration  of  all 
those  morbid  conditions  of  the  nervous  structures  of  the  body,  not  essen- 
tially inflammatory  in  their  nature.  And,  to  those  non-inflammatory,  or 
functional  diseases  of  the  nervous  structures,  I  gave  the  general  name  of 
neuroses.  The  nature  of  the  functions  performed  by  the  nervous  system, 
in  its  several  parts,  is  of  such  a  character  that  it  affords  a  great  variety  of 
phenomena,  or  morbid  conditions,  and  is  so  connected  with  the  mind  or 
thinking  faculty  of  man,  that  it  has  constituted  a  more  productive,  and  at 
the  same  time  a  more  obscure  and  difficult  field  of  study  than  the  morbid 
conditions  of  any  other  part  of  the  human  body.  Hence,  the  special  culti- 
vation of  this  field,  during  the  last  few  years,  has  developed  a  great  variety 
of  divisions,  or  subdivisions,  both  of  nerve  fvinctions  and  nervous  de- 
rangements, bringing  into  use  many  additional  names.  Some  of  these 
are  intended  to  designate  morbid  phenomena;  others,  more  particularly 
to  aid  in  making  classifications  founded  upon  the  supposed  pathological 
conditions,  and  still  others,  resulting  from  an  effort  to  arrange  them  on 
the  basis  of  etiology,  and  yet,  without  that  clear  and  certain  knowledge 
either  of  the  subdivisions  of  structure,  the  special  functions  or  the  causa- 
tion, to  enable  any  arrangement  to  be  complete  on  either  of  the  several 
bases  to  which  I  have  alluded.  Consequently,  if  you  refer  to  different 
authors  on  diseases  of  the  nervous  system,  you  will  find  it  difficult  to  rec- 
oncile their  differences,  and  oftentimes  difficult  to  prevent  being  confused 
by  the  complexity  of  their  nomenclature.  It  may  contribute  to  a  clearer 
and  more  ready  appreciation  of  the  various  morbid  conditions  of  the 
nerve  structures,  if  we  keep  in  mind  the  fact  that  nerve  matter  is  capable 
of  being  primarily  divided  into  two  forms  of  anatomical  structure;  the 
one  is  essentially  cellular  i.  e.  consisting  of  affgregations  of  cells  or 
nerve  atoms,  and  the  other  linear  or  arranged  into  fibers,  and  that  these 
anatomical  differences  in  the  primary  structure,  coincide  Avith  the  divis- 
ion of  function  into  sentient,  and  transmitting.  The  word  sentient 
is  used  to  indicate  or  to  include  both  the  capability  to  receive  im- 
pressions, and  to  originate  nerve  force;  the  other  includes  simply  the 
power  of  transmitting  impressions  either  from  a  sentient  center  to 
muscular  structure,  or  from  one  center  to  another.  The  power  of  trans- 
mitting to  muscular  structures  results  in  movements,  through  muscular 
contraction. 


NERVE     FUiNCTIONS.  695 

These  two  great  divisions  of  nerve  structure  have  been  designated  as 
nerves  of  sensation  and  nerves  of  motion,  from  the  days  of  Sir  Charles 
Bell,  and  other  early  investigators  in  the  physiology  of  the  nervous  sys- 
tem. You  must  remember,  however,  that  the  nerves  of  sensation,  or  more 
properly  the  sentient  nerve  structures,  are  again  divisible  into  such  as  are 
connected  either  indirectly  or  directly  with  the  cerebral  hemispheres,  and 
are  consequently  instruments  of  mind,  and  those  which  are  connected 
with  the  various  ganglia  or  aggregations  of  nerve  matter,  whether  in  the 
interior  and  l)ase  of  the  brain  or  in  the  spinal  cord,  or  in  the  ganglia 
along  different  portions  of  the  nervous  cords  tliat  arc  not  directly 
connected  with  the  cerebral  hemispheres  in  their  ordinary  func- 
tion. The  first  of  these  divisions,  or  sentie.nt  nerves,  connected  with  the 
cerebral  hemispheres,  and  constituting  instruments  of  mind,  are  tliose 
which  convey  to  the  mind  impressions  that  are  denominated  sensations, 
and  of  which  the  mind  takes  cognizance  more  or  less.  Those  which  are 
connected  with  the  ganglia  or  aggregations  of  nerve  cells  elsewhere  than 
the  cerebrum,  and  not  directly  connected  with  mental  perceptions, 
nevertheless  receive  impressions  and  convey  or  give  rise  to  the  evolution 
of  nerve  force  in  response  to  those  impressions.  The  aggregations  of 
nerve  matter  in  the  form  of  ganglia  upon  the  roots  of  the  spinal  nerves, 
along  the  jo«r  vagum^  in  connection  with  some  of  the  more  important 
nervous  plexuses  in  the  thorax  and  abdomen,  in  the  spinal  cord,  and  the 
aggregations  of  gray  matter  near  the  base  of  the  brain,  all  receive  im- 
pressions, and  give  rise  to  responsive  nerve  force  through  conducting 
fibers  and  result  in  the  inducement  of  actions,  both  motor  and  otherwise, 
as  perfectly  without  the  consciousness  of  the  individual,  as  those  impres- 
sions are  transmitted  through  the  cerebral  nerves  to  the  cerebral  hemi- 
spheres. But  in  the  latter  case  the  sensation  or  impression  produced  is 
mentally  perceived  and  recognized,  in  the  other  the  sensat'on  is  received 
and  responded  to,  unconeciously  to  the  mind.  Hence,  there  is,  properly 
speaking,  voluntary  sensibility  belonging  to  the  cerebral  portion  of  the 
nervous  system,  and  an  involuntary  or  organic  sensibility  belonging  to 
the  non-cerebral  or  ganglionic  portion  of  the  nervous  system.  The  same 
division  exists  in  the  motor  nerve  structures.  The  one  class  having 
their  connections  and  relations  with  the  sentient  nerves  belonging  to 
the  cerebral  hemispheres  whose  action  is  subject  to  mental  consciousness, 
and  the  others  having  their  connection  with  organic  nerve  centers  in 
different  portions  of  the  system  and  performing  their  office  in  the  natural 
condition  independent  of  mental  consciousness  or  recognition.  Many  of 
the  neurologists  and  physiologists  of  the  present  day  divide  still  further 
the  involuntary  or  organic  nervous  system,  makino"  one  division  of  it 
under  various  names  to  correspond  essentially  with  the  exci to-motor 
system  of  Marshall  Hall,  which  was  only  an  extension  of  the  respiratory 
system  of  Sir  Charles  Bell. 

In  this  they  include  all  those  sentient  nerves  and  nervous  centers  which 
are  connected  with  the  performance  of  involuntary  movements,  in  their 
natural  condition  independent  of  the  will  and  yet  within  certain  limits 
influenced  by  the  will.  For  instance,  respiration  is  a  movement  carried 
on  by  the  involuntary  nervous  center  in  response  to  certain  impressions 
made  by  the  air  upon  the  nerves  of  the  membrane  lining  the  respiratory 
passages  and  of  the  cutaneous  surface,  without  any  act  of  the  will,  or 
even  of  mental  consciousness.  And  yet  you  all  know  that  the  mental 
portion  of  the  nervous  system  enables  us  temporarily  to  interfere  with  these 
involuntary  movements,  so  as  to  make  them  faster  or  slower,  or  to  stop 
temporarily  in  obedience  to  our  will.     This  control  of  the  will,  however,  is 


G96  NEUEOSES. 

limited  to  a  very  brief  period  of  time.  To  the  same  class  belong  the 
sphincter  nerves  of  the  bladder  and  rectum.  They  are  capable  of  receiv- 
ing and  transmitting  impressions,  and  causing  an  active  relaxation  of  the 
sphincter  muscles  and  of  producing  evacuations  without  any  recognition 
of  the  mind,  or  any  mental  action,  and  yet,  as  in  the  case  of  respiration 
when  the  mind  is  awake  and  conscious,  it  is  capable  of  regulating  these 
movements  within  certain  limits,  but  without  absolute  control.  In  this 
way  you  perceive  that  there  is  an  important  portion  of  the  involuntary 
nervous  svstcm  that  performs  its  functions  in  obedience  to  excitation,  and 
vet  is  in  a  limited  degree  under  mental  control. 

It  was  this  portion  of  the  nervous  system,  having  its  chief  center  in  the 
medulla  oblongata,  that  Sir  Charles  Bell  called  the  respiratory,  and  Mar- 
shall Hall,  extending  it  to  include  the  sphincters  of  the  body,  denominated 
It  the  excito-motory  nervous  system.  At  the  present  time  another  very 
important  part  of  the  nervous  system  is  denominated  vaso-motor;  by  which 
is  meant,  that  part  which  presides  over  all  the  muscular  structures  con- 
nected with  the  blood  vessels  throughout  the  body.  Their  natural  office 
is  to  receive  impressions  made  by  the  blood  upon  the  interior  of  the  heart 
and  the  vessel  walls,  and  in  response  to  cause  such  movements  of  muscu- 
lar fibers  as  will  aid  in  moving  the  blood  through  the  extended  ramifica- 
tions of  the  vascular  system  with  a  degree  of  uniformity.  This  part  of  the 
nervous  system  is  distinguished  from  the  excito-motory,  of  which  we  have 
just  spoken,  by  the  fact  that  we  can  exert  no  mental  control  over  it,  even 
in  the  most  limited  manner,  still,  in  its  function  it  is  as  much  excito-mo- 
torv  as  the  other.  Impressions  are  received,  and  nerve  force  transmitted 
in  response  to  muscular  structures  commanding  certain  limited  move- 
ments in  the  walls  of  the  vessels  and  in  the  heart,  without  any  mental 
recognition  of  the  fact.  There  are  also  some  eminent  writers  of  the  pres- 
ent day,  who  make  still  a  third  division  of  the  involuntary  portion  of  the 
nervous  system,  which  they  call  the  trophic  nerves.  To  this  part  of  the 
nervous  sj^stem  they  attribute  a  certain  degree  of  control  over  the  molec- 
ular movements  constituting  nutrition  and  disintegration.  They  suppose 
the  centers  of  this  system  to  be  chiefly  in  the  ganglia  upon  the  posterior 
roots  of  the  spinal  nerves,  in  some  portions  of  the  gray  matter  in  the  lateral 
cornua  and  portions  of  the  spinal  cord,  and  extending  up  into  the  brain 
through  the  medulla  oblongata. 

This  class  of  physiologists  or  neurologists  attribute  to  the  influence  of 
morbid  conditions  of  this  trophic  system  of  nerves,  most  of  those  changes 
which  constitute  atrophy  of  various  kinds  such  as  progressive  muscular 
atrophv  and  the  arrest  of  nutrition  under  various  circumstances.  It  is  not 
clearly  established,  however,  that  there  is  a  valid  distinction  between  what 
is  denominated  trophic  nerves  and  the  vaso-motor.  If  you  scan  closely 
the  writings  upon  this  subject,  you  will  find  a  failure  to  maintain  a  clear 
line  of  distinction  between  these  two.  On  the  contrary,  while  writing 
upon  the  trophic  system  of  nerves,  apparently  unconsciously  the  writers 
are  continually  representing  in  the  group  the  functions  which,  when  study- 
ing the  vaso-motor,  they  have  said  belonged  to  that.  And  it  is  extremely 
doubtful  whether  there  is  any  portion  of  the  nervous  system  capable  of 
influencing  molecular  movements  through  the  wails  of  the  capillaries,  and 
their  addition  to  the  tissues  constituting  nutrition,  or  their  detachment 
again  from  the  tissues  and  return  back  as  waste  matter, — I  say  it  is 
very  doubtful  whether  it  can  be  demonstrated  that  any  portion  of  the 
nervous  system  especially  influences  these  atomic  movements,  except  in 
an  indirect  way.  The  vaso-motor  nerves  regulating  the  tone  and  caliber 
of  the  minute  arteries  and  veins,  are  capable  of  influencing  continually  the 


NERVE   FUNCTIONS.  697 

quantity  of  blood  flowing  to,  or  throufvh  a  given  part.  I  think  all  the 
phenomena  that  has  b^en  attributed  to  the  trophic  system  of  nerves,  can 
be  quite  as  well  explained  through  the  action  of  the  vaso-motor  system,  in 
its  regulating  the  blood  supply  to  any  given  tissue,  as  by  the  supposition 
that  a  separate  system  of  nerves  exists  which  influences  direct  molecular 
movements.  I  have  thus  called  your  attention  to  an  outline  of  the  physiology 
and  anatomy  of  the  nervous  system,  that  you  might  have  clearly  before 
you  the  essential  functions  of  nerve  matter,  namely,  on  the  one  hand, 
the  reception  of  impressions  and  origination  of  nerve  force,  both 
voluntary  and  involuntary;  and  on  the  other,  the  function  of  transmit- 
ting impressions  either  from  a  sentient  center  capable  of  originating 
nerve  force  to  muscular  structure  either  voluntary  or  involuntary,  or 
transmitting  impressions  from  one  nerve  center  to  another.  Keep- 
ing clearly  in  mind  these  functions  of  the  nervous  system,  you  will 
be  able  to  study  the  morbid  phenomena  that  arise  from  disturbance 
in  any  given  part  of  the  nervous  system  with  more  satisfaction  than 
you  could  without  this  definite  appreciation  of  their  natural  func- 
ti(>n.  In  studying  the  morbid  conditions  of  the  nervous  system,  we  may 
divide  them  primirily  into  such  as  involve  organic  or  structural  changes, 
which  is  only  another  expression  for  alterations  of  nutrition,  and  such  as 
are  accompanied  only  by  alterations  or  modifications  of  function  without 
structural  change.  A  large  portion  of  the  diseases  included  in  the  first 
division  pathologically,  we  have  already  considered  in  presenting  to  you 
the  inflammations,  acute  and  chronic,  that  aff"ect  the  principal  nervous 
structures  of  the  body.  It  is  one  of  the  essential  features  of  infiammation, 
as  you  have  already  le  irned,  that  it  involves  both  alterations  of  nutrition 
and  of  molecular  movements,  and  consequently  changes,  at  least  for  the 
time  being,  the  structural  condition;  but  passing  by  what  we  have  already 
discussed  under  the  head  of  inflammations,  thsre  are  still  changes  of  struct- 
ure that  do  not  necessarily  depend  upon  inflammatory  action.  These 
changes  may  be  arranged  under  three  divisions,  namely,  those  that  are 
accompanied  by  loss  of  substance,  or  diminution  of  atoms,  generally  de- 
nominated atrophy;  those  which  are  accompanied  by  an  increase  in  the 
amount  of  structure,  and  consequently  increased  bulk,  denominated 
h^qoertrophy;  and  the  third,  consisting  neither  of  atrophy  nor  of  hyper- 
trophy, but  of  a  perversion  in  the  molecular  movements,  by  which  the 
structure  becomes  changed  in  its  composition;  as  when  fat  granules  are 
deposited  in  the  place  of  nerve  cells,  and  when  through  perversion  of  the 
affinity  existing  in  the  tissue,  the  nerve  cell  is  found  to  degenerate  from  its 
natural  relation,  as  in  the  degeneration  of  nerve  structur.^  proper  into  the 
caseous  or  fatty  material,  or  of  the  connective  tissue  surrounding  nerve  mat- 
ter itself  undergoing  similar  changes.  These  are  called  metamorphoses  or 
transformations  of  tissue,  and  under  these  three  heads,  atrophy,  hyper- 
trophy, and  transformation  or  degeneration  of  structure,  we  may  embrace 
all  those  structural  changes  of  the  nervous  system  which  are  not  inflam- 
matory in  their  character.  On  the  other  hand,  we  have  a  class  of  impor- 
tant and  frequently  recurring  afl^ections  of  the  nerves  that  are  purely  func- 
tional, or  at  least  are  accompanied  by  no  appreciable  change  of  structure. 
These  are  appreciable  to  the  patient  only  in  that  portion  of  the  nervous 
system  connected  with  the  mind,  simply  because  it  is  only  through  the 
mind  that  we  can  recognize  whether  the  influence  is  greater  or  less,  more 
or  less  intense.  But  we  may  apply  the  same  rule  for  studying  the  morbid 
phenomena  as  shown  by  resulting  disturbances  of  involuntary  funct  on,  just 
as  readily  as  in  those  connected  with  the  mind.  The  only  difference  is, 
that  the   one   is  readily  appreciable   by   the  individual  patient,  and  ths 


698  NEUROSES. 

other  is  not  appreciable  by  his  consciousness.  But  both  are  capable  of 
being  appreciated  by  the  physician  in  his  study  of  the  resulting  phe- 
nomena. The  diminution  of  nerve  sensibility,  voluntary  or  involuntary, 
is  named  according  to  the  degree  of  diminution,  either  paresis  or  anaes- 
thesia. The  first  means  simply  impairment  of  sensibility,  and  the  latter 
loss  of  sensibility.  Informer  times  it  was  simply  denominated  partial 
or  complete  paralysis  of  sensation.  But  the  words  paresis,  and  anassthesia 
as  applied  to  diminished  sensibility  or  loss  of  it,  you  will  find  now  more 
universally  used  in  the  books  you  consult.  Again,  another  class  of  cases 
is  characterized  by  an  increase  in  the  sensibility,  whether  mental  or  or- 
ganic, above  the  natural  standard,  and  this  is  generally  called  hyper- 
ffisthesia.  Differing  from  both  these,  anesthesia  and  hjqDeraisthesia,  is 
perversion  of  the  normal  sensibility  in  the  nerve  structures  of  the  body, 
in  which  unnatural  sensations  are  produced,  not  capable  of  being  classified 
as  increased  above,  or  diminished  below,  but  only  capable  of  being  ex- 
pressed by  the  word  perversion.  This  condition  is  most  easily  studied  in 
some  of  the  special  senses;  the  nerve  of  taste  for  instance  may  be  per- 
verted, so  that  in  some  instances,  a  sweet  substance  actually  appears  to  the 
patient  sour  and  the  reverse.  Perversions,  to  some  extent,  of  taste  are  not 
infrequent.  The  same  thing  is  illustrated  in  the  auditory  nerve  giving 
rise  to  perversion  of  sounds,  to  a  less  degree  perhaps  in  the  optic  nerve 
and  its  connections,  giving  rise  to  false  colors.  But  what  is  thus  easily 
studied  because  more  easily  appreciated  in  the  nerves  of  special  sense, 
exists  in  all  the  nerves  of  sensation,  such  as  tactile  nerves  and  those 
which  are  naturally  affixed  to  the  involuntary  system;  and  not  a  few  of 
those  obscure  chronic  functional  disturbances  so  often  met  with  are  de- 
pendent upon  altered  conditions  of  nerve  sensibility  in  the  involuntary 
nervous  centers.  If  we  extend  this  analytical  study  of  the  morbid  condi- 
tions of  the  nervous  system,  and  connect  with  it  somewhat  of  the  modus 
operandi  of  the  causes  capable  of  producing  disturbance  of  nervous  func- 
tion, we  might  perhaps  arrive  at  the  conclusion  that  all  the  varied  morbid 
phenomena,  whether  of  anesthesia,  hyperesthesia  or  perversion  of  nerve 
sensibility  and  trai.smissibility,  were  traceable  to  alterations  in  the  prop- 
erties of  the  nerve  structure. 

You  will  remember  that  in  the  preliminary  lectures  of  the  present  course, 
I  claimed  that  all  organic  matter  endowed  with  vitality  was  possessed  of 
two  inherent  or  elementary  properties,  independent  of  any  nervous  influ- 
ence, and  inherent  in  the  living  organic  atom  or  cell,  and  necessary  to  its 
condition  of  life  from  the  first  aggregation  of  matter  or  bioplasm  consti- 
tuting the  germinal  cell  of  the  ovum  up  through  all  the  stages  of  growth 
to  the  most  complex  of  organic  structures.  And  the  necessity  for  acknowl- 
edging the  existence  of  such  properties  is  here  clearly  seen  in  the  exam- 
ination of  the  functions,  whether  normal,  or  abnormal,  of  nerve  matter. 
For  surely  there  is  no  other  fctructure  that  can  communicate  to  nerve  matter 
sensibility  or  impressibility,  and  3'et  agents  are  constantly  acting  and  making 
impressions  upon  the  nervous  structures.  There  is  therefore  an  inherent 
susceptibility,  or  capacity  to  receive  impressions  from  external  influences, 
in  the  primary  nerve  matter.  And  in  addition  to  this  property  inherent 
in  the  atoms  of  the  structure,  there  is  the  property  which  regulates  the 
movements  of  the  atoms  constituting:  the  structure,  such  as  the  addition 
of  new  ones  in  the  process  of  nutrition  and  the  displacement  of  old  ones 
in  the  waste,  and  this  is  denominated  vital  affinity.  Now  if  w^e  concede 
that  the  nerve  structure,  whether  belonging  to  the  cerebral  hemispheres 
and  consequently  coming  under  the  class  of  voluntary  nerve  matter,  or 
purely  organic  or  involuntary,  is  possessed  of  these   two  primary  proper- 


GENERAL    CONSIDERATIONS.  699 

ties,  we  can  easily  perceive  that  wherever  influences  are  brought  to  bear 
which  diminish  the  susceptibility  of  the  nerve  structure,  it  would  necessa- 
rily diminish  its  function  as  manifested  in  sensibility,  or  in  originating 
nerve  force.  And  if  iiifiuences  are  brought  to  bear  of  such  nature  as  to 
increase  or  intensify  the  primary  susceptibility  in  the  nerve  structure,  it 
would  result  in  exaltation  and  increase,  or  hyperesthesia  of  the  sensibil- 
ity and  originating  force  of  the  nerve  matter;  and  the  same  would  be 
true  of  the  function  of  the  transmitting  part  of  the  nervous  system.  In 
the  one  case  impressions  diminishing  the  susceptibility  would  render  the 
transmission  slow,  while  those  increasing  it  would  quicken  the  movements 
and  we  would  thus  have  a  mode  by  which  these  two  morbid  conditions  of 
function  become  explainable.  All  those  conditions  accompanied  by  pare- 
sis or  anaesthesia  would  belong  to  causes  that  had  diminished  the  primary, 
elementary  property  called  susceptibility;  and  those  which  were  accom- 
panied by  increase  or  hyperaesthesia  would  depend  upon  causes  that  had 
produced  an  increase  of  the  same  property.  An  intermediate  class  of 
causes,  capable  of  making  impressions  and  altering  this  property  of  sus- 
ceptibility, would  develop  those  phenomena  that  we  call  perversions.  It 
requires  but  a  step  further  in  the  study  of  the  subject  to  perceive 
that  the  same  classes  of  causes  that  thus  may  disturb  function,  if  contin- 
ued bevoud  a  given  length  of  time  would  almost  necessarily  result,  on  the 
one  hand  in  corresponding  diminution  of  molecular  movements  sufficient 
to  result  in  diminished  nutrition,  or  atrophy;  on  the  other  hand,  persist- 
ence in  the  exaltation  of  susceptibility  would  develop  an  addition  of  new 
atoms  constituting  hypertrophy.  While  a  perversion  of  impression  would 
be  precisely  such  as  would  correspond  with  the  ultimate  development  of 
transformations  or  degenerations  in  the  molecules  of  which  the  tissue  is 
composed.  These  views  are  in  strict  consonance  with  clinical  observa- 
tion. It  is  well  known  that  the  effects  of  long  continued  perversions  of 
function  of  a  marked  character,  result  in  change  of  structure  from 
altered  nutrition.  Not  only  are  these  views  susceptible  of  being  largely 
illustrated  by  direct  clinical  observation,  but  a  study  of  the  causes  which 
are  capable  of  producing  either  alterations  in  the  structure  not  of  an  in- 
flammatory character,  or  in  the  line  of  simple  atrophy,  hypertrophy  and 
transformations,  or  the  more  temporary  derangements  of  a  purely  func- 
tional character,  will  enable  us  to  divide  them  into  classes  corresponding 
almost  perfectly  with  the  diflerent  pathological  conditions  to  wliich  I 
have  alluded,  namely,  such  causes  as  produce  sedative  impressions  upon 
nerve  matter  and  thereby  diminish  the  manifestations  of  function,  and  if 
continued  long  enough,  the  development  of  structure  also.  Another  class 
act  as  direct  excitants,  quickening  function  and  ultimately  leading  to  in- 
crease of  structure.  There  is  an  intermediate  class  of  cases,  of  a  wide 
range,  that  can  not  be  classed  under  either  of  these  heads  of  simple  nerve 
sedatives  or  nerve  excitant-',  but  which  more  or  less  impress  the  nervous 
system  in  such  a  way  as  to  alter  its  natural  action,  constituting  perversions, 
or  morbid  impressions.  And,  were  it  not  for  the  fact  that  the  nerve  struct- 
ures of  the  human  body  are  subdivided  into  so  many  parts  and  exert  an 
influence  over  so  great  a  variety  of  functions,  it  might  be  possible  to  carry 
out  a  classification  of  nervous  diseases,  founded  on  these  elementary  views 
of  the  pathology  of  the  nervous  system.  But,  when  you  remember  that 
each  of  these  varied  pathological  conditions  may  be  limited  to  particular 
parts  of  the  nervous  system,  and  that  the  phenomena  which  will  be  present 
within  the  body,  will  depend  largely  upon  the  particular  function  ovev 
which  that  part  of  the  nervous  system  presides,  you  will  see  clearly  whv 
there  is  a  seeming  necessity  for  clinical  purposes  of  adhering  for  the  p]-es- 


700  APOPLEXY. 

cnt  to  the  older,  and  more  common  division  of  non-inflammatory  nervous 
derangements,  such  as  grouping  them  under  the  heads  of  apoplexy,  epi- 
lepsy, chorea,  catalepsy,  convulsions,  tetanus,  hysteria,  paralysis,  neuralgia, 
insomnia,  mental  diseases,  etc.  I  shall,  therefore,  in  the  further  considera- 
tion of  this  subject,  proceed  to  consider  the  particular  non-iiifiammatory 
diseases  of  the  nervous  system  under  the  various  heads  that  are  familiar  to 
the  profession  at  large;  beginning  with  those  conditions  of  the  brain  v^'hich 
are  included  under  the  terms  cerebral  hyperaemia,  cerebral  hemorrhage 
and  apojjlexy 


LECTUEE  LXVIII. 


Apoplexy-  Its  "Varieties,  Causes,  Clmical  History,  Anatomical  Changes,  Diagnosis,  Prognosis  and 
Treatment. 

GENTLEMEN  :  The  word  apoplexy  is  used  to  indicate  a  loss  of  con- 
sciousness or  coma,  occurring  suddenly  without  mechanical  injury  or 
the  influence  of  poisons.  For  instance,  when  a  patient  is  taken  somewhat 
suddenly  with  feelings  of  vertigo,  dimness  of  vision,  a  turgid  condition  of 
the  vessels  of  the  face,  and  speedily  becomes  unconscious  with  more  or 
less  stertorous  breathing,  with  a  slow  intermittent  or  full  and  hard  pulse, 
and  loss  of  power  over  the  voluntary  muscular  system,  he  is  said  to  have 
an  attack  of  apoplexy.  In  some  cases,  these  symptoms  may  prove  tem- 
porary, lasting  from  half  an  hour  to  one  or  two  days,  followed  by  slow, 
gradual  improvement  till  they  pass  away  entirely  and  the  patient  re- 
covers, or  the  improvement  may  proceed  oidy  to  the  extent  of  restoring 
consciousness,  with  ability  to  use  one  part,  or  one  half  of  the  voluntary 
muscular  system,  while  the  other  remains  paralyzed.  In  such  cases  it 
takes  the  name  of  hemiplegia  or  paralysis,  rather  than  that  of  apoplexy. 
In  still  another  and  large  class  of  cases,  instead  of  the  symptoms  begin- 
ning after  a  brief  period  of  time  to  improve,  the  unconsciousness  becomes 
more  profotind,  the  pupils  of  the  eyes  dilate,  the  breathing  becomes  very 
slow  and  stertorous,  the  vessels  of  the  face  and  neck  very  much  con- 
gested, of  a  leaden  or  bluish  hue,  the  pulse  sometimes  soft  and  inter- 
mittent, at  other  times  small,  soft  and  quick,  an  entirely  motionless  con- 
dition of  the  voluntary  muscular  system,  except  perhaps  an  occasional 
automatic  drawing  up  of  a  limb  and  letting  it  down  again,  relaxation  of 
the  sphincters,  involuntary  discharges  and  death.  The  latter  might  occur 
within  even  a  few  minutes  after  the  commencement  of  the  attack,  or  it 
might  be  deferred  for  one,  two  or  three  days.  Attacks  of  this  character 
are  very  rare  in  childhood  and  youth,  but  increase  in  frequency  from  the 
middle  of  adult  life  to  old  age.  A  very  large  majority  of  all  the  cases 
occur  after  fifty  years  of  age.  The  disease  does  not  appear  to  be  in- 
fluenced in  a  marked  degree  by  season  of  the  year,  or  by  climate,  and  but 
little  by  sex.  In  my  own  experience  I  have  met  with  more  cases  in  males 
than  in  females;  and  a  moderately  larger  number  during  the  extreme  cold 
seasons  of  the  year,  than  in  the  warm.  Having  used  the  word  apoplexy 
in  its  generally  accepted  sense  to  cover  all  those  cases  in  which  there  is 
suffioient  interference  with  the  circulation  of  blood  in  the  central  portion 
of  the   nervous  system   to   at  least   temporarily   suspend  its  functions,  it 


CAUSES.  701 

must  be  admitted  that  pathoioo-ical  conditions  varying-  much  from 
each  other  are  equally  included  by  such  use  of  the  word,  inasmuch  as 
blooJ  may  accumulate  in  the  nerve  structure  of  soma  portion  of  the  brain 
by  simple  hypera3mia,  or  venous  congestioti  of  the  minuter  vessels  and 
capillaries  and  overwhelm  function,  or  the  vessel  may  be  ruptured  from 
so.ne  sudden  and  severe  pressure  of  bloo;l  upon  its  walls,  or  from  a  pre- 
vious impairment  of  the  texture  of  the  wails  of  the  vessel  itself,  causing 
extravasation  of  blood  sufficient  by  its  pressure  to  wholly  interrupt  the 
further  manifestation  of  function;  or  we  may  have  emboli  detached  from 
fibrinous  clots  in  the  heart  or  some  of  the  larger  vessels  and  carried  into 
the  brain,  plug-ging  the  vessels,  so  as  to  interrupt  circulation  and  produce 
results  as  speedy  and  severe  as  would  result  from  hemorrhage  in  the 
brain  itself.  Or  we  may  have  still  another  condition  ;  that  of  impairment 
of  the  vaso-motor  nerve  influence  in  the  vessels  of  the  brain,  producing 
vaso-motor  nerve  paralysis,  passive  dilatation  and  consequent  apoplectic 
pressure  upon  the  nerve  matter;  thus  making  no  less  than  four  or  live 
essentially  different  pathological  conditions,  all  of  which  may  be  accom- 
panied by  such  interference  with  the  circulation  through  the  nerve  struct- 
ures of  the  brain  as  to  completely  interrupt  the  manifestions  of  function 
or  in  other  words  to  develop  the  ordinary  symptoms  of  apoplexy.  If  we 
may  thus  have  a  variety  of  pathological  conditions  leading  to  the  develop- 
ment of  such  symptoms  as  are  called  apoplectic,  it  follows  that  the  causes 
of  apoplexy  may  be  equally  various. 

Causes. — In  directing  your  attention  to  the  causes  of  apoplexy  I  shall 
divide  them  into  those  which  are  predisposing,  and  those  which  are  more 
directly  exciting  causes.  The  predisposing  causes  embrace  all  such  in- 
iluences  as  are  capable  of  increasing  in  a  marked  degree  the  rapidity  of 
the  flow  of  blood  to  the  brain  on  the  one  hand,  and  of  such  as,  thouo-h  not 
increasing  the  rapidity  of  flow  to  the  brain,  nevertheless  impair  the  con- 
dition of  vessels  themselves  in  the  brain,  in  such  a  way  as  to  lessen  their 
capacity  to  allow  blood  to  pass  freely  through  them.  The  other  group  of 
predisposing  causes  includes  such  influences  as  are  capable  of  increasing 
the  susceptibility  or  irritability  of  the  brain  substance.  x\mong  the  more 
common  or  prominent  of  the  first  group  of  predisposing  causes,  or  those 
which  favor  an  increased  rapidity  of  flow  of  blood  to  the  head,  are  hyper- 
trophy of  the  heart  with  increase  of  its  muscular  walls,  dilatation  or  en- 
largement of  the  aorta,  carotid  and  vertebral  arteries  by  which  their 
capacity  for  carrying  blood  is  increased,  and  as  all  the  older  writers 
claimed,  a  physical  development  marked  by  a  broad  chest  and  a  short 
fall  neck,  indicating  disproportionate  development  of  the  respiratory  and 
circulatory  organs.  You  need  but  a  moment's  reflection  to  see  that  with 
a  given  size  or  capacity  of  the  capillary  vessels  of  the  brain,  and  increased 
size  and  force  of  the  heart,  the  vessels  leading  directly  from  it  to  the  head 
would  tend  to  carry  more  blood  to  the  brain  in  a  given  period  of  time,  and 
consequently  would  place  the  patient  in  a  condition  continually  favorable  for 
supplying  the  vessels  of  the  brain  faster  than  they  were  capable  of  passing 
the  blood  to  the  venous  side  of  the  circulation  and  consequently  produce 
either  capillary  cong'estion  or  rupture  and  extravasation  of  blood  sufficient 
to  overwhelm  function  and  produce  all  the  phenomena  of  apoplexy.  Any 
conformation  of  the  system  favoring  thus  an  excessive  flow  of  blood  to  the 
brain  would  constitute  a  predisposing  cause  of  one  form  of  apoplexy. 
Among  the  more  common  of  the  second  group  of  causes,  or  those  which 
tend  to  impair  the  capacity  and  activity  of  the  vessels  of  the  brain  render- 
ing the  natural  flow  of  blood  to  it  liable  to  accumulate  and  produce 
apoplectic  pressure,  are  the  use  of  alcoholic  d.inks,  some  of  the  narcotics, 


702  APOPLEXY. 

particularly  tobacco,  the  indulgence  in  sedentary  habits  in  connection  with 
full  diet,  and  in  fact  all  those  hygienic  conditions  which  interfere  slowly 
with  the  oxygenation  and  decarbonizatioii  of  the  blond,  or  tend  to  impair  the 
activity  of  the  vaso-motor  system  of  nerves.  The  first,  those  which  inter- 
fere with  the  oxygenation  and  decarbonization  of  blood  slowly  and 
habitually  from  day  to  day,  always  favor  the  occurrence  of  fatty  or 
atheromatous  degeneration  of  structure  in  different  parts  of  the  body. 
When  such  degeneration  takes  place  in  the  coats  of  the  arteries  or  the 
smaller  vessels  of  the  brain  they  not  only  lessen  the  tonicity  of  the  vessel 
walls  and  favor  the  occurrence  of  rupture  and  hemorrhages,  but  they  also 
lessen  the  efficiency  of  reaction  or  contraction  of  the  vessels  with  each 
impulse  of  blood  into  them,  and  consequently  favor  passive  distension  or 
accumulation  of  blood.  The  presence  of  alcohol  habitually  in  the  blood 
as  in  the  case  of  habitual  drinkers  is  well  known  to  do  this;  both  in 
diminishing  the  amount  of  oxygen  taken  up,  and  of  carbon  exhaled  from 
the  lungs;  and  no  fact  is  better  established  than  that  such  habits  con- 
tinued from  year  to  year  favor  fatty  degeneration  throughout  almost  all 
the  structures  of  the  body,  and  frequently  so  in  the  liver,  kidneys,  muscu- 
lar and  fibrous  structures  of  the  vascular  system.  Sedentary  habits  act  in 
the  same  direction  by  diminishing  the  amount  of  exhalation  of  waste  mat- 
ter, and  the  activity  of  the  respiratory  function  in  supplying  oxygen  to  the 
blood.  Tobacco,  and  other  narcotic  substances  act  more  directly  by  im- 
pairment both  of  the  respiratory  and  vaso-motor  nervous  systems  in  their 
sensibility  and  efficiency  of  action,  and  indirectly  also  favor  to  some  ex- 
tent fatty  degenerations.  Another  cause  of  predisposing  character  be- 
longino-  to  this  group  consists  in  what  might  be  termed  the  effects  of  old 
ao-e  in  favoring  the  degeneration  of  structure  in  the  vessels  of  the  brain  as 
well  as  an  impairment  of  the  vaso-motor  nerve  influence.  You  will  thus 
see  from  the  enumeration  I  have  made  that  the  group  of  predisposing 
causes  capable  of  favoring  apoplectic  obstruction  of  the  circulation  in  the 
brain  are  numerous  and  common.  And  your  own  observation  and  re- 
flection will  enable  you  to  add  many  other  influences,  which,  when  con- 
tinued from  day  to  day  through  considerable  periods  of  time  would  tend 
more  or  less  actively  to  produce  the  same  effects  in  one  or  the  other  of 
the  modes  I  have  already  mentioned. 

The  third  group  of  predisposing  causes  includes  such  as  are  capable  of 
increasing  the  excitability  and  susceptibility  of  the  cerebral  structure,  as 
in  the  preceding  lecture,  you  will  remember,  I  reminded  you  of  the  ex- 
istence of  inherent  properties  in  nerve  structure,  as  well  as  in  all  other 
living  organic  matter,  one  of  which  was  the  susceptibility  to  impres- 
sions. Whatever  tends  habitually  to  increase  this  susceptibility  in 
the  brain  also  increases  the  readiness  with  which  the  brain  becomes 
hvpergemic  or  increased  by  fullness  of  blood.  Perhaps  there  is  no 
class  of  causes  that  predisposes  in  this  direction  so  directly,  as  that 
of  the  habitual  indulgence  in  violent  passions  and  emotions  of  the  mind, 
or  in  too  protracted  and  intense  intellectual  application.  Either  of  these 
indulgences,  if  continued  for  a  considerable  period  of  time,  is  capable  of  so 
increasing  the  excitability  of  the  cerebral  structure,  as  to  establish  an  un- 
due degree  of  fullness  of  blood  or  hypereemia,  which  would  only  require 
the  supervention  of  some  strong  exciting  cause  to  determine  positive 
apoplectic  results.  You  see  sometimes  on  the  one  hand,  in  individuals 
given  to  over-indulgence  in  passions  and  emotions,  especially  those  more 
or  less  of  a  vicious  character,  that  when  suddenly  overtaxed  by  sonie 
violent  act  of  exertion  or  some  unusually  strong  and  violent  fit  of  anger  or 
passion,  they  are  at  once  and  suddenly  overwhelmed  with   an   apoplectic 


.  SYMPTOMS.  703 

attack.  On  the  other  hand  it  has  mMny  times  happened  that  those  who 
liiive  passed  the  middle  period  of  lii'e,  by  indulging  in  protracted  intel- 
lectual labor  through  considerable  periods  of  time  and  depriving  themselves 
of  suffitjient  rest  every  twenty-four  hours  to  secure  recuperation,  have  fallen 
suddtMdy,  sometimes  in  the  midst  of  an  intellectual  effort  in  the  forum  or 
the  pulpit  in  a  sadden  and  overwhelming  attack  of  apoplexy.  You  will 
perceive  that  all  the  various  causes  that  I  have  mentioned  are  more  fre- 
quently brought  to  bear  in  the  middle  and  later  periods  of  life  than  at 
any  other,  except  perhaps  that  of  h^-pertrophy  of  the  heart,  and  the  in- 
dulgence simply  of  the  more  violent  passions  and  emotions  especially  of  a 
vicious  character.  To  act  as  predisposing  causes  proper,  all  these  in- 
fluences to  which  I  have  alluded  must  be  continued  habitually  through 
considerable  periods  of  time.  Some  of  them,  when  acting  with  an  unusual 
degree  of  intensity  and  suddenness,  may  become  direct  exciting  causes. 
As  I  have  already  intimated,  sudden  and  violent  passions  in  an  individual 
previously  predisposed,  is  capable  of  bringing  on  an  attack,  or  too  pro- 
tracted and  intense  intellectual  effort  when  there  is  decided  predisposi- 
tion, may  produce  a  similar  result.  Any  other  exciting  cause  being 
brought  to  bear  upon  those  already  predisposed,  such  as  violent  physical 
exertion  or  extreme  muscular  efforts  in  lifting,  large  doses  of  alcoholic 
drinks  or  other  anaesthetics  and  narcotics,  under  similar  circumstances  of 
predisposition,  may  induce  so  full  a  suspension  of  the  vaso-motor  in- 
fluence in  the  cerebral  vessels  as  to  determine  an  immediate  attack.  The 
presence  of  certain  toxaemic  agents  in  the  blood  are  also  to  be  considered 
as  direct  exciting  causes,  capable  sometimes  of  producing  apoplectic  en- 
gorgements and  death.  Perhaps  the  most  frequent  of  these  agents  are 
those  derived  from  retained  excretory  elements  of  urine,  in  the  progress 
of  renal  diseases  of  a  structural  character;  as  in  the  retention  occurring 
in  the  advanced  stages  of  granular  or  other  degenerations  of  the  kidney. 
Overloading  the  stomach  with  a  full  meal  or  with  indigestible  articles  of 
food  has  sometimes  by  its  reflex  influence  upon  the  vessels  of  the  brain  in 
persons  previously  predisposed,  resulted  in  developing  direct,  and  even 
fatal  apoplectic  attacks. 

Sipnptoyns. — From  the  number  and  varying  nature  of  the  causes,  both 
predisposing  and  exciting,  which  I  have  mentioned,  you  will  have  antici- 
pated that  the  symptoms  which  characterize  attacks  of  apoplexy  may  vary 
much  in  different  cases;  and  for  convenience  and  accuracy  of  clinical 
history  I  will  group  all  the  cases  into  three  divisions.  Those  belonging  to 
the  first  group  are  such  as  are  produced  by  causes  fevoring  a  direct  in- 
creased determination  of  blood  to  the  brain,  and  consequently  may,  by 
way  of  distinction,  be  called  apoplexy  from  active  determination  of  blood 
to  the  head.  They  are  met  with  mostly  in  the  middle  period  of  life,  and 
y.re  either  in  persons  of  strongly  sanguine  temperament,  or  with  positive 
structural  changes  in  the  heart  giving  it  increased  muscular  force.  In 
most  of  such  persons  the  first  symptoms  of  an  apoplectic  attack  are  sud- 
den and  extreme  congestion  of  blood  in  the  vessels  of  the  face  and  neck, 
giving  it  a  very  turgid  and  reddened  appearance,  sometimes  with  sudden 
flashes  of  light  like  streaks  or  flashes  of  fire  before  the  eyes,  sense  of 
vertigo,  followed  quickly  by  dimness  of  vision,  frequently  twitching  of 
the  muscles  of  the  face,  jerking  of  the  eyeballs  upwards,  a  falling  of  the 
patient  to  the  floor  if  in  a  sitting  or  erect  position  and  within  a  very  few 
moments  the  supervention  of  entire  unconsciousness,  in  which  state  the 
breathing  is  usually  slower  than  natural,  with  more  or  less  noise  occasioned 
by  the  rapid  gathering  of  mucus  in  the  fauces,  imperfect  control  of  the 
tongue,  and  partial  paralysis  of  the  muscular  system  generally.     In   most 


704  APOPLEXY. 

instances,  though  the  pupils  of  the  eyes  are  contracted  at  first,  in  a  short 
time  one  or  both  become  more  or  less  dilated,  and  they  are  found  not  to 
respond  to  variations  in   light  nor   to  maintain   their   natural  parallelism, 
the  one  with  the  other.     The  face   not  only  continues  turgid    with   blood, 
but  there  is  unusual  redness  over  the  whole  surface  of  the  body,  neck  and 
upper  part  of  the  chest,  and  in  the  severer  class  of  cases   the  surface   as- 
sumes  more   or  less  of  a  purplish   redness,  the   extremities   become  cold, 
ends  of  the  fingers  leaden   color  and  often  cold,  with  a  pulse  at  first  firm, 
hard   under   the  finger,  full   in  volume,  but  slow   and   occasionally  inter- 
mitting.     If  the   case  is   proceeding  rapidly  toward  a   fatal  result,  the 
pulse  every  hour  lessens  in  force,  until  it  becomes  soft,  easily  compressed, 
breathing  very  laborious   and   stertorous,  entire   motionless  condition  of 
the  limbs,  upper  and  lower,  indicating  general  paralysis.     The  respiratory 
acts  are  protracted,  with  unusual  depression  of  the  abdominal   walls  with 
each    expiration;     sometimes    at  the     beginning     muscular     twitchings, 
slight  spasmodic  action,  and  usually,  as  the  fatal  result  approaches,  entire 
general  paralysis,  involuntary  discharge  both  of  urine  and  feeces,  and  more 
and    more    impairment  of  respiration    and    circulation    till     both    cease. 
Generally,  the   pupils  become   widely   dilated  after  the  fi^rst  one   or   two 
hours  from  the  commencement  of  fatal  attacks.     These   changes  in  this 
class  of  cases  may  take  place  so   rapidly  that  the   fatfll   result  is   reached 
within  from  one  to   three  hours,  or  they  may  be  more   slow  in  their  prog- 
ress, and   terminate  only  at  the  end   of  the   second,  third  or  fourth  day. 
But;  in  the  larger  proportion,  after  continuing  this  latter  period,  there  is 
usually  either  partial  or  complete  recovery,  by  a  slow,  steady  subsidence 
of  all  the  bad  symptoms,  the  patient  recovering  gradually  consciousness, 
the  power  of   muscular  action,  and  finally  convalescence.     In   the  second 
groujD  of  cases  to  v.'hich  I  have   alluded,  the  symptoms  usually  vary  some- 
what from  those  I  have  just  described,  more  particularly  in  the  condition 
of  the  pulse,  and  in  the  extent  of  the  congestion  of  the  face  and  external 
parts  of  the  head  and  neck.     The  cases  occur,  not  from  increased  impetus 
of  blood  to  the  head,  but  from   failure   in  the  condition  of  the  circulation 
through  the   brain;  and   hence   there   is   generally  a   supervention  of  the 
same    vertigo,   twitching   perhaps   of   the  muscles   of  the   face,  unsteady 
motion  of  the  eye-balls,  purplish  color  of  the  face,  accompanied   by  entire 
unconsciousness,  more  or  less  labored  and  stertorous  breathing,  but  with- 
out the  intense  congestion  and  redness  of  the   face,  and   if  congested  at 
all  only  moderately  so,  and  without  the   full  labored  pulse.     On  the   con- 
trary, the   pulse  is  soft,  easily  compressed,  generally  slower  than  natural, 
somewhat  unsteady   and   not   infrequently  intermittent.     The   pupils  of 
the  eyes  become  earlier  dilated,  but  otherwise  the  paralytic  symptoms,  re- 
laxation of  the  sphincters,  involuntary  discharges,  proceed  as  in  the  cases 
already  described.     Or  if  they  are  less  severe,  accompanied  by  no  marked 
rupture  of  vessels  and  actual  extravasation  of  blood,  there  may  be  a  slow 
recovery.     The   third   class  of  cases  is  such   as  occurs  in   patients  whose 
cerebral    vessels   have  undergone   impairment   by   fatty  degeneration  or 
otherwise,  and   consequently  apoplectic  engorgement  into  which  they  fall 
is  purely  of  a  passive  character.     In  those  of  less  degree  of  severity  there 
will  be  but  little  fullness  in  the  vessels  of  the  face  and  neck,  giving  rather 
a  purplish  hue.     Tne  pupils  of  the  eyes  are  dilated  almost  from  the  first, 
breathing   unsteady   and    troubled   at  first,  but    not    entirely    stertorous, 
though  less  frequent  than  natural,  but  gradually  passing  on  to  a  stertorous, 
irregular  character  in  those  in  which  the  weakness  of  the   vessels  is  such 
as  to  cause  minute  extravasation  of  blojd.     When  such  extravasations  oc- 
cur more  freely  there  is  sudden  interruption  of  cons:'iousness,  with  the  face 


ANATOMICAL    CHANGES.  705 

and  lips  more  frequently  blanched  or  pale;  pulse  extremely  weak,  surface 
ueiierallv  cool,  the  fingers  and  toes  rapidly  become  bluish  and  cold,  with 
entire  paralysis  of  the  whole  muscular  system  as  indicated  by  absence  of 
all  muscular  movements,  immediate  relaxation  of  the  sphincters  of  the 
bladder  and  rectum,  and  speedy  death;  the  patient  sometimes  giving 
but  one  or  two  gasps  for  breath.  These  are  cases 'where  from  pre- 
vious impairment  of  the  walls  of  the  vessels  in  some  portion  of  the 
brain,  rupture  takes  place,  and  a  sufficient  degree  of  hemorrhage  to 
immediately  overwhelm  all  the  functions  of  the  brain  with  direct  pressure. 
Occasionally  a  case  of  apoplexy  may  occur,  as  I  have  already  mentioned, 
from  emboli.  Although  these  are  much  more  liable  to  produce  obstruc- 
tion in  only  a  limited  portion  of  the  brain,  and  to  result  in  paralysis  than 
in  full  apoplexy,  yet  sometimes  the  latter  may  be  the  result,  because  of 
fibrinous  clots  plugging  up  cerebral  vessels,  of  such  size  as  to  suddenly 
deprive  the  brain  of  a  large  portion  of  its  supply  of  blood,  and  there- 
fore equally  suddenly  deprive  the  patient  of  consciousness  and  cerebral 
action.  Death  may  be  almost  instantaneous.  Or  if  the  vessels  obstructed 
are  smaller,  and  the  circulation  interrupted  through  more  limited  por- 
tions of  the  brain,  there  will  consequently  be  less  complete  suspension 
of  its  function,  which  may  allow  the  re-establishment  of  circulation  in 
collateral  vessels  and  a  slow  recovery,  either  partial  or  complete. 

Anatomical  Changes. — From  the  description  I  have  given  both  of  the 
causes  and  of  the  symptoms  of  apoplexy  in  its  varied  forms  vou  will 
anticipate  that  the  pathological  changes  accompanying  such  disease  will  be 
varied,  both  in  their  extent  and  in  their  character.  Where  death  has 
resulted  from  apoplectic  engorgement  of  the  brain  in  the  class  of  cases  I 
have  described  as  resulting  from  active  determination  of  blood,  the  brain 
may  be  found  in  either  of  two  conditions:  first,  that  of  intense  capillary 
engorgement  of  the  smaller  arteries,  veins  and  capillaries  with  blood, 
making  the  cerebral  substance  redder  than  natural,  and  the  cut  surface 
to  ooze  blood  from  a  much  larger  number  and  larger  sized  arteries  and  veins, 
than  in  the  natural  condition.  Examined  more  closely,  under  proper  mag- 
nifying power  the  venous  portion  of  the  blood  will  be  found  to  have  exuded 
or  extravasated  into  the  cerebral  texture,  with  perhaps  only  here  and 
there  evidence  of  the  extravasation  of  the  red  corpuscles  and  of  the 
leucocytes.  Such  are  cases  in  which  the  suspension  of  function  has  been 
complete,  and  fatal  to  the  patient  by  the  intensity  of  the  engoro-ement  of 
the  minute  vessels  with  only  the  addition  of  serous  exudation  into  the 
textures.  Sometimes  this  has  been  termed  by  different  writers,  serous  apo- 
plexy. In  other  cases  of  this  same  class  derived  from  active  determina- 
tion of  blood  to  the  brain  in  addition  to  what  I  have  described  as  the 
intensity  of  the  engorgements,  there  will  be  found  numerous  minute 
hemorrhagic  exudations,  from  rupture  of  the'  smaller  vessels  in  many 
places,  and  constituting  true  but  mmute  points  of  hemorrhage.  In  still 
other,  but  a  smaller  number  of  cases,  the  rupture  of  one  or  more  larger 
vessels  may  take  place,  and  a  more  decided  hemorrhagic  extravasation 
occur,  giving  rise  to  the  formation  of  a  clot  imbedded  in  the  cerebral  sub- 
stance, or  upon  some  part  of  the  surface.  In  examining  the  brain  in  tliose 
cases  which  belong  to  the  second  group,  or  such  as  have  been  accompanied 
by  impairment  of  the  cerebral  vessels,  in  addition  to  the  appearance  of 
accumulation  of  blood  intensely  filling  the  capillary  vessels,  together  with 
either  serous  or  sanguineous  exudations  or  both,  there  will  be  found  on 
minute  examination,  in  many  of  them,  all  the  appearances  of  fatty  de- 
generation of  the  coats  of  the  vessels,  more  especiallv  in  the  parts  of  the 
45 


706  APOPLEXY. 

brain  that  have  undergone  the  greatest  degree  of  engorgement,  and 
wherever  ruptures  have  given  rise  to  hemorrhagic  extravasations.  These 
degenerations  will  vary  of  course  in  diiFerent  patients  both  in  regard  to  the 
kind  and  extent  of  the  structural  changes.  In  some  cases  they  are  easily 
traced,  not  only  in  the  connective  tissue  and  muscular  fibers  of  the  vessels, 
but  also  in  a  less  degree  in  the  neurilemma  of  the  nerve  structure  itself. 
Diagnosis. — There  is  little  difficulty  in  making  a  reliable  diagnosis  be- 
tween apoplexy  and  other  forms  of  disease  of  the  brain.  To  distinguish 
it  from  all  the  varieties  of  inflammation  of  the  brain  and  its  appendages, 
you  have  only  to  compare  the  symptoms  I  jjave  mentioned  with  those 
that  I  gave  in  the  lectures  upon  the  subject  of  inflammation  of  those 
structures.  The  suddenness  of  the  supervention  of  unconsciousness  with- 
out any  preceding  pain,  fever  or  delirum,  are  so  unlike  the  phenomena  of 
inflammation,  that  it  is  hardly  possible  to  confound  the  one  with  the 
other.  The  diagnosis  between  sudden  hemiplegic  attacks  and  apoplexy 
can  not  always  be  made  at  the  first  moment  of  the  attack;  both  may  be 
dependent  upon  the  same  class  of  causes  and  the  same  pathological  con- 
ditions and  in  the  first  onset  the  symptoms  will  be  identical. 

But   in   the  hemiplegic    attacks     entire   unconsciousness   usually  is  of 
brief   duration,  and    in   a   few  hours,  at  most,  the  patient  begins   to  show 
imperfect     symptoms    of     returning    consciousness,    and    perhaps  at  no 
part  of  the  time  has  failed  to  continue  moving  one  ai'm  or  one   leg,  while 
the  other  has  remained  motionless.     But  in  real  apoplexy,   there  is  gener- 
ally, in  addition  to    unconsciousness,  an   almost  equal   impairment  or  sus- 
pension of  muscular  action  and  motion  on   both  sides  of  the  body.     It  is 
only  during  the  first  few  hours  of    the  case,  that  there   is  difficulty  in  de- 
termining whether  it  is  to  be  called  true  apoplexy,  or  hemiplegia.     Almost 
the  only  conditions  which  might   trouble   the   inexperienced  observer  in 
diagnosis,    are    the    profound    influence     of    narcotics    and    anaisthetics. 
Some  of  the  phenomena  of  profound  stupor  from  alcoholic   drinks  resem- 
ble an  apoplectic  condition.     I  have  seen  some  of  these  cases  of  profound 
stupor   from    intoxicating    drinks    in   which    the   face  had   a  purplish     or 
leaden  hue,  a  purple  hue  under  the  nails  and  ends  of  the  fingers,  a  labored 
and   slow  breathing,   a    compressible,  slow  and  variable  pulse  correspond- 
ing closely  with  many  of  the  cases  of  apoplexy,  dependent  upon  impair- 
ment in  the  efficiency  of  the  circulation  through  the   brain.     But  on  close 
examination    in  all    these  cases,   the    pupil    of    the   eye    was    found    less 
changed  than  in  tiue  apoplexy.     In  a  majority  of  them  it  is  slightly  dilated 
from  the  effects  of  alcohol,  but  not  nearly  so    much  as  is  usually  the  case 
in  ajDoplexy,  and  the    eyeballs  almost  always    maintain  their  parallelism. 
It  is  very  rare  that  there  is  not  also  a  distinct  alcoholic  odor   recognizable 
in  the  breath.     These  are  circumstances  which  will,   in  a  large  majority  of 
cases,  enable  you  to  distinguish  accurately  between  cases  of  profound  in- 
toxication, and  that  of  apoplexy.     Profound  stujDor,  or  narcotism  from  opi- 
ates, also  sometimes  may  lead   to    doubt   or  to    hesitation     in    comparison 
with  apoplexy.     There  is,  however,  this  difference  in  almost  all  instances: 
that  opiates  produce  close  contraction  of  the  pupils  of  the   eyes,  whereas 
apoplectic  attacks  sufficiently  profound    to   cause    actual   paralysis,    and 
other  conditions,  compared  with  extreme  narcotism,  are  accompanied  by 
dilatation  of  the  pupils,  and  a  failure  to  respond  to  any  alterations  in  the 
intensity  of  light. 


PROGNOSIS,  707 


LECTUEE  LXIX. 


Apoplexy  Continued— Its  Prognoss  and  Treatmi'nt. 

GENTLEMEN:  If  what  I  stated  in  the  preceding  lecture  in  regard  to 
the  pathological  conditions  of  the  brain  involved  in  different  cases  of 
apoplexy  is  correct,  it  follows,  necessarily,  that  the  disease  in  all  its 
varieties  is  one  of  extreme  danger  and  terminates  fatally  in  a  very  large 
proportion  of  the  cases  that  occur.  When  the  disease  is  caused  by  active 
determination  of  blood  from  any  cause,  without  previous  degeneration  or 
impairment  of  the  functions  of  the  cerebral  vessels,  if  seen  and  promptly 
and  judiciously  treated  almost  immediately  after  the  development  of  the 
symptoms  have  commenced,  the  disease  may  not  infrequently  be  arrested. 
Indeed,  with  very  prompt  attention  on  the  part  of  the  physician,  all  the 
cases  of  that  class,  except  such  as  are  accompanied  by  positive  rupture  of 
vessels  and  extravasation  of  blood,  may  be  relieved.  Unfortunately, 
however,  many  of  them  may  be  so  far  distant  from  their  physician,  that 
the  stage  of  intense  capillary  engorgement  will  have  given  place  to  ex- 
udation, so  that  practically  a  large  proportion  of  this  class  of  cases  will 
terminate  fatally,  not  so  much  from  necessity  in  the  nature  of  the  attack 
as  from  the  very  brief  period  of  time  in  which  remedial  measures  can  be 
used  with  success;  this  particular  brief  period  being  the  one  in  which 
the  vessels  of  the  brain  are  only  intensely  engorged  and  before  either 
serous  or  sanguineous  exudation  has  actually  occurred.  Undoubtedly,  in 
some  cases,  recovery  has  taken  place  when  the  treatment  has  been  com- 
menced even  after  some  degree  of  serous  exudation.  Relieving  the  full- 
ness of  the  vessels  themselves,  the  serous  exudation  has  been  re-absorbed 
and  removed.  But  as  might  be  expected  where  the  attack  of  apoplexy 
has  been  preceded  by  impairment  of  the  texture  of  the  cerebral  vessels, 
from  degeneration  through  long  continued  action  of  predisposing  causes, 
very  few  are  capable  of  surviving  a  full  apoplectic  attack.  It  is  other- 
wise, however,  with  a  limited  class  of  cases  in  which  the  attack  has  re- 
sulted from  impairment  of  the  vaso-motor  nerve  influence  as  the  primary 
pathological  condition,  and  the  apoplectic  condition  has  come  from  pas- 
sive dilatation  of  the  vessels  and  consequent  extreme  capillary  engorge- 
ment. These  are  cases  in  which,  if  they  could  be  properly  diagnosticated 
and  treatment  practiced  at  once,  efficiently,  for  the  purpose  of  restoring  a 
more  active  condition  of  the  vaso-motor  nerve  influence,  they  might  be 
arrested  and  a  speedy  recovery  secured.  You  will  perceive  that  there  is 
necessity  for  a  careful  diagnosis,  not  between  the  apoplectic  condition 
and  some  other  disease,  but  between  those  cases  of  apoplexy  arising  from 
passive  engorgement  of  cerebral  vessels  from  failure  of  vaso-motor  nerve 
influence,  from  those  active  cases  in  which  the  accumulation  has  taken 
place  from  active  determination  of  blood  to  the  head. 

Without  such  a  diagnosis  you  would  be  entirely  at  a  loss  for  a  choice 
in  the  class  of  remedies  applicable  to  each  individual  case.  Nothing  is 
more  plain  than  that  those  remedies  most  efficient  in  relieving  or  arrest- 
ing the  progress  of  an  active  deternnination  of  blood,  causing  hyperaemia 
of  the  brain,  if  applied  directly  to  a  case  of  passive  accumulation  of  blood, 
under  a  suspension  or  impairment  of  vaso-motor  nerve  influence,  would 
only  increase  the  risk  of  a  fatal  result  in  the  latter,  and  vice  versa.  It  is 
therefore  not  only  necessary,  in  studying  the   diagnosis   and  prognosis   in 


708  APOPLEXY. 

cases  of  apoplexy  that  they  be  studied  in  relation  to  the  general  differ- 
entiation of  apoplectic  conditions  from  other  diseases,  but  in  reference  to 
diffcMonces  between  one  class  of  cases  of  apoplexy  and  another.  This  in- 
volves the  necessity  for  a  careful  inquiry  into  the  previous  condition  of 
each  individual  patient,  and  the  circumstances  and  influences  that  have 
been  actively  at  work  with  them  during,  perhaps,  months  previous  to  the 
attack.  As  a  general  rule,  the  prognosis  in  apoplexy  must  be  said  to  be  un- 
favorable, yet  as  I  have  already  stated  some  cases  are  capable  of  recovery. 

Treatment. — As  the  essential  phenomena  of  all  forms  of  apoplexv, 
except  rare  cases  caused  by  emboli,  depend  primarily  upon  pressure  on 
the  cerebral  substance,  and  as  this  same  pressure  constitutes  the  chief 
source  of  danger  to  the  life  of  the  patient,  the  adoption  of  such  measures 
as  are  calculated  to  relieve  this  morbid  condition  constitutes  the  leading 
object  of  treatment  in  all  cases  where  the  physician  is  called  to  the  patient 
during  the  early  stage  of  the  disease.  It  matters  not  whether  the  pressure 
is  the  result  of  intense  capillary  congestion,  serous  extravasation,  or  hem- 
orrhagic exudation,  it  is  the  pressure  in  each  case  that  suspends  cerebral 
function.  The  second  indication  to  be  fulfilled  in  the  management  of 
cases,  consists  in  the  adoption  of  measures  to  hasten  there-absorption  of 
whatever  exudations  or  extravasations  have  taken  place,  as  the  second 
step  in  the  pathological  changes.  The  third  indication  to  be  kept  in  view 
in  the  management  of  all  such  cases  as  do  not  terminate  fatally,  is  to  pro- 
mote, as  far  as  possible,  the  removal  of  the  special  morbid  conditions 
which  may  have  contributed  to  produce  an  attack  and  which  by  their  con- 
tinuance would  directly  increase  the  ordinary  predisposition  to  a  relapse. 
These  three  distinct  objects  to  be  accomplished  in  the  management  of 
apoplexy  should  be  kept  in  view,  and  each  should  receive  due  attention; 
and  the  judgment  and  discrimination  of  the  practitioner  is  to  be  exercised 
to  the  fullest  extent  in  choosing  the  means  best  adapted  for  accomplishing 
those  purposes  in  each  individual  case. 

In  former  times,  before  pathological  anatomy  had  been  studied  with  the 
care  which  has  been  bestowed  upon  it  in  later  years,  it  was  an  almost  uni- 
versal custom  to  commence  treatment  when  called  soon  after  the  seizur  e 
of  the  patient,  with  the  abstraction  of  blood,  with  but  little  regard  to  the 
prior  history  of  the  patient,  or  what  might  be  the  special  pathological 
condition  existing  in  the  brain.  You  will  readily  see  from  the  discrim- 
ination we  have  given  of  the  pathological  changes  and  symptoms,  that 
this  remedy,  if  practiced  to  any  degree  in  all  that  class  of  cases  which 
are  characterized  by  degeneration  of  the  coats  of  the  vessels  and  struct- 
ural alterations  in  the  substance  of  the  brain,  or  still  more  in  those 
where  the  primary  step  has  been  impairment  or  suspension  of  the  influence 
of  the  vaso-motor  nerves,  it  must  be  limited  in  amount,  and  done  with 
extreme  caution,  only  in  the  very  first  beginnings  of  the  attack,  and 
then  the  effects,  so  far  as  affording  relief  are  concerned,  unless  followed 
promptly  by  remedies  of  a  different  character,  would  prove  only  tem- 
porary, and  the  patients  would  speedily  relapse  into  a  more  profound 
condition  of  coma,  than  before  trie  abstraction  of  blood.  But  in  all  those 
cases  occurring  in  the  early  and  middle  part  of  adult  life,  having 
their  origin  in  such  conditions  of  the  heart  or  blood  vessels  as  give  rise  to 
excessive  flow  of  blood  to  the  brain,  the  prompt  abstraction  of  blood  by 
venesection  is  the  remedy  above  all  others  best  calculated  to  check  tne 
progress  of  the  disease  by  relieving  the  vascular  fullness  before  any  con- 
siderable exudation,  either  serous  or  hemorrhagic,  has  taken  place,  and 
consequently  should  be  resorted  to,  in  that  particular  class  of  cases  with 
the  least  possible  loss  of  time.     The  rule  which    will   constitute  your  best 


TREATMENT.  709 

guide  as  to  the  amount  of  blood  to  be  drawn  is  to  make  a  free  opening 
into  the  vein  in  the  arm  so  as  to  allow  the  blood  to  flow  in  a  pretty  full 
stream,  and  suffer  it  to  continue  until  the  respiration  and  pulse  become 
more  steady  and  natural  in  quality,  and  the  congested  condition  of  the  face 
subsides.  Then  the  bandage  may  be  removed  from  the  arm  and  the  flow 
of  blood  stopped.  Duringthe  time  of  bleeding  it  is  well  to  have  the 
head  and  shoulders  of  the  patient  elevated  somewhat  on  pillows,  and 
■when  the  flow  of  blood  ceases,  remove  the  pillows  and  let  the  patient  into 
a  nearly  horizontal  position. 

In  this  class  of  cases  the  bleeding  should  be  followed  as  speedily  as 
possible  by  such  arterial  sedatives  as  veratrum  and  aconite,  in  such  doses 
and  with  such  frequency  of  repetition  as  will  insure  an  early  and  free  sed- 
ative influence  upon  the  circulation,  with  a  view  of  perpetuating  the 
effect  that  has  been  produced  more  directly  by  the  abstraction  of  blood. 
Wliile  doing  this,  such  laxatives  or  purgatives  should  be  given,  if  the 
patient  can  be  induced  to  swallow,  as  will  produce  early  and  free  move- 
nientsof  the  bowels.  Liberal  doses  of  the  saline  cathartics,  or  one  full 
dose  of  six  decigrammes  (gr.  x.)  of  the  mild  chloride  of  mercury,  followed  in 
two  hours  by  a  saline  cathartic,  may  be  preferable  to  the  saline  without  the 
mercurial.  In  most  of  this  class  of  patients,  there  is  increased  heat  of  the 
head,  and  cold  applications  may  be  made  there,  while  warm  applications 
or  sinapisms  should  be  kept  to  the  exti'emities.  After  the  bowels  have 
been  freely  opened,  there  is  probably  no  remedy  that  will  be  more  ef- 
ficient in  lessening  the  tendency  to  serous  exudation  into  the  texture  of 
the  brain,  and  at  the  same  time  encourage  liberal  action  of  the  kidneys, 
than  moderately  full  doses  of  the  iodide  of  potassium.  The  iodide  of  po- 
tassium and  cardiac  sedatives  should  be  continued,  being  guided  as  to  the 
activity  of  their  administration  by  the  respiration  and  pulse  of  the  patient, 
till  consciousness  is  well  restored.  Then,  if  symptoms  of  del:)ility  appear, 
or  the  action  of  the  heart  becomes  quick  and  rather  weak,  digitalis  may 
be  given  in  connection  with  the  iodide  of  potassium,  instead  of  continuing 
veratrum  or  aconite.  If  after  consciousness  has  been  restored,  the  patient 
exhibits  a  considerable  degree  of  restlessness,  and  indisposition  to  sleep, 
the  bromides  and  belladonna  will  be  more  likely  to  induce  a  fair  degree 
of  rest,  and  with  less  risk  of  doing  harm,  than  any  preparation  of  the 
opiate  class.  In  some  cases  in  which  a  prompt  free  bleeding  has  been 
attended  at  the  beginning  with  partial  relief  of  the  cerebral  pressure,  in 
from  twelve  to  twenty-four  hours  the  patient  ceases  to  improve,  and 
exhibits  an  increase  of  the  symptoms  of  congestion  and  pressure,  the  ap- 
plication of  leeches  to  the  temples  and  mastoid  spaces,  sufficient,  to  pro- 
duce pretty  free  local  bleeding,  will  frequently  be  of  much  advantage,  and 
be  safer  perhaps  than  a  repetition  of  the  bleeding  from  the  arm.  While 
treatment  by  direct  and  active  depletion,  arterial  sedatives  and  active 
evacuants,  such  as  cause  free  movements  of  the  bowels  and  secretion  from 
the  kidneys  and  skin,  constitute  plainly  and  unmistakably  the  appropriate 
treatment  for  the  class  of  cases  of  apoplexy  dependent  on  active  deter- 
mination of  blood  to  the  head,  even  where  there  may  be  more  or  less  exuda- 
tion, either  serous  or  hemorrhagic;  in  all  those  cases  in  which  the  dis- 
ease has  supervened,  not  from  active  determination  of  blood,  but  from 
some  cause  which  has  impaired  the  action  of  the  vessels  in  the  brain,  the 
question  of  the  direct  abstraction  of  blood  either  by  venesection  or  leeches 
is  one  of  no  small  difficulty  to  decide,  especially  in  some  of  the  cases. 
For  instance,  in  such  as  have  been  induced  by  excessive  and  protracted 
mental  exercise,  or  that  class  of  causes  which  I  have  described  as  calcu- 
lated to  increase  cerebral  excitability,  together  with  all  those  cases    that 


710  APOPLEXY. 

may  have  originated  with  paralysis,  or  impairment  of  the  action  of  the 
vaso-motor  nerves  of  the  brain,  if  the  patient  is  brought  under  observa- 
tion very  speedily  after  the  commencement  of  the  attack,  the  abstraction 
of  blood,  either  by  venesection,  or  locally  by  leeches,  to  a  moderate  ex- 
tent, will  usually  be  found  advantageous.  But  the  bleeding  in  such  cases 
can  not  be  carried  to  the  same  extent  as  in  those  that  have  been  caused  by 
active  determination  of  blood. 

It  will  seldom  be  admissible  in  these  cases  to  take  more  than  from  ten 
to  fifteen  ounces  of  blood  by  veriesection,  or  to  apply  at  one  time  more 
than  from  six  to  eight  good  leeches.  The  whole  object  of  the  bleeding  in 
these  cases  is  to  give  a  temporary  moderate  degree  of  relief  to  the  vascu- 
lar fullness,  for  the  purpose  of  gaining  time  to  obtain  the  action  of  such 
agents  as  may  be  necessary  to  re-establish,  on  the  one  hand,  vaso-motor 
activity,  and  on  the  other  hand  to  directly  retard  the  morbid  excitability^ 
of  the  cerebral  structures.  But  experience  has  demonstrated  that  wheu 
there  is  present  sufficient  positive  accumulation  of  blood  to  overwhelm 
the  cerebral  functions,  and  produce  ordinary  symptoms  of  apoplexy,  even 
in  this  class  of  cases,  the  abstraction  of  a  few  ounces  of  blood  sufficient  to 
diminish  that  fullness,  will  enable  the  other  remedies,  especially  those 
calculated  to  increase  the  activity  of  the  vaso-motors  in  restoring  the  tone 
of  the  vessels,  to  act  much  more  efficiently  than  they  would  without 
the  temporary  relief  afforded  by  the  loss  of  blood.  In  all  these  cases, 
you  perceive,  it  would  be  a  very  great  mistake  to  bleed  to  the  same 
extent  as  in  the  first,  and  a  greater  mistake  still  to  follow  bleeding  by 
the  same  arterial  sedatives.  For  here,  the  heart's  action  is  usually  dimin- 
ished in  force,  the  tone  of  the  vessels  themselves  impaired,  and  we  would 
consequentlv  follow  the  moderate  check  to  the  fullness,  with  such  means  as 
will  most  speedily  and  efficiently  increase  the  tone  of  the  vascular  system 
through  the  vaso-motors  and  diminish  the  excitability  of  ihe  cerebral 
structure.  For  these  purposes,  efficient  doses  of  ergotine,  addressed  to 
the  vaso-motor  nervous  system  is  perhaps  the  best  that  can  be  resorted  to, 
and  if  the  action  of  the  heart  be  actually  irregular,  giving  alternately 
with  the  doses  of  ergotine,  moderate  doses  of  digitalis,  or  its  active  prin- 
ciple, digitaiine,  will  sometimes  be  found  of  more  or  less  advantage.  In 
those  cases  which  are  associated  with  increased  cerebral  excitability  pre- 
ceding the  attack,  instead  of  the  ergotine,  bromides  may  be  conjoined 
with  digitalis,  or  the  combinatiou  of  bromides  and  iodides  in  moderately 
full  doses  given  alternately  with  the  digitalis,  will  effect  the  double  pur- 
pose of  securing  the  sedative  effect  of  the  bromides  upon  the  nerve  ex- 
citability, sustaining  cardiac  or  vascular  tone  by  the  digitalis,  and  the 
counter-action  to  some  extent  at  least  of  serous  exudation,  by  the  in- 
fluence of  the  iodides.  While  these  remedies  may  be  administered  as 
speedily  as  they  can  be  brought  to  bear  in  the  early  progress  of  the  case, 
it  is  desirable  to  procure  also  early  evacuations  from  the  bowels;  not  as 
freely  and  thoroughly  as  in  cases  of  active  detenainatiou  of  blood,  because 
it  is  not  desirable  to  largely  deplete  in  any  way  this  class  of  subjects. 
But  a  moderately  free  movement  of  the  bowels,  warm  and  stimulating 
applications  to  the  extremities,  as  by  bottles  of  hot  water  or  mustard 
sinapisms,  with  cold  applications  to  the  head,  would  be  desirable.  The 
cases  most  difficult  to  devise  remedies  for  are  such  as  are  dependent 
directly  upon  fatty  degeneration  of  the  cerebral  vessels  and  more  or  less 
of  the  cerebral  substance,  and  sometimes  connected  with  more  or  less 
calcareous  deposit  in  the  vessel  walls,  as  is  the  case  in  a  arge  proportion 
of  apoplexies  that  take  place  in  advanced  life.  Nearly  all  such  cases  are 
accompanied  from  the  outset  with  either  rupture  of  some   portion  of  the 


TREATMENT.  711 

dec^enerated  vessels,  and  sufficient  extravasation  of  blood  to  form  clots 
and  very  speedy  fatal  compression,  or  numerous  smaller  ruptures,  causing 
hemorrhagic  exudations,  and  it  is  exceedingly  difficult  to  devise  any 
remedial  agents  which  are  calculated  to  afford  even  the  most  temporary 
relief,  or  to  make  any  impression  upon  the  progress  of  the  case.  Con- 
sequently, nearly  all  such  cases  terminate  fatally  without  exhibiting  any 
marked  changes  from  whatever  treatment  may  have  been  adopted. 

In  some  cases  of  merely  threatened  apoplexy,  the  symptoms,  indicating  a 
strong  tendency  to  develop  only  partial  attacks,  may  sometimes  be  warded 
ff  by  the  administration  of  nerve  tonics,  very  moderate  evacuations,  the 
[promotion  of  secretion,  entire  quiet  to  the  patient,  and  the  use  of  mild 
nourishment.  But  such  warding  off  usually  proves  only  temporary,  and 
sooner  or  later  is  followed  by  a  full  and  fatal  attack.  The  treatment  I 
have  now  suggested  as  applicable  to  the  different  forms  of  apoplexy,  is 
as  well  calculated  as  any  I  have  been  able  to  devise  to  fulfill  the  first  and 
second  indications  that  I  pointed  out,  namely,  relief  of  the  vascular  full- 
ness and  the  promotion  of  the  re  absorption  of  whatever  exudation, 
whether  serous  or  hemorrhagic,  may  have  taken  place.  In  those  cases  in 
which  cerebral  hemorrhage  occurs,  and  it  does  not  prove  directly  fatal, 
there  is  almost  always  only  a  partial  recovery.  After  the  treatment  I 
have  mentioned,  the  immediate  pressure  is  relieved,  consciousness  returns, 
but  the  patient  remains  paralyzed  in  some  part  of  the  system,  more  fre- 
quently one  side,  constituting  hemiplegia  from  the  continued  pressure  of 
the  clot  that  had  formed  from  the  extravasated  blood:  it  is  exceedingly 
slow  in  disintegrating,  and  seldom  fully  disappears.  In  such  cases,  after 
the  active  symptoms  have  passed  by  and  the  patient  has  made  the  partial 
recovery  to  which  I  have  just  alluded,  perhaps  the  management  which 
will  be  most  likely  to  effect  further  disintegration  and  absorption  of  the 
hemorrhagic  clot,  and  preserve  the  cerebral  substance  with  which  it  is  in 
contact  from  undergoing  degenerative  changes,  will  be  the  use  of  a  mild, 
simple  diet,  consisting  mostly  of  milk,  farinaceous  articles,  with  but  little 
meat,  yet  sufficient  in  quantity  to  afford  a  fair  degree  of  general  nutrition; 
careful  abstinence  from  any  undue  physical  or  mental  exercise,  and  the  use, 
for  a  considerable  period  of  time,  of  moderate  doses  of  the  iodide  of  potas- 
sium alone,  or  if  there  be  undue  cardiac  irritability  indicated  by  a  quick, 
irritable  and  rather  compressible  pulse,  digitalis  will  make  a  valuable  ad- 
dition to  the  iodide. 

If  the  patient  is  restless,  especially,  not  inclined  to  get  a  fair  degree  of 
sleep  at  night,  this  may  be  best  obviated  in  most  cases,  by  giving  a  single, 
moderately  full  dose  of  the  bromide  of  ammonium  or  of  potassium  near 
bed  time.  Sometimes  it  will  add  to  the  efficacy  of  this,  if  it  is  given 
in  connection  with  as  large  a  dose  of  hyoscyamus  or  belladonna,  as  will 
be  borne  without  drying  the  mouth  and  fauces  or  altering  the  pupil  of  the 
eye.  It  is  desirable  as  far  as  possible  to  avoid  opiates,  not  only  because 
they  tend  to  increase  the  fullness  of  the  cerebral  vessels,  but  they  also 
tend  to  impair  the  patient's  appetite  and  constipate  the  bowels,  as  well 
95  to  lessen  secretory  action  generally.  In  most  of  the  cases  now  under 
consideration,  the  bowels  are  almost  always  habitually  inclined  to  consti- 
pation. It  is  necessary  to  devise  means  to  obviate  this  and  maintain  as 
healthy  a  regularity  as  possible;  for  by  so  doing,  you  will  do  much  to 
guard  against  a  renewal  of  the  cerebral  attacks.  In  many  of  this  class, 
the  bowels  can  be  best  regulated  by  giving  a  pill  every  evening,  com- 
posed of  six  centigrammes  (gr.  i)  each,  of  the  extract  of  hyoscyamus, 
sulphate  of  iron,  aloes  and  blue  mass,  with  two  centigrammes  (gr.  ^)  of 
the  extract  of  nux  vomica  added  to  each  pill.     In    a   majority  of  patients, 


712 


APOPLEXY. 


one  pill  containinof  these  ingredients  given  regularly  at  night,  will  estab- 
lish a  natural,  healthy  evacuation  the  following  day.  Where  the  subjects 
are  advanced  in  life,  and  affected  by  more  or  less  of  the  degenerative 
changes,  all  depressing  agents,  such  as  iodide  of  potassium  alterants  of 
any  kind  or  evacuants,  except  such  as  are  calculated  to  keep  the  digestive  or- 
gans in  good  order,  are  to  be  avoided.  A  mild,  unstimulating  but  nutri- 
tious diet  as  far  as  practicable,  good  air,  passive  exercise  by  riding,  and 
sometimes  mild  tonics  will  be  required  to  give  this  class  of  patients  the 
most  comfort,  and  the  longest  duration  of  life.  In  the  treatment  of  the 
convalescing  stage  of  all  cases  of  apoplexy,  it  is  necessary  to  take  great 
care  for  several  days,  and  sometimes  weeks,  to  avoid  every  kind  of  mental 
and  physical  excitement  or  exertion.  Quiet  is  of  great  value.  I  know  of 
no  class  of  patients  predisposed  to  apoplexy,  or  recovering  from  a  direct 
attack  in  -which  any  form  of  diffusible  stimulants  are  of  value.  A  very 
•  moderate  use  of  tea  and  coffee  may  be  allowed  riiore  especially  to  the 
aged;  where  there  is  no  direct  increased  cardiac  force  or  irrita- 
bility, tea  and  coffee  used  moderately,  will  seldom  produce  unpleas- 
ant effects.  But  the  alcoholic  class  of  agents,  whether  fermented  or 
distilled,  are  directly  and  positive!}'-  objectionable,  both  on  account  of 
their  tendency  to  produce  deficient  oxygenation  and  decarbonization  of 
the  blood  and  favor  fatty  degenerations,  and  also  on  account  of  their  di- 
rect anaesthetic  effect  upon  the  sensibility  of  the  cerebral  substance,  and 
upon  vaso-motor  nerve  influence. 

I  have  met  with  a  few  patients  a  little  past  the  middle  period  of  life, 
two  of  whom  live  still  under  my  observation,  who  have  repeatedly  mani- 
fested symjDtoms  indicating  imminent  danger  of  full  apoplectic  attacks. 
One  of  these  is  a  female,  about  forty-five  years  of  age,  who  during  the  last 
six  years  has  been  habitually  inclined  to  deficient  urinary  secretion,  but 
without  evidence  of  any  structural  disease  of  the  kidneys,  also  a  moderate 
increase  of  flesh  or  fullness,  and  some  degree  of  constipation,  but  no  car- 
diac hypertrophy,  and  no  undue  fullness  or  tension  of  the  pulse.  Almost 
regularly  during  every  year  she  has  exhibited  an  increase  of  cerebral  full- 
ness or  congestion  in  the  vessels  of  the  brain,  until,  if  not  interfered  with, 
she  would  be  seized  with  vertigo,  dimness  of  vision,  slight  twitching  of  the 
muscles  of  the  face,  and  a  complete  suffusion,  or  congestion  of  the  vessels 
of  the  face,  neck  and  head,  causing  the  surface  to  have  an  almost  purple 
color  accompanied  by  every  symptom  of  innnediately  impending  apoplexy. 
When  these  attacks  first  made  their  appearance  I  resorted  to  every  means 
that  I  could  devise  for  warding  off  the  threatened  apoplectic  condition, 
without  resorting  to  direct  abstraction  of  blood.  Free  opening  of  the 
bowels,  diuretics,  cold  applications  to  the  head,  sinapisms  to  the  extremi- 
ties, and  at  first  vascular  sedatives  were  used.  Failing  to  get  benefit  from 
these,  vaso-motor  excitants  and  full  doses  of  ergotine  were  tried  but  all 
without  any  perceptible  relief.  A  vein  was  then  opened  in  the  arm  and 
blood  drawn,  to  the  extent,  in  the  earlier  attacks^  of  from  half  to  two 
thirds  of  a  liter  (3xvi  to  fxx).  This  was  followed  by  relief  both  speedy 
and  entirely  satisfactory.  And  subsequently  the  palliating  remedies  ad- 
dressed to  an  increase  of  the  secretion  of  the  kidneys,  regulation  of  the 
bowels,  and  of  all  the  functions  that  might  be  out  of  order,  j^roduced 
effects  very  much  more  ready  and  satisfactory  than  the  same  remedies 
before  the  abstraction  of  blood.  I  have  apparently  warded  oft'  these  at- 
tacks in  both  the  patients  alluded  to,  for  the  last  six  or  seven  years,  by 
the  occasional  abstraction  of  blood.  During  the  later  years  not  more 
than  260  or  360  cubic  centimeters  (3viii  or  3xii)  have  been  required  to  aftbrd 
the   needed   relief.     During  the  last  five  years  one  of  these  patients    has 


TKEATMENT.  713 

been  under  the  care,  at  different  times,  of  several  other  physicians,  who 
most  perseveringly  endeavored  to  afford  relief  without  resort  to  bleeding, 
but  with  no  better  success  than  I  had  myself.  I  have  no  doubt  but  that 
the  patient  would  have  died  several  years  since,  instead  of  being  in  such 
health  as  to  be  able  to  superintend  her  household  affairs,  as  she  is  at 
present,  if  venesection  had  not  been  resorted  to  for  her  relief. 

Another  equally  well  marked  instance  is  an  adult  male  engaged  in 
mercantile  business,  in  which  the  threatened  cerebral  congestion  was  asso- 
ciated with  very  marked  increased  action  of  the  heart,  with  no  apprecia- 
ble indication  of  valvular  disease  or  structural  changes,  but  an  increased 
activity,  apparently  extending  to  the  aorta  and  the  vessels  of  the  nock. 
This  case, when  first  coming  under  my  observation  presented  such  symptoms 
as  indicated,  a  turgid  condition  of  the  vessels  of  the  face  and  a  nearly 
suspended  cerebral  function,  and  caused  no  hesitation  in  resorting  to  ve- 
nesection. The  patient  was  bled  to  the  extent  of  nearly  one  liter  (jxxx). 
He  too  had  been  subject  for  a  considerable  time  to  defective  action  of 
the  kidneys,  slight  tendency  to  constipation,  and  had  noticed  some  degree 
of  vertigo.  He  was  a  man  of  naturally  sanguine  temperament,  broad 
chest,  short  neck,  and  in  his  case  after  the  prompt  relief  that  was  ob- 
tained by  the  free  bleeding,  he  was  put  directly  upon  the  use  of 
a  combination  of  bromide  of  lithium,  wine  of  colchicura  root  and 
for  a  time  the  tincture  of  veratrum  viride,  and  with  the  most  de- 
cided beneficial  effect.  The  urinary  secretion  became  abundant,  the 
excitability  of  the  heart  and  cerebral  vessels  apparently  returned  to  the 
natural  standard,  and  by  the  continuance  of  full  doses  of  this  combina- 
tion of  remedies  each  night  and  morning  for  two  or  three  months,  the 
patient  gained  an  exemption  from  this  tendency  to  cerebral  congestion, 
which  had  lasted  him  through  at  least  two  full  years.  Subsequently, 
when  indulging  more  sedentary  habits  than  usual,  the  symptoms  returned 
upon  him,  and  with  such  a  degree  of  intensity  as  required  another,  but 
more  moderate  bleeding.  Since  that  time,  now  four  years,  the  re- 
sort for  a  few  weeks  at  the  time,  two  or  three  times  a  year,  to  the  use  of 
a  combination  of  bromide  of  lithium,  wine  of  colchicum,  and  tincture  of 
digitalis,  in  moderate  doses,  at  first  three  times  a  day  for  one  week,  and 
then  morning  and  evening  for  a  few  weeks  subsequently,  has  kept  him 
from  any  return  of  symptoms  sufficient  to  attract  attention,  or  interfere 
with  his  usual  occupation.  I  have  mentioned  these  cases,  and  the  treat- 
ment that  I  have  given  them,  for  the  purpose  of  guiding  you  in  reference 
to  similar  cases  that  are  liable  to  be  met  with  in  practice,  especially  among 
patients  of  sedentary  habits,  accustomed  to  moderately  full  living,  and  who 
at  the  same  time  have  much  of  either  business  or  other  cares  and  mental 
anxieties  influencing  them.  Of  course,  in  the  management  of  all  such 
patients,  strict  attention  should  be  given  to  the  judicious  regulation  of 
their  diet  and  their  exercise;  to  the  condition  of  the  digestive  organs,  as 
well  as  soine  degree  of  attention  to  the  condition  of  the  renal  secretion. 
The  latter  escapes  attention  very  frequently,  when  it  would  be  very  much 
to  the  advantage  of  the  patient  if  it  was  as  studiously  inquired  after  and 
properly  regulated,  as  the  evacuations  from  the  bowels,  or  the  condition 
of  the  digestive  organs,  which  are  not  nearly  as  likely  to  produce  direct 
effects  upon  the  brain  as  deficiency  in  the  quality  and  quantity  of  the  urine. 


714  PAEALYSIfc, 


LECTURE  LXX. 


Paralysis— Its  Varieties,  Causes,  Clinical  History,  Anatomical  Changes,  Diagnosis,  Prognosis  and 
Treatment. 

GENTLEMEN:  After  directing  your  attention  as  much  in  detail  as  is 
necessary  to  the  nature  and  management  of  the  different  varieties  of 
apoplexy,  I  next  ask  your  attention  to  a  subject  in  some  respects  closely 
allied  to  it,  namely  paralysis.  This  term  is  made  to  include  a  group  of 
affections  differing  in  many  respects,  especially  in  regard  to  their  patho- 
logical relations,  causes,  symptoms  and  consequences.  The  word  implies, 
as  it  is  generally  used,  impairment  or  loss  of  the  natural  function  of  nerve 
structure.  And  as  the  I'urctions  of  the  nervous  system  are  two-fold, 
sensory  and  motor,  paralysis  may  consist  in  impairment  or  complete  loss, 
eitlier  of  the  function  of  sensation  properly  denominated  ana3S- 
thesia,  or  of  motion  by  which  the  muscles  supplied  with  the  nerves 
whose  motor  power  has  been  lost,  become  inactive  or  incapable 
of  normal  contractions.  Sensory  and  motor  paralysis  may  exist  to- 
gether, causing  a  loss  both  of  feeling  or  sensibility  and  the  power 
of  motion,  or  either  one  may  exist  separately  without  the  other. 
Cases  of  paralysis  are  often  named  in  reference  to  the  immediate  or 
proximate  cause:  cerebral,  when  the  cause  or  pathological  condition 
giving  rise  to  them  is  located  fa  any  part  of  the  brain  or  contents  of  the 
cranium;  spinal  paralysis,  when  the  seat  of  the  disease  is  in  some  portion 
of  the  spinal  cord;  and  reflex  paralysis  when  the  primary  seat  of  irritation  is 
in  the  periphery  of  some  one  or  more  nerves,  and  the  influence  is  re- 
flected upon  the  nerve  center  either  in  the  cord  or  brain.  Some  writers 
group  their  cases  of  paralysis  not  in  accordance  with  their  direct  proxi- 
mate cause,  their  location  or  the  pathological  condition  giving  rise  to 
them,  but  in  accordance  with  the  extent  and  location  of  the  parts 
paralyzed;  as  facial  paralysis,  when  the  parts  affected  are  only  some  por- 
tion of  the  face;  or  if  it  affects  a  particular  muscle  only,  the  name  will  be 
indicated  by  the  name  of  the  muscle  involved.  If  it  affects  the  whole  of 
one  side,  they  denominate  it  hemiplegia.  If  it  affects  a  part  of  both  lower 
extremities,  or  the  whole  up  to  a  given  line  transversely,  it  is  designated 
paraplegia.  In  considering  the  non-inflammatory  conditions  capable  of 
giving  rise  to  paralysis,  either  motor  or  sensory,  we  find  almost  the  same 
pathological  conditions,  either  in  the  brain,  medulla  or  spinal  cord,  that  I 
have  already  described  as  giving  rise  to  apoplexy.  The  chief  difference  is 
generally  in  the  extent  of  the  parts  involved.  In  apoplexy,  the  congestion 
of  the  cerebral  mass  is  more  general,  or  if  it  depends  upon  hemori'hagic  ex- 
udation or  extravasation,  the  quantity  of  blood  extravasated  is  sufficient ' 
not  to  interrupt  merely  the  function  of  a  portion  of  the  brain,  but  of  the 
whole.  And  if  degeneration  of  vessels  and  cerebral  structure  from  any 
cause,  whether  from  age,  from  the  action  of  alcohol,  syphilis,  or  any  other 
toxgemic  agent  acting  through  the  blood,  affects  but  a  limited  portion  of 
the  cerebro-spinal  substance,  instead  of  producing  apoplectic  symptoms, 
it  will  only  cause  suspension  of  the  functions  of  the  parts,  sensory  or 
motor,  to  which  the  nerves  are  distributed,  having  direct  or  indirect  con- 
nection with  the  locality  in   which  the   disease   exists,  and   consequently 


HEJIIPLEGIA.  715 

will  constitute  paralysis  instead  of  apoplexy.  But  when  this  condition 
exists  in  the  cerebral  substance,  it  frequently  happens,  as  I  have  men- 
tioned when  speaking  of  the  symptoms  of  apoplexy,  that  the  attacks 
primarily  present  all  the  symptoms  of  the  latter  disease,  but  in  the  proa;'- 
ress  of  recovery  the  greater  portion  of  the  cerebral  mass  becomes  relieved 
from  pressure,  apoplectic  symptoms  disappear,  but  paralysis,  usually  in 
the  form  of  hemiplegia,  is  left.  In  such  patients  you  can  maintain  no 
line  of  distinction  in  the  primary  seat  of  disease,  between  apoplectic 
and  paralytic  attacks.  They  are  identical;  the  paralytic  condiiion 
being  the  result  of  only  a  partial  recovery  from  cases  presenting  all  the 
characteristics  of  apoplexy  at  their  beginning.  In  the  further  considera- 
tion of  the  subject  of  paralysis,  I  shall  direct  your  attention,  first,  to  those 
cases  which,  the  pathological  lesion  being  in  some  part  of  the  cerebral 
mass,  may  properly  be  called  cerebral  paralysis;  second,  to  those  originat- 
ing from  changes  in  some  portion  of  the  spinal  cord,  under  the  name  of 
spinal  paralysis,  including  what  is  denominated  as  infantile  paralysis, 
reflex  or  indirect  paralysis,  and  what  might  be  termed  hysterical  or  lalse 
paralysis. 

Hemiplegia. — As  the  word  would  indicate,  hemiplegia  means  paralysis 
more  or  less  complete  of  one  half  of  the  body,  including  one  upper  and 
one  lower  extremity,  and  is  the  most  common  form  of  paralysis  resulting 
from  non-inflammatory  afl^eotions  within  the  cranium.  Attacks  of  hemi- 
plegia ordinarily  commence  suddenly,  often  without  premonitory  symp- 
toms of  more  than  a  few  minutes'  duration.  In  some  instances,  however, 
there  are  sensations  of  numbness  in  the  hands  and  feet,  or  both,  occurring 
at  short  intervals,  and  in  others  vertigo,  for  a  considerable  period  of  time 
before  a  decided  attack  of  paralysis  supervenes.  In  a  large  majority  of 
instances,  however,  complete  hemiplegia  arises  from  either  emboli  ob- 
structing suddenly  one  or  more  cerebral  vessels,  or  the  rupture  of  some 
vessel,  the  walls  of  which  had  become  more  or  less  weakened  by  degener- 
ation, and  the  extravasation  of  blood.  A  considerable  number  of  cases 
met  with  in  practice  are  simply  the  sequelae  of  attacks  of  apoplexy,  during 
which  hemorrhage  had  taken  place  causing  the  formation  of  a  clot,  which 
remains  after  the  more  fluid  part  of  the  blood  has  been  absorbed.  The 
presence  of  such  clot  is  sufficient  to  prevent  the  resumption  of  the  com- 
plete functions  of  the  motor  influence  emanating  from  the  hemisphere 
into  which  the  hemorrhage  had  taken  place,  and  consequently  hemiplegia 
remains.  In  all  the  classes  of  cases  that  are  dependent  either  upon  embol- 
ism, or  upon  the  extravasation  of  blood,  the  primary  symptoms  supervene 
suddenly.  The  symptoms  which  more  particularly  characterize  hemip'e- 
gia  when  it  is  complete,  embracing  one  side  of  the  face,  neck,  arm,  leg 
and  one  half  of  the  tongue,  are  the  drooping  or  relaxation  of  the  muscles 
of  the  paralyzed  side  of  the  face,  which  cause  the  mouth  to  be  drawn  to 
the  opposite  side  whenever  the  muscles  contract,  giving  to  the  face  an 
expression  of  laughter.  There  is  difiiculty  of  moving  the  food  in  the  mouth 
from  the  paralyzed  condition  of  the  buccinator  muscles,  and  the  turning 
of  the  tongue  toward  the  paralyzed  side  when  it  is  protruded,  because  of 
the  action  of  the  niuscles  upon  one  side  only.  There  is  also  impaired 
deglutition  and  speech.  The  paralysis  seldom  includes  the  nerves  supply- 
ing the  eyelids,  or  the  muscles  controlling  the  eye-ball,  consequently  move- 
ments of  these  parts  remain  on  the  paralyzed  side  the  same  as  on  the  other. 
The  arm,  however,  hangs  motionless,  and  when  the  patient  is  raised  into 
the  erect  position,  the  shoulder  droops,  and  the  lower  extremity  fails  of  all 
power  of  motion.  Sensibility  in  most  instances  remains  nearly  perfect 
throughout,  but  in  some  there  is  impairment  or  loss  of  sensibility  as  well  as  of 


7 16  HEMIPLEGIA. 

motion.  In  some  cases  the  paralysis  embraces  the  viscera  of  the  pelvis, 
so  as  to  paralyze  one  half  of  the  rectum  and  bladder,  giving  rise  either  to 
retention  of  urine  till  the  bladder  is  overfull,  when  it  would  dribble,  and 
the  discharge  of  feeces  with  only  a  very  partial  control  on  the  part  of  the 
patient.  When  complete  hemiplegia  has  supervened,  presenting  the 
symptoms  just  described  suddenly,  it  renders  the  patients  usually  for  the 
first  week  entirely  helpless;  and  they  may  remain  so,  failing  in  strength, 
without  control  over  the  sphincters  of  the  body,  and  the  temperature  of 
the  extremities  falling  below  the  natural  standard.  The  dribbling  of 
urine  and  wetting  of  the  bed,  unless  great  care  is  taken  to  avoid  it, 
hastens  the  appearance  of  inflammation,  excoriation,  and  sometimes  gan- 
grene over  the  hips  and  nates  or  parts  in  contact  with  the  bed,  leading, 
in  many  instances,  to  deep  and  large  bed  sores;  the  patient  loses  his  ap- 
petite, the  mind  becomes  weakened,  sometimes  wandering,  and  after 
lingering  in  a  very  uncomfortable  condition  of  entire  helplessness  from 
one  to  six  weeks,  death  may  supervene,  apparently  from  asthenia  or 
exhaustion. 

But  in  a  very  large  proportion  of  cases  of  hemiplegia,  whether  orignat- 
ing  from  full  apoplectic  attacks  or  from  hemorrhagic  exudation,  the  pa- 
tients, instead  of  failing,  as  I  have  just  mentioned,  slowly  improve  fr.-^.m 
day  to  day,  more  especially  in  the  movement  of  the  muscles  of  the  face 
or  tongue,  so  much  so  that  in  many  the  face  becomes  nearly  even,  only 
active  muscular  action  showing  impairment,  and  the  movement  of  the  tongue 
being  entirely  restored.  These  improvements  also  enable  the  patient  to 
regain  his  usual  freedom  of  speech  and  deglutition.  While  these  improve- 
ments are  taking  place  in  the  paralyzed  parts  of  the  face,  tongue  and  neck, 
there  is  usually  a  manifest  improvement  perceptible  in  the  ability  to 
move  the  arm  and  the  leg.  At  first,  this  consists  simply  of  the  power  to 
slightly  draw  the  leg  up  an  inch  or  two,  by  bending  the  knee,  and  of 
making  a  motion  of  the  arm  more  from  the  muscles  of  the  shoulder,  than 
from  those  on  the  arm  proper.  It  is  seldom  that  such  patients  suffer 
from  any  severe  pain  in  the  head,  or  any  other  part  of  the  body,  unless 
it  is  from  being  compelled  to  lie  or  sit  too  long  in  one  position.  Those 
that  present  these  improvements  usually  recover  also  pretty  fully  the  con- 
trol of  the  bladder  and  rectum.  They  have  a  good  appetite,  and  in  all  re- 
spects feel  well,  except  the  inability  to  use  the  upper  and  lower  extremity. 
Where  the  improvement  takes  place  thus  far,  the  patient  usually  com- 
mences to  get  upon  his  feet,  and  to  make  efforts  to  walk.  These  efforts 
to  use  the  paralyzed  limb  become  systematic,  and  with  the  aid  of  a  cane 
or  a  crutch,  they  are  able  to  walk,  by  giving  to  the  paralyzed  leg  a  swing- 
ing or  partially  circular  motion,  bringing  it  forward  more  by  the  swinging  of 
the  pelvis  forward,  than  from  the  regular  picking  up  of  the  limb  and  set- 
ting it  forward,  as  is  natural  in  the  process  of  walking.  This  m.ode  of  walk- 
ing is  peculiar  to  the  partially  paralyzed  of  a  hemiplegic  character.  In  al- 
most all  cases,  where  partial  recovery  takes  place,  the  patient  being  able 
to  be  upon  his  feet,  the  recovery  of  the  use  of  the  leg  is  much  greater  in 
proportion  than  that  of  the  arm  and  hand.  As  the  patient  feels  less 
necessity  for  the  daily  efforts  to  use  the  paralyzed  hand  and  arm,  the 
other  affording  a  ready  substitute  for  most  of  his  wants,  they  are  allowed  to 
remain  more  passive,  and  consequently  are  much  slower  in  recovering,  and 
generally  recover  less  perfectly  than  does  the  lower  extremity.  If  the 
paralysis  has  originated  primarily  from  serous  exudation,  or  only  a  partial 
plugging  of  the  vessels  by  an  embolus,  recovery  may  be  complete,  and. 
that  in  the  course  of  fro:il  three  to  six  weeks,  by  the  re-absorption    of 


SYMPTOMS.  717 

the  exudative  material,  and  tlie  dissolution  or  disappearance  of  the  em- 
bolus that  had  obstructed  the  vessels  and  temporarily  suspended  circula- 
tion in  a  portion  of  the  cerebral  sul)stance.  It  is  not  always,  however, 
that  emboli  are  capable  of  rem  )val  in  this  way,  consequently  many  cases 
dependent  upon  them,  either  make  only  a  partial  recovery  or  no  improve- 
ment. 

Tiiose  cases  of  hemiplegia  that  occur  from  direct  extravasation  of  blood 
and  the  formation  of  fibrinous  clots,  very  rarely  progress  to  an  entire  re- 
covery, but  only  make  such  a  degree  of  improvement  as  enables  the  patient 
to  walk  with  some  difficulty  and  unsteadiness  by  bringing  the  leg  forward 
at  each  step  with  a  semi-rotatory  motion  of  the  pelvis,  while  the  hand  and 
arm  remain  almost  entirely  useless.  When  the  disease  becomes  thus  per- 
manent it  may  remain  stationary  for  a  very  variable  period  of  time. 
Cases  that  have  come  under  my  own  observation  have  remained  appar- 
ently stationary  for  several  years.  But  in  all  of  these,  sooner  or  later,  there 
have  been  renewals  of  the  extravasation  or  exudation  of  blood,  bringing 
renewals  of  a  more  complete  hemiplegia,  until  in  some  instances  the 
extravasation  has  been  sufficient  to  overwhelm  the  functions  of  the  brain, 
inducing  coma,  universal  piralysisand  death.  In  other  cases  there  has 
been  no  relapse  in  their  progress,  but  the  brain  surrounding  the  clot  has 
undergone  a  slow  degenerative  process,  usually  of  the  nature  of  an  arrest 
of  nutrition,  and"  consequently  softening  of  structure,  correspondingly 
impairing  more  and  more  the  strength  of  the  patient  and  his  ability 
to  use  either  the  upper  or  lower  extremity.  At  the  same  time  I  have 
noticed  a  decided  failure  in  the  mental  capacity,  usually  in  the  direc- 
tion of  simple  mental  weakness,  impairment  of  meraoiy,  incoherence 
and  steady  progress  toward  imbecility.  This  slow  deteriorative  proc- 
ess in  the  cerebral  substance  surrounding  the  primary  clot  may  increase 
gradually  till  at  the  end  of  two,  three  or  four  years  the  patient  l)ecome3 
quite  imbecile,  paying  little  or  no  heed  to  evacuations  of  urine  or  faeces, 
yet  taking  food  freely  and  even  ravenously  whenever  it  is  put  into  the 
mouth,  but  manifesting  neither  capacity  for  connected  thought  nor  mental 
activity,  and  becoming  entirely  devoid  of  ability  to  maintain  the  upright 
position,  either  upon  the  feet  or  in  the  sitting  posture.  In  this  condition 
of  helplessness  and  mental  imbecility  he  may  still  live  for  a  considerable 
period  of  time;  but  usually  sinks  gradually  into  an  unconscious  condition 
with  general  paralysis  and  dies.  Such  is  a  general  statement  of  the  symp- 
toms and  progress  of  the  common  forms  of  hemiplegia,  resulting  from 
non-inflammatory  obstructions  in  some  portion  of  the  brain.  Cases  may 
be  met  with  in  which  the  lesion  is  in  the  brain,  and  yet  it  may  not  im- 
pair or  paralyze  the  entire  half  of  the  body,  but  only  a  certain  portion  of 
one  side;  as  when  it  interrupts  the  function  only  of  the  motor  nerves  of 
one  side  of  the  face,  producing  what  is  thus  styled  facial  paralysis.  In 
another  instance  it  affects  only  the  function  of  those  nerves  which  supply 
the  arm,  rendering  it  incapable  of  motion,  while  the  face  above  and  the 
lower  extremities  remain  unaffected.  In  perhaps  a  smaller  number  of 
cases,  a  single  leg  may  be  paralyzed  without  involving  the  arm  or  the 
face  and  yet  the  seat  of  disease  may  be  in  the  brain.  Ferrier,  in  his 
efforts  to  localize  the  functions  of  the  brain,  has  pointed  out  particular 
parts,  which,  when  obstructed  by  hemorrhagic  exudation,  tumors  or  any 
other  mode  of  pressure,  had  given  rise  to  movements  in  particular  parts  of 
the  body.  He  claimed  to  have  established  the  fact  that  when  one  leg 
was  paralyzed  the  seat  of  disease  was  in  that  part  of  the  cerebral  mass 
above  the  corpus-callosum  of  the  side  opposite  to  the  leg  paralyzed.  In 
paialysls  of    the   upper   extremity,    the    seat   of  disease    was   somewhat 


718  HEMIPLEGIA. 

anterior,  and  connected  with  the  auterior  lobe  of  the  brain,  or  near  its 
junction  with  the  middle  lobe.  ,  While  in  paralysis  of  the  face,  muscles  of 
the  tongue,  and  esi^ecially  in  aphasia  or  that  form  of  paralysis  destroying 
tlie  ability  to  speiik,  the  seat  of  disease  was  said  to  be  located  in  the  con- 
volutions on  the  inner  side  of  the  anterior  lobe,  opposite  to  the  parts 
paralyzed.  These  views  of  Ferrier  have  many  facts  to  confirm  them,  and 
yet  they  require  a  much  la,rger  collection  of  pathological  facts  and  results 
of  recorded  cases  to  estaljlish  their  absolute  correctness. 

Anatomical  Changes. — When  death  takes  place  from  hemiplegia,  and  a 
post-mortem  examination  is  had,  the  anatomical  changes  found  in  the  brain, 
differ  in  different  cases,  and  with  differences  in  the  length  of  time  that  the 
disease  had  existed  before  the  death.  In  those  cases  that  supervene  sudden- 
ly producing  complete  hemiplegia  proceeding  to  a  fatal  result  early,  there 
will  usually  be  found  simply  a  rupture  of  one  or  more  blood  vessels,  and 
the  extravasation  of  blood,  the  serous  portion  of  which  may  have  been 
partially  absorbed,  but  a  fibrinous  clot  it  left.  In  most  instances,  close 
examination  will  show  that  the  extravasation  has  been  the  result  of 
fatty  degeneration  of  the  coats  of  the  ruptured  vessels,  or  some  other 
form  of  structural  impairment.  It  is  very  rarely  that  such  rupture  has 
taken  place,  unless  from  direct  violence,  without  proceeding  from  condi- 
tions impairing  the  structure  of  the  vessels  themselves.  In  some  instances, 
examination  has  shown  the  origin  of  the  disease  to  have  been  in  the 
plugging  of  one  or  more  vessels  by  emboli,  or  fibrinous  clots.  In  such 
CMses  the  portion  of  the  brain  supplied  by  the  vessels  thus  plugged  will 
exhibit  deficiency  in  the  supply  of  blood,  provided  the  vessel  is  an  artery. 
If  it  be  a  vein,  the  capillaries  and  smaller  arteries  connected  with  the 
distribution  of  the  vein  may  be  intensely  engorged,  or  even  exhibit  serous 
or  sanguineous  exudation  into  its  texture.  In  some  instances,  the  par- 
alysis or  hemiplegia  has  been  found  dependent  on  the  formation  of  one 
or  more  tumors,  which  had  developed  either  in  the  cerebral  substance  or 
in  the  membrane  covering  it.  Tne  most  common  form  of  morbid  growth 
is  sarcomatous  enlargement  of  the  glands  lying  along  the  longitudinal 
sinus,  or  in  the  vicinity  of  it,  mo:e  frequently  than  elsewhere.  Some- 
times tumors  originating  in  the  membranes  of  the  brain  attain  consid- 
erable size,  developing  slowly,  and  the  cranium  being  incapable  of  yield- 
ing, the  tumor  becomes  imbedded  deeper  and  deeper  into  the  cerebral 
substance,  producing  a  variety  of  symptoms  during  its  progress  that  vary 
from  simple  severe  attacks  of  pain,  and  temporary  spasmodic  twitching  of 
muscles,  up  to  that  of  complete  paralysis,  and  often  coma  followed  by  death. 
Of  course  you  will  keep  in  mind  that  I  am  now  speaking  only  of  paraly- 
sis arising  from  non-inflammatory  affections  of  the  brain.  I  have  already 
had  occasion  to  point  out  the  occurrence  of  paralysis  in  all  its  degrees  of 
development  as  the  result  of  inflammation  and  effusions,  when  speaking 
of  the  inflammation  of  the  central  portion  of  the  nervous  centers.  Our 
present  purpose,  however,  is  simply  the  consideration  of  those  of  a  non- 
inflammatory character. 


DIAGNOvSIS.  719 


LECTURE  LXXI. 


Hemiplogia  continued— Its  Diagnosis,  Prognosis    and    Treatment;  Paraplegia;  Paralysis  from 
Lead  and  Mercnry,  and  Paralysis  Agitans. 

GENTLEMEN:  The  diagnosis  of  hemiplegia,  either  partial  or  complete, 
so  far  as  relates  to  the  existence  of  the  paralysis  is  not  difficult.  The 
characteristic  phenomena  are  mainly  objective  and  easily  recognized.  The 
only  difficulty  consists,  not  in  deciding  whether  paralysis  actually  exists, 
but  what  is  the  nature  and  location  of  the  pathological  condition  on 
which  the  paralysis  depends?  Whether  the  conditions  are  located  within 
the  cranium,  and  have  resulted  from  inflammation,  capillary  congestion, 
hyDerfemia  from  cardiac  hypertrophy,  degenerative  changes  in  the 
blood  vessels,  emboli,  or  mere  reflex  irritation,  is  not  in  every  case  easy  to 
determine. 

To  distinguish  these  cases  from  paralysis  depending  on  inflammation, 
you  have  only  to  remember  that  the  latter  have  a  history  showing  all  the 
phenomena  or  symptoms  usually  produced  by  acute  or  sub-acute  inflamma- 
tions of  important  structures,  such  as  pain,  fever,  or  intensity  of  excitement 
for  a  longer  or  shorter  period  previous  to  the  occurrence  of  the  paralysis; 
while  in  the  conditions  of  a  non-inflammatory  character,  whether  the 
onset  be  sudden  or  gradual,  it  is  accompanied  by  no  fever,  or  perceptible 
rise  of  temperature,  or  any  one  of  the  assemblage  of  symptoms  which 
indicate  active  inflammation.  To  difi"erentiate  hemiplegic  paralysis  de- 
pendent on  the  cerebral  lesion  from  those  of  a  mere  reflex  character, 
which  are  liable  to  occur  chiefly  in  hysterical,  choreic,  and  epileptic  pa- 
tients, and  by  some  supposed  to  be  capable  of  arising  from  reflex  irrita- 
tion of  worms  and  other  disturbing  influences  in  the  alimentary  canal, 
you  have  only  to  inquire  carefully  into  the  history  of  the  patient's  case. 
Such  history  will  readily  show  whether  there  has  been  the  existence  of 
hysterical,  choreic  or  epileptic  paroxysms,  and  the  connection  of  the  par- 
alysis with  the  supervention  of  the  paroxysms  of  any  one  of  these  affec- 
tions. It  may  ])e  proper  to  remark,  however,  that  in  addition  to  a  history 
showing  prior  existence  of  some  one  of  the  nervous  affections  named, 
a  hemiplegia,  arising  from  or  in  connection  with  these  diseases,  is  seldom 
complete.  More  generally  it  is  only  partial  and  passes  away  in  a  few  days 
after  a  paroxysm  of  the  affection  on  which  it  depends. 

JPrognosis. — From  the  nature  of  the  pathological  changes  I  have  men- 
tioned as  giving  rise  to  hemiplegia,  you  will  infer  that  the  prognosis,  so 
far  as  relates  to  complete  restoration,  is  very  unfavorable.  But  few  of 
these  cases  are  in  danger  of  immediate  death  on  the  supervention  of  hem-  , 
iplegia,  while  there  is  still  less  prospect  that  any  considerable  number 
will  make  a  complete  recovery.  A  majority  recover  partially,  but  linger 
for  months  and  sometimes  years,  in  an  impaired  condition  so  far  as  loco- 
motion and  control  of  muscular  acti-m  is  concerned,  and  they  gradually 
decline  from  further  degenerative  changes  in  the  brain,  till  the  final 
termination  of  the  life.  Consequently,  while  there  is  but  little  danger  of 
immediate  fatal  results  in  attaclis  of  iiemiplegia,  there  is  no  reasonable 
prospect  in  a  majority  of  cases,  of  reaching  an  entire  recovery.  And,  if 
recovery  is  not  reached,  in  process  of  time  there  occurs  more  or  less 
softening  or  disintegration  from  degenerative  changes  in  the  portion  of 
the  brain  affected,  constituting-  a  species  of  impairment  of  texture,  and  con- 


720  HEMIPLEGIA, 

sequently  of  fanction,  to  such  an   extent  as  to  terminate   the  life   of   the 
patient. 

Treatment. — The  treatment  in  hemiplegia  is  in  all  respects  similar  to 
that  of  apoplexy,  except  there  is  very  rarely  any  indication  for  the  abstrac- 
tion of  blood  by  venesection.  In  a  paralytic  affection  having  originated 
from  the  establishment  of  some  direct  pressure  upon  the  cerebral  substance, 
such  as  the  formation  of  a  clot  or  embolus  or  presence  of  a  tumor,  the  ab- 
straction of  blood  could  have  but  little  effect  in  altering  the  circulation  in 
the  obstructed  vessels  of  the  brain.  The  leading  indication  for  treatment 
when  these  cases  come  into  the  hands  of  the  physician,  are,  on  the  one 
hand,  to  favor  as  much  as  possible,  the  removal  by  absorption,  of  whatever 
material  may  be  producing  the  paralyzing  pressure  upon  the  cerebral 
structure,  and  on  the  other  to  prevent  further  deterioration  or  impairment 
of  structure  in  the  vessels  and  cerebral  substance  constituting  the  seat  of 
the  disease,  and  thereby  lessen  the  danger  of  renewed  extravasations  or' 
the  increase  of  degenerations  and  morbid  growth.  There  are  no  better 
remedies  for  the  accomplishment  of  these  different  purposes  than  those 
which  I  have  pointed  out  to  you  in  a  previous  lecture  when  speaking  of 
the  treatment  of  the  different  stages  of  apoplexy,  more  particularly  of  those 
cases  that  depend  upon  either  serous  or  sanguineous  exudation,  and  those 
which  result  from  degeneration  and  consequent  passive  accumulation  of 
l)lood  in  the  vessels  of  the  part,  consequently  it  would  be  a  needless  repe- 
tition to  state  these  remedies  again  at  this  time.  So  far  as  paralytic  syAip- 
toms  are  found  associated  with  epilepsy,  chorea  and  hysteria,  they  will  be 
noted  with  more  advantage  when  I  call  your  attention  especially  to  those 
affections.  The  paralysis  following  diphtheria,  sometimes  called  diphther- 
itic paralysis,was  considered  with  a  sufficient  degree  of  fullness  when  speak- 
ing of  the  sequel©  of  that  disease  in  the  earlier  part  of  the  present  course. 
The  same  remark  is  applicable  to  those  cases  of  partial  or  complete  hemi- 
plegia, dependent  upon  syphilitic  diseases  of  the  membranes  covering  the 
brain;  they  having  been  sufficiently  considered  when  speaking  to  you  of 
constitutional  syphilis  in  the  class  of  general  diseases. 

Paraplegia. — This  is  an  affection  characterized  by  loss  of  motion,  usu- 
ally in  both  lower  extremities,  up  to  a  given  transverse  line.  That  line 
may  be  at  any  point  between  the  ankles  and  the  armpits.  A  large  ma- 
jority of  cases  of  paraplegia,  however,  consist  in  paralysis  of  the  lower 
extremities  from  the  hips  down.  The  paralysis  may  involve  complete 
loss  of  motion,  rendering  both  lower  limbs  entirely  helpless  and  motion- 
less, or  it  may  be  only  partial,  rendering  the  movements  so  weak  that  the 
patient  is  unable  to  walk  or  even  to  maintain  an  erect  position  upon  his 
feet.  In  very  few  cases  is  paraplegia  accompanied  by  loss  of  sensation 
coincidently  with  that  of  motion,  but  sometimes  this  is  the  case,  and  in 
some  very  rare  instances  sensation  alone  is  lost  while  motor  power  re- 
mains. Nearly  all  the  cases  of  paraplegia  depend  upon  inflammation,  and 
its  consequences,  particularly  in  the  develojjment  of  sclerosis  and  other 
morbid  conditions  of  the  spinal  cord.  But  some  cases  are  liable  to  be 
met  with  by  every  practitioner,  arising  from  pathological  conditions  in 
some  portion  of  the  spinal  cord,  of  the  same  nature  with  those  that  have 
been  described  as  taking  place  in  the  brain,  namely  hemorrhagic  extravasa- 
tions, either  upon  the  surface  or  into  the  texture  of  the  cord,  emboli  plug- 
ging some  of  the  vessels,  or  the  development  of  tumors,  or  more  frequent- 
ly thickening  and  induration  of  the  membrane  surrounding  the  cord,  and 
occasionally  there  may  be  disease  of  the  bones  producing  sufficient  curva- 
ture to  compress  the  cord  and  thus  paralyze  the  parts  below.  The  patho- 
logical   conditions  in  the  spinal  cord  giving  rise  to  paraplegia,   are   the 


LEAD    PARALYSIS.  721 

same  in  kind  as  those  wliich  give  rise  to  hemiplegia  when  located  in  the 
brain.  The  same  principles  of  treatment  apply,  as  well  as  the  same  rules 
for  diagnosis,  as  has  been  already  stated  in  speaking  of  hemiplegia. 
These  alFoctions  of  the  spinal  cord  are,  however,  much  more  rare  than  the 
corresponding  morbid  conJitions  taking  place  in  the  brain;  and  hence,  as 
I  have  before  remarked,  much  the  larger  number  of  cases  of  paraplegic 
diseases  are  dependent  upon  some  grade  of  inflimmatory  action,  inducing 
some  degree,  either  of  sclerosis  or  effusion,  and  consequent  atrophy  of 
nerve  substance  in  the  cord.  Such  is  the  case  with  what  is  denominated 
infantile  paralysis,  which  usually  attacks  infants  or  children  between  the 
ages  of  six  months  and  five  or  six  years.  Most  such  cases  occur  suddenly 
and  involve  sometimes  one,  but  more  frequently  both  lower  limbs  at  the 
same  time.  In  many  the  inflammatory  condition  yields  under  appropriate 
management  and  the  paralysis  disappears.  In  others,  however,  the  in- 
flammatory process  results  in  exudation,  and  ultimate  atrophy  of  the  nerve 
structures,  more  particularly  those  which  regulate  the  supply  of  blood, 
consequently  causing  an  arrest  of  the  growth  of  the  parts  paralyzed,  and 
leading  ultimately  to  permanent  shortening  of  the  limb  or  limbs  and  to  a 
s'ze  much  less  in  proportion  than  the  rest  of  the  body. 

These  cases,  however,  are  so  generally  dependent  on  congestion  or  inflam- 
matory action,  that  their  management  was  sufficiently  indicated  when 
lecturing  upon  the  different  grades  of  inflammation,  and  sclerosis  of  the 
spinal  cord. 

Progressive  locomotor  ataxia,  progressive  muscular  atrophy,  were  also 
included  among  the  diseases  of  an  inflammatory  character,  consequently 
the  only  forms  of  paralysis  remaining  to  which  I  will  ask  your  attention, 
are  those  arising  from  the  effects  of  lead,  called  leadj  palsy ^  those  arising 
from  mercurial  preparations,  and  some  c2L%Q'=,oi paralysis  ayitans  or  shak- 
ing 2^alsy. 

Paralysis  arising  from  the  introduction  of  carbonate  of  lead  into  the 
system  usually  comes  on  gradually,  and  in  a  majority  of  instances  is  felt 
first  in  the  muscles  of  the  fore-arm, more  particularly  the  extensor  muscles 
on  the  back  of  the  fore-arm,  that  extend  the  hand,  while  the  flexors  upon 
the  front  of  the  arm  remain  unaffected.  This  renders  the  patient  in- 
capable of  lifting  the  hands  backward,  and  causes  them  to  droop  or  hang 
down,  giving  to  the  disease  the  name  of  torist-drop.  AVhile  the  muscles 
of  the  fore-arm  are  in  most  cases  the  first  to  show  the  paralyzed  condition, 
the  disease  may  attack  almost  any  of  the  muscles  of  the  body,  either 
voluntary  or  involuntary.  But  it  is  often  manifested  in  the  muscular  coat 
of  the  intestines,  arresting  intestinal  evacuations  and  producing  that 
most  obstinate  and  painful  affection  of  the  bowels,  denominated  lead 
colic.  The  symptom?  which  accompany  lead  palsy,  in  addition  to  ths 
peculiar  impairment  of  the  muscles  of  the  fore-arm,  and  perhaps  the  arrest 
of  peristaltic  motion  in  the  intestines,  are  a  general  paleness  or  anjeraic 
hue  of  the  patient,  a  rather  dejected  and  saddened  expression  of  counte- 
nance, feelings  of  lassitude,  indisposition  to  exertion,  and  more  particular- 
ly a  blue  line  along  the  edges  of  the  gums  surrounding  the  teeth.  This 
blue  line  usually  occupies  the  thin  edge  of  the  gum  surrounding  the  neck 
of  the  tooth.  It  is  shown  pretty  generally  in  the  gums  of  both  upper  and 
lower  jaws,  whenever  the  system  is  sufficiently  affected  to  materially  in- 
terfere with  muscular  action  in  the  extremities  or  in  the  intestines. 
Besides  the  usual  constipation  of  the  bowels,  general  weakness  of  the 
muscles  and  the  special  loss  of  power  in  those  of  the  fore-arm,  most  of  the 
patients  have  impaired  appetite,  restlessness  at  night,  and  scantiness  of 
46 


722  LEAD    PALSY. 

urine.  But  the  paralysis  and  constipation,  with  colic  pains  and  the  blue 
line  at  the  edge  of  the  gums,  are  the  most  reliable  diagnostic  symptoms. 
If  the  accumulation  of  lead  in  the  system  is  allowed  to  continue  and  the 
patient  to  go  without  appropriate  treatment,  the  impairment  of  muscular 
action  may  continue  to  increase  till  the  patient  becomes  helpless,  while 
the  obstructed  condition  of  the  bowels  leads  to  entire  suspension  of 
digestion,  with  frequent  turns  of  nausea  and  vomiting,  accompanied  by 
rapid  emaciation,  until  complete  asthenia  and  death  result,  after  a  period 
of  suffering  varying  from  one  to  eight  or  ten  years.  Cases  have  occurred 
in  which  the  lead  poison  affected  the  brain  and  its  membranes,  producing 
obscure  cerebral  symptoms,  ending  finally  in  entire  unconsciousness  or 
coma  and  death.  The  cerebral  affection,  however,  is  rare;  the  great 
majority  of  patients  retaining  their  mental  faculties  throughout  the  whole 
course  of  the  disease.  While  lead  poisoning  is  often  cajjable  of  destroy- 
ino-  life,  yet  if  the  further  introduction  of  the  mineral  into  the  system  is 
avoided,  and  the  patient  placed  in  favorable  circumstances,  the  general 
rule  is  that  it  is  slowly  eliminated  even  without  the  aid  of  remedies.  But 
the  elimination  may  be  hastened  by  treatment  till  the  system  becomes 
entirely  free,  and  the  patient  restored  to  a  fair  degree  of  health. 

Prognosis. — The  prognosis,  therefore,  is,  in  most  cases  of  lead  poisoning, 
favorable. 

The  great  majority  of  patients  who  become  affected  with  this  disease 
receive  the  lead  by  absorption  through  the  cutaneous  surface  and  through 
inhalation  of  the  fine  dust  as  it  is  floating  in  the  atmosphere  of  the  room 
in  which  they  work.  A  great  majority  of  these  have  become  affected  by 
the  continuous  use  of  white  lead  or  carbonate  of  lead,  particularly  while 
working  in  doors,  and  those  most'  exposed  to  this  poison  are  employed 
in  the  manufacture  of  white  lead.  Another  not  very  infrequent  source  of 
poisoning  with  lead  is  the  use  of  cosmetics  containing  this  mineral  by 
females,  under  the  erroneous  idea  of  improving  their  complexion.  I  have 
met  with  a  considerable  number  of  cases,  in  young  and  middle-aged  women 
who  had  not  only  produced  a  troublesome  series  of  symptoms,  consisting 
of  deranged  digestion  and  general  impairment  of  the  blood  and  nutritive 
processes,  but  had  established  well-marked  paralysis  of  the  extensor 
muscles  of  the  forearm,  rendering  them  incapable  of  raising  their  hands 
to  their  heads  or  of  doing  any  ordinary  work.  The  effects  were  induced 
bv  the  almost  daily  use  of  powders  containing  carbonate  of  lead  applied 
pretty  freely  to  the  surface  of  the  face  and  exposed  parts  of  the  neck. 

Treatment. — The  first  object  to  be  attained  in  the  treatment  of  such 
cases  is  the  removal  of  the  patient  entirely  from  the  further  operation 
of  the  exciting  cause.  All  handling  of  the  carbonate  of  lead,  or  any 
preparation  of  lead  capable  of  assuming  the  form  of  a  carbonate,  must  be 
discontinued,  whether  in  manufacturing,  painting,  or  in  using  it  as  a 
cosmetic.  And  where  none  of  these  things  have  been  the  cause,  it  may 
be  found  that  the  patient  has  received  his  supply  from  water  drained 
throuo-h  lead  pipes.  If  so  this  must  be  sought  out  and  carefully  avoided. 
The  remedies  which  have  succeeded  best  in  my  hands  in  hastening  the 
elimination  of  the  poison  and  thereb}'  removing  its  effects,  whether  in  the 
muscular  coats  of  the  iiitestines  or  in  the  voluntary  musclt^s  of  the  arm  or 
other  parts,  has  been  the  use  of  the  iodide  of  potassium  in  moderate 
doses,  but  persistently,  for  a  considerable  length  of  time.  When  the  case 
has  involved  much  pain,  as  in  lead  colic,  I  have  found  it  beneficial  to 
combine  with  the  iodide,  conium  or  hyoscyamus,  in  such  doses  as  would 
be  borne  without  producing  dryness  of  the  mouth,  or  affecting  the  pupil 
of  the  eye.     Opiates  are  to  be  avoided,  as  far  as  possible,  on  account  of 


TREATMENT.  723 

their  increasing  constipation  and  impairing,  more  or  less,  general  secretory 
action.  In  a  great  majority  of  cases,  from  three  to  five  decigrammes 
(or.  V  to  viii)  of  iodide  of  potassium  given  in  solution  three  or  four  times 
in  the  twenty-four  hours,  and  accompanied,  when  tiiere  is  much  pain  or 
restlessness,  by  suitable  doses  of  either  conium  or  hyoscyamus,  will  be 
sufficient  to  produce  marked  improvement  during  the  first  week  after 
commencing  treatment.  But  to  render  the  improvement  permanent,  it  is 
often  necessary  to  keep  the  patient  under  the  use  of  the  same  remedies  to 
the  extent  of  from  two  to  four  doses  in  the  twenty-four  hours  from  three 
to  six  weeks.  In  the  meantime  the  diet  should  be  simple,  easily  digested, 
but  sufficient  to  nourish  the  patient  well;  and  as  far  as  possible  allow  him 
to  have  good,  pure  air.  and  more  or  less  passive  outdoor  exercise.  But 
all  severe  exertion,  both  physical  and  mental,  should  be  avoided  when 
possible. 

Paralysis  supposed  to  arise  from  mercurial  preparations  is  much  more 
rare,  and  generally  only  partial,  consisting  rather  of  paresis  or  impairment 
of  muscular  power,  with  more  or  less  trembling  and  unsteadiness  of  ac- 
tion. It  is  to  be  relieved  by  avoiding  all  further  introduction  of  the  poi- 
son which  has  produced  the  disease,  placing  the  patient  at  rest  in  good 
hygienic  condition,  and  the  moderate  use  of  the  iodide  of  potassium  inter- 
nally. After  the  elimination  of  the  poison,  if  there  is  remaining  much 
debilitv,  tonics  and  a  more  nutritious  diet,  and,  at  least,  free  passive  exer- 
cise in  the  open  air,  will  usually  render  recovery  complete.  A  large  por- 
tion of  the  cases  denominated  paralysis  agitans  or  trembling  paralysis 
depend  upon  sclerosis,  or  what  has  been  called  disseminated  sclerosis  in. 
the  upper  portion  of  the  spinal  cord  and  medulla  oblongata,  and  have 
already  been  considered  under  the  head  of  inflammatory  affections  of  the 
cord.  Some  of  these  cases,  however,  appear  to  be  dependent  upon  simple 
paresis  or  impairment  of  the  functions  of  the  cord,  and  are  associated  with 
general  weakness,  or  more  frequently  with  the  general  deteriorations  of 
old  age.  Indeed,  the  affection  is  restricted  mostly  to  persons,  whether 
male  or  female,  in  advanced  life.  The  treatment,  when  dependent  thus 
upon  the  deteriorations  of  age,  or  debility,  must  be  simply  palliative  and 
supporting.  Relieving  the  patient  of  mental  anxiety  as  far  as  possible, 
allowing  much  rest  in  the  recumbent  position  with  short  periods  of  pas- 
sive exercise,  by  riding  in  the  open  air  whenever  the  atmospheric  condi- 
tions are  favorable,  and  such  mild  tonics  and  nutrients  as  the  condition 
of  the  system  may  indicate  in  each  case,  constitute  the  best  treatment. 
No  remedies  have  been  found  to  exert  a  very  satisfactory  or  reliable  con- 
trol, directly  as  remedies  addressed  to  the  nervous  system,  in  diminish- 
ing the  trembling  of  the  muscles  whenever  motion  is  attempted.  In 
rfvany  of  these  cases  the  trembling  continues  when  the  patient  is  entirely 
at  rest,  but  in  the  greater  number  of  instances  it  ceases  during  sleep. 
Bat,  while  no  remedies  have  been  found  reliable,  or  satisfactory  in  their 
influence,  several  have  been  found  to  mitigate  or  lessen  the  degree  of 
trembling  and  thereby  to  afford  more  or  less  comfort  to  the  patient. 
Moderate  doses  of  cannabis  indica,  mono-bromonated  camphor,  chloral 
hydrate,  and  different  preparations  of  valerian,  are  perhaps  among  the 
best  for  palliative  purposes. 

Having  thus  reviewed  the  forms  of  paralysis,  depending  upon  non- 
inflammatory conditions,  and  not  connected,  as  sequelce,  with  general 
acute  diseases,  we  will  next  call  your  attention  to  the  consideration  of 
epilepsy. 


724  EPILEPSY. 


LECTUEE  LXXII. 


Epilepsy— Its  Varieties,  Causes,  Clinical  Hisiory,  Anatomical  Changes,  Diagnosis,  Prognosis 
and  Treatment. 

GENTLEMEN:  The  morbid  conditions  giving  rise  to  the  phenomena  of 
epilepsy,  are  among  the  most  important  of  the  functional  diseases  of  the 
nervous  system.  They  may  be  met  with  at  any  period  of  life,  although 
they  commence  much  more  frequently  in  childhood  and  youth,  than  dur- 
ing adult  life  or  in  old  age.  They  occur  also  in  both  sexes,  but  of  those 
cases  originating  between  fourteen  and  twenty  years,  perhaps  a  larger 
proportion  occur  among  females  than  among  males,  A  considerable 
number  of  cases  of  epilepsy  have  their  beginning  during  infancy,  being 
manifested  by  the  occasional  sudden  occurrence  of  convulsions,  from 
which  the  little  ones  quickly  recover,  leaving  little  apparent  impairment, 
and  which,  at  the  time,  are  considered  to  be  ordinary  convulsions  arising 
from  teething,  or  from  supposed  irritants  in  the  alimentary  canal.  Their 
epileptic  character  in  many  cases  is  not  suspected  until  their  re-occur- 
rence at  a  latter  period  of  the  child's  growth.  The  disease  is  manifested 
in  various  degrees  of  severity,  from  a  slight  momentary  interruption  of 
consciousness,  accompanied  by  sudden  rolling  of  the  eyes  upwards,  with 
a  slight  tremulous  or  irregular  motion  of  the  eye-balls,  to  that  of  a  full, 
general,  clonic  spasm  or  convulsion.  In  some  instances  the  disease  mani- 
fests itself  Oiily  in  these  slight  momentary  interruptions  of  the  conscious- 
ness of  the  patient,  not  lasting  long  enough  to  produce  a  fall  before  tiiey 
resume  their  consciousness,  and  oftentimes  proceed  directly  with  what 
they  were  doing  before,  as  though  no  interruption  had  taken  place. 
Children  at  play  with  their  comrades  will  thus  be  taken,  momentarily  in- 
terrupting their  play  and  allowing  them  to  resume  it  again  before  they 
had  hardly  attracted  the  attention  of  those  with  whom  they  were  engaged. 
These  slight  symptoms  may  occur  only  at  intervals  of  several  days,  or 
they  may  occur  several  times  during  the  same  day.  But  most  patients  who 
become  subject  to  these  frequent  slight  turns,  at  longer  intervals  varying 
in  the  early  stage  of  the  disease  from  one  to  six  or  eight  months,  will  have 
a  full  epileptic  paroxysm,  called  by  them  a  general  convulsion  or  fit. 
There  are  others  that  seldom  have  these  slight  turns,  but  are  subject  only 
to  the  recurrence  of  the  general  paroxysms,  at  first,  after  long  in- 
tervals, and  then  gradually  with  more  frequency  in  proportion  to  the  time 
of  its  continuance.  Another  mode  of  manifestation  with  many  epileptics, 
is  the  occurrence  at  irregular  intervals  of  a  certain  degree  of  vertigo, 
differing  from  ordinary  vertigo,  in  being  accompanied  by  some  peculiar 
sensations  originating  pretty  uniformly  in  a  portion  of  the  cutaneous  sur- 
face, either  upon  the  trunk  of  the  body  or  upon  one  of  the  extremities, 
and  apparently  moving  from  its  point  of  origin  toward  the  head,  and  as 
it  advances  high  enough  to  reach  the  neck  or  throat,  there  succeeds  a  pe- 
culiar sensation  in  the  head  as  of  an  inclination  to  turn  or  fall  in  a  given 
direction.  In  many  instances,  they  Avill  neither  turn  nor  fall,  but  after 
the  sens  ition  has  been  experienced  for  a  few  seconds,  it  passes  away  with 
the  original  morbid  feeling  upon  the  surface,  and  they  proceed  Avith  their 
ordinary  train  of  thought  or  work  as  though  nothing  had  happened. 

In  another  class  of  patients,  I  have   observed   that   the  first   symptoms 
of  which  they  complain  as  the  direct  precursor  of  an  attack  or  convulsive 


SYMPTOMS.  725 

paroxysm  is  a  choking  sensation  in  the  throat,  a  sensation  as  thono;h 
somethinc^  was  rising  in  the  throat,  producing  a  choking  nn(l  a  disposition 
to  swallow,  and  at  the  same  moment  ol'  time  a  certain  degree  of  giddiness 
or  swimming  in  the  head.  The  choking  and  giddiness  both  subside  often 
without  et\tirely  suspending  the  consciousness  of  the  individual,  or  pro- 
voking any  spasmodic  manifestations;  but  at  longer  intervals  these  same 
phenomena  are  follovped  by  entire  unconsciousness,  and  more  or  less  of  gen- 
eral spasmodic  action.  I  have  mentioned  these  different  modes  of  manifes- 
tation of  the  disease,  because  they  are  often  noticed  in  children  for  a  con- 
siderable period  before  the  full  development  of  the  disease,  as  indicated 
by  the  occurrence  of  a  general  convulsive  paroxysm.  And  if  they  were 
duly  recognized  and  understood,  it  would  give  the  family  and  physician 
opportunity  to  commence  treatment  much  earlier  and  with  better  pros- 
pect of  success  than  when  they  are  overlooked  and  neglected  till  the 
disease  is  more  fully  developed.  From  what  I  have  already  stated,  you 
will  infer  that  the  active  manifestations  of  disease  are  not  continuous  in 
the  epileptic,  but  occur  strictly  in  paroxysms.  While  they  are  parox- 
ysmal, however,  there  is  no  near  approach  to  regularity  in  the  periods  of 
time  at  which  the  paroxysms  come  en  in  a  large  majority  of  the  cases; 
neither  is  there  any  particular  time  in  the  twenty-four  hours  that  the 
disease  manifests  itself  with  any  uniformity,  yet,  judging  from  my  own 
observation,  I  would  regard  it  as  correct  to  state  that  at  least  two-thirds 
of  all  the  cases  of  epilepsy  manifest  their  severe  and  full  paroxysms, 
especially  during  the  first  two  or  three  years  progress,  in  the  night  time 
or  early  in  the  morning.  In  some  cases  the  paroxysm  is  most  apt  to 
occur  after  the  first  hour  of  sound  sleep,  in  the  early  part  of  the  night. 
But  in  a  much  larger  number,  the  convulsive  paroxysm  makes  its  appear- 
ance in  the  last  part  of  the  night  or  on  first  rising  in  the  morning. 
Another  law,  which  seems  to  be  a  pretty  uniform  one,  is  that  when  the 
disease  has  once  commenced,  if  it  is  not  interfered  with  by  treatment, 
there  is  tendency  to  shorten  the  interval  between  the  recurrence  of  the 
paroxysms,  with  increasing  ratio,  the  longer  the  disease  continues. 
Hence,  you  will  often  meet  with  cases  in  vphich,  in  the  early  stage  of  the 
disease,  the  patient  had  but  one  or  two  paroxysms  in  a  year,  leaving  an 
interval  of  six,  and  sometimes  eight  or  even  ten  months  between  their  recur- 
rence, with  hardly  a  perceptible  minor  symptom  of  any  kind  in  the  inter- 
vals. But  at  the  end  of  five  or  six  years  they  will  be  recurring  in  full  parox- 
ysms every  month,  and  sometimes  two  or  three  times  a  month,  with  the  minor 
indications,  such  as  momentary  suspension  of  consciousness,  or  spasmodic 
motion  of  the  eyeballs,  eyelids,  or  momentary  turns  of  vertigo,  and  chok- 
ing sensations  in  the  neck  almost  every  day.  The  disease  thus  continues, 
manifesting  its  active  paroxysms  more  and  more  frequently,  and  at  the 
same  time  producing  more  decided  deteriorative  effects  upon  the  mental 
manifestations  of  the  patient,  as  well  as  upon  his  physical  movements. 

Symptoms . — In  describing  more  minutely  the  symptoms  accompanying 
cases  of  epileptic  disease,  I  may  remark,  that  there  is  no  uniform  temper- 
ament, or  physical  conformation  which  belongs  to  the  epileptic  patient. 
But  the  disease  may  be  met  with  in  temperaments  of  the  most  diverse 
character.  Some  patients  suffering  from  this  disease  will  have  short  necks, 
broad  chests,  an  active,  sanguine  tempfjrament,  and  exhibit  all  the  marks 
of  good  nutrition,  and  a  good  degree  of  physical  strength  and  hardihood. 
Others  will  exhibit  a  pale,  anasmic  hue  of  the  surface,  spare  muscles  and 
limbs,  narrow  chest,  long  necks,  and  the  very  opposite  of  the  sanguine,  or 
bilious  temperament,  the  nervous  and  anasmic.  And  I  think  it  not  incor- 
rect to  say,  that  you  will  find  almost  every  gradation  of  difference  between 


726  EPILEPSY. 

these  two  extremes.  The  phenomena  of  the  disease  may  be  considered 
under  two  divisions:  one  belonging  to  the  patient  between  the  paroxysms 
and  the  other  the  symptoms  that  accompany  the  full  active  paroxysm  it- 
self. In  the  early  stage  of  the  disease,  which  may  be  said  to  cover  a  pe- 
riod varying  with  different  patients  from  six  to  eighteen  months,  there 
are  often  no  symptoms  in  the  interval  between  the  general  paroxysms,  in- 
dicative of  any  raorbid  condition  whatever.  In  others,  however,  there  is 
during  this  early  peiiod,  in  the  interval  between  the  full  paroxysms,  an 
unusually  excitable  condition  of  the  patient,  especially  in  reference  to  the 
excitement  of  the  more  violent  passions.  If  in  childhood,  they  are  ofter 
regarded  as  passionate,  ill-tempered,  difficult  to  govern,  and  often  more  oi 
less  disturbed  with  dreams  and  startings  during  the  night.  As  a  rule,  the 
appetite  is  stronger  than  in  good  health,  especially  the  appetite  for  some 
of  the  more  rich  and  nutritious  articles  of  food.  Sometimes  this  exists  to 
such  an  extent  as  to  merit  the  name  of  voracious  appetite.  The  evacua- 
tions from  the  bowels  are  seldom  diiferent  from  that  of  health,  unless  there 
be  in  some  cases  moderate  constipation.  The  urinary  secretion  is  usually 
normal  in  quantity  and  quality.  After  the  disease  has  existed  for  a  long 
period  of  time,  there  will  almost  always  be  in  the  intervals  between  the 
full  paroxysm  more  or  less  of  a  sudden  supervention  of  momentary  loss 
of  consciousness,  or  periods  of  giddiness,  and  feelings  described  as  aura._ 
creeping  sensations  over  some  portion  of  the  surface,  and  a  sense  of 
choking-  in  the  neck;  but  very  variable  in  the  frequency  of  their  occur- 
rence, and  in  the  time  of  day  that  they  may  be  noticeable.  The  symp- 
toms which  characterize  a  direct,  fair  paroxysm  of  epilepsy,  though  vaiying 
much  in  severity  and  the  duration  of  the  paroxysms,  are  nevertheless  suf- 
ficiently uniform  in  their  essential  characters  to  be  easily  understood. 
The  onset  is  generally  sudden,  sometimes  without  any  premonitory  sensa- 
tions. The  first  noticeable  feature  will  be,  if  the  patient  is  awake  and 
within  observation,  a  sudden  arrest  of  all  motion,  except  in  the  face  and 
head;  the  latter  is  thrown  a  little  back  and  the  lace  upward  with  a  jerk- 
ing, irregular  motion,  and  usually  slight  twitching  of  some  of  the  muscles 
of  the  face,  and  in  a  second  or  two,  the  jerking  extends  throughout  the 
whole  voluntary  system  of  muscles,  causing:  all  the  phenomena  of  general 
spasms  or  clonic  convulsion,  arresting  respiratory  movements,  causing  the 
face  to  become  extremely  turgid  with  blood,  the  jaws  alternately  clinched 
and  open,  not  infrequently  allowing  the  tongue  to  be  caught  between  the 
teeth  and  bitten;  sometimes  also  folds  of  the  inside  of  the  cheeks  and 
lips,  lacerating  them  sufficiently  to  cause  more  or  loss  of  a  flow  of  blood 
with  the  frothy  saliva  from  the  mouth.  When  the  convulsion  has 
held  the  respiratory  movements  in  check  long  enough  to  cause  the 
face  and  lips  to  become  purple  and  swollen,  and  the  pupils  a  little  di- 
lated, the  accumulated  carbonic  acid  gas  in  the  blood,  and  absence  of  oxy- 
gen, overwhelms  the  sensibility  of  the  nervous  system  to  such  a  degreq 
as  to  arrest  the  further  spasmodic  action;  then  the  muscles  pretty  rapidly 
relax,  the  patient  begins  to  catch  his  breath,  at  first  with  a  loud  rattling 
noise,  from  the  sudden  forcing  of  the  air  through  the  mouth  and  throat 
which  contains  more  or  less  viscid  mucus,  and  as  the  air  is  forced  suddenly 
in  and  out,  an  abundance  of  frothy  saliva,  often  tinged  with  blood  from 
the  bitten  places  in  the  tongue  and  cheeks,  is  expelled  from  the  mouth,  which 
with  the  rattling  noise,  adds  much  to  the  feelings  of  terror  created  in  the 
bvstanders.  But  in  two  or  three  minutes  the  patient  has  gained  sufficient 
regularity  in  breathing  to  again  oxygenate  and  decarbonize  the  blood; 
the  turgid,  or  dark  purple  hue  of  the  face  recedes  rapidly,  and  gives  place 
to  a  more  natural  color,  and  in  the  space  of  three  to  five  minutes,  or   less, 


SYMPTOMS.  727 

the  patient  has  passed  into  a  condition  in  all  respects  resembling  profound 
sleep.  The  breathing  is  nearly  regular,  color  of  the  face  natural,  and  all 
the  muscles  relaxed. 

If  tlie  patient  is  undisturbed,  in  a  majority  of  instances  this  apparent 
sleep  will  continue  a  period  of  time  varying  from  fifteen  minutes  to  one 
or  two  hours,  when  he  will  spontaneously  awake  entirely  conscious, 
but  with  a  look  of  surprise  as  though  for  a  moment  not  aware  of  where 
he  was  or  what  had  happened.  But  he  almost  immediately  recognizes  his 
position,  and  if  not  interfered  with,  gets  up  at  once,  takes  up  whatever 
he  had  dropped  at  the  time  the  convulsion  seized  him  and  goes  about  his 
ordinary  previous  work,  whatever  it  might  have  been.  All  of  these  pa- 
tients thus  have  a  period  of  quiet  and  apparent  sleep  following  imme- 
diately a  full  convulsion.  Most  of  them  can  be  aroused  out  of  this  sleep 
at  a  much  earlier  period  by  shaking  them,  dashing  a  little  water  upon  the 
face,  and  friends  will  almost  always  do  this  from  anxiety  to  bring  them  to 
consciousness.  It  is  better,  however,  to  allow  them  to  remain  entirely  at 
rest  until  they  awake  spontaneously,  so  far  as  the  wellfare  of  the  patient 
is  concerned.  While  many  patients  are  thus  seized  with  fits  suddenly 
without  any  premonition,  there  are  many  others,  who  as  uniformly  have 
certain  premonitory  feelings  that  warn  them  regularly  of  the  approach  of 
the  paroxysms.  The  most  common  of  these  premonitory  symptoms  are 
sensations  of  a  somewhat  peculiar  character,  generally  described  as  aura. 
It  is  a  creeping  sensation,  not  distinctly  cold  perhaps,  but  such  that  the 
patient,  after  feeling  it  once  or  twice,  recognizes  fully  its  meaning.  It 
may  begin  at  any  part  of  the  cutaneous  surface,  more  generally  either  up- 
on some  part  of  the  arm  or  leg,  and  frequently  in  the  epigastric  region. 
But  wherever  it  may  commence,  the  movement  of  the  sensation  is  at  a 
pretty  uniform  rate  directly  upward  toward  the  neck  and  head.  And 
it  is  usually  not  more  than  two  or  three  minutes,  and  sometimes  not  as 
many  seconds,  from  the  commencement  of  the  sensation  before  it  has 
reached  the  neck  and  there  uniformly  produces  a  choking  feeling,  imme- 
diately followed  by  an  arrest  of  consciousness.  With  the  commencement 
of  the  jerking  convulsive  motions  that  I  have  already  described,  if  the  pa- 
tient is  in  the  standing  position  or  sitting,  he  immediately  falls  prostrate, 
wherever  he  may  be,  and  not  infrequently  suffers  much  harm  from  inju- 
ries produced  by  falling  on  hot  bodies,  or  wpon  hard  substances,  and  if 
grown  to  maturity,  sometimes  falling  from  stairs,  windows,  or  other  high 
places,  producing  the  most  disastrous  consequences.  But  the  same 
phenomena  take  place  if  the  paroxysms  approach  while  the  patient  is 
in  bed  and  in  profound  sleep.  This  peculiar  sensation  commencing  up- 
on some  portion  of  the  surface  and  proceeding  in  a  regular  line  toward 
the  neck  and  head,  is  denominated  in  the  books,  epileptic  aura.  There 
are  other  cases,  which  instead  of  commencing  with  the  aura  upon  the 
surface,  will  pretty  uniformly  have  a  distressed  feeling  of  fullness,  like 
gaseous  distension  of  the  stomach,  or  a  positive  pain  in  the  epigastrium. 
This  pain,  commencing  in  the  epigastrium,  extends  like  compression  or 
tightness  up  through  the  chest  as  though  it  would  stop  the  respiratory  and 
circulatory  movements,  but  quickly,  on  reaching  the  upper  part  of  the 
chest  and  neck,  is  superseded  by  sudden  loss  of  consciousness  and  the 
development  of  the  spasmodic  phenomena  of  a  paroxysm.  In  whatever 
way  a  full  paroxysm  of  epilepsy  commences,  whether  with  or  without 
premonition,  there  is  perhaps  with  great  uniformity  a  loss  of  sensation  or 
the  suspension  of  consciousness,  with  more  or  less  general  spasmodic 
action  throughout  the  muscular  system. 

With  this  general   cessation  of  the   consciousness  of  the  patient,  the 


728  EPILEPSY. 

time,  from  that  moment  till  waking  after  the  paroxysm  has  ceased,  re- 
mains an  entire  blank,  the  patient  having  no  recollection  or  consciousness 
of  anything  that  transpired,  or  even  of  his  existence  during  the  interven- 
ing period  of  time.  Another  characteristic  that  is  pretty  uniform,  is  the 
suddenness  with  which  consciousness  returns  after  the  paroxysm  has 
ceased.  In  most  other  morbid  conditions  of  the  brain  and  nervous 
centers,  accompanied  by  unconsciousness,  the  recover}'  from  the  uncon- 
sciousness is  more  or  less  slow  and  oftentimes  imperfect.  But  with  the 
epileptic,  on  the  cessation  of  the  paroxysm,  he  is  seldom  awake  or  aroused 
to  any  recognition  of  anything  more  than  a  few  seconds,  before  this  con- 
sciousness is  apparently  as  complete  as  in  health.  There  is  apt  to  remain, 
however,  more  or  less  of  a  feeling  of  discomfort  and  strangeness  through 
the  head  for  several  hours  after  the  occurrence  of  a  full  attack.  In  many 
there  is  a  dull,  heavy  pain  in  the  head  for  the  greater  part  of  twenty-four 
hours.  It  will,  also,  often  happen  not  only  that  there  is  dull  headache 
with  pressure  and  dizziness  following  the  paroxysms,  but  an  increased 
dullness  of  mental  operations  and  inability  to  remember  well,  for  two  or 
three  days  after  each  paroxysm.  This  is  generally  not  the  case  until  the  dis- 
ease has  advanced  far  enough  to  begin  to  alter,  more  or  less,  the  nutritive 
function  in  the  nervous  centers.  While  such  are  the  characteristic  symptoms 
of  the  paroxysm,  and  the  general  phenomena  the  patient  exhibits  during 
the  intervals  from  one  paroxysm  to  the  next,  in  the  larger  proportion  of 
cases  of  epilepsy  that  have  their  beginning  in  childhood,  the  paroxysms 
not  only  tend  steadily  to  recur  more  frequently,  but  the  disease  is  accom- 
panied by  very  gradual  impairment  in  the  nutrition,  and  consequently  in 
the  manifestation  of  the  functions  of  the  brain.  So  true  is  this,  that  very 
few  individuals  who  commence  the  disease  in  early  childhood  and  con- 
tinue with  it  gradually  increasing  in  the  frequency  of  its  paroxysms  till 
they  have  passed  the  period  of  puberty,  escape  having  the  mental  faculties 
decidedly  impaired.  In  most  cases,  memory  becomes  unreliable,  the 
appetite  and  passions  of  the  patient  fickle  or  variable,  and  sometimes 
altogether  uncontrollable.  Their  sleep  is  more  or  less  disturbed,  appetite 
for  food  voracious,  intellectual  operations  slow  and  often  subject  to  inter- 
ruption giving  a  noticeable  disconnectedness  to  their  expressions,  while 
their  passions  and  emotions  become  much  more  prominent  and  more  . 
easil}'  excited  to  violence.  As  the  disease  progresses  still  further,  each 
year  adds  to  their  mental  impairment  and  loss  of  self-control,  until  in  many 
instances,  before  they  have  arrived  at  adult  life,  they  become  apparently 
demented,  with  a  peculiar  expression  of  countenance,  usually  drooping:  at 
the  angles  of  the  mouth,  allowing  much  of  the  time  the  saliva  to  flow 
out  uncontrolled.  At  length  there  come  also  impairments  in  the  power  of 
speech  and  of  deglutition,  requiring  care  to  avoid  choking  in  taking  food, 
and  ultimately  a  condition  of  entire  imbecility  and  helplessness,  in  which 
the  patients  pay  little  or  no  heed  to  the  evacuations  either  of  urine  or  Igeces, 
and  retain  not  sufficient  mental  capacity  to  feed  themselves  or  to  exercise 
the  least  care  over  their  most  necessary  daily  needs  and  habits.  In  cases 
where  epilepsy  has  commenced  in  infancy  and  the  paroxysms  have  be- 
come frequent  from  that  time  up  to  five,  six  or  eight  years,  they  are  very 
liable  to  be  accompanied  by  partial  arrest  in  the  growth  of  the  brain, 
causing  the  brain,  anteriorly  at  least,  to  be  narrow,  and  the  whole  head  to 
be  below  the  normal  size  of  development  proportionate  to  their  age. 
Where  this  is  the  case,  it  is  almost  always  accompanied  by  a  correspond- 
ing enfeeblement  of  mind  or  entire  imbecility. 

When  the   epilepsy    commences  at   a   later  period    in   life  or  after  the 
time    of  i^uberty,    it    is    seldom    accompanied    in    its    progress    by   such 


CAUSES  729 

alterations  in  nutrition,  and  in  mental  manifestations  as  we  have  just  de- 
scribed. Yet,  even  in  such  cases,  it  may  induce  much  weakness  and  the 
paroxysms  come  so  often  as  to  destroy  the  visefulness  of  the  patient  al- 
together in  any  pursuit  of  life,  and  to  impair  somewhat  the  memory  and 
the  control  of  the  reasoning-  faculties  over  the  passions.  Still  it  is  rare 
that  it  reduces  them  to  that  state  of  imbecility  which  very  frequently  re- 
sults when  the  disease  has  commenced  in  infancy  and  its  paroxysms  be- 
come frequent  in  recurrence  through  early  childhood.  There  are  some 
instances  where  the  disease  has  commenced  its  first  manifestations  at  or 
after  puberty,  in  which  the  patient  seldom  manifests  a  perceptible  im- 
pairment of  any  of  the  mental  faculties,  not  even  after  the  disease  has 
continued  for  twenty  or  thirty  years. 

Causes. — In  the  great  majority  of  instances,  no  well  ascertained  cause 
or  causes  can  be  identified  as  having  originated  the  disease.  During  in- 
fancy and  early  childhood,  the  popular  mind  will  attribute  all  the  earlier 
paroxysms  either  to  teething,  to  worms  in  the  alimentriry  canal,  or  a  little 
later  during  early  childhood,  to  intestinal  irritation  and  indigestion.  But 
it  is  very  doubtful  whether  any  of  these  causes  are  operative  in  a  large 
majority  of  all  the  cases  of  epilepsy  that  occur  at  the  early  period  of  life. 
Hereditary  influence  undoubtedly  exists  in  many  cases,  and  in  a  large 
proportion  of  them,  dufi  inquiry  would  develop  the  fact  that  the  parents 
or  ancestors  in  some  part  of  the  family  line  had  been  subject  more  or  less 
to  the  disease.  There  are  some  statistics  which  would  lead  to  the  infer- 
ence, that  children  born  of  parents  who  have  become  strongly  addicted 
to  the  excessive  use  of  alcoholic  drinks,  are  more  subject  to  attacks 
of  epilepsy  than  those  born  of  parents  not  addicted  to  the  same  practices. 
The  use  of  alcoholic  drinks  on  the  part  of  young  persons  and  some- 
times at  any  period  of  life  appears  to  incline,  or  predispose  to  attacks  of 
epilepsy,  but  only  to  a  limited  extent.  In  females  there  are  a  considerable 
number  of  cases  that  have  had  the  beginning  of  their  occurrence  with 
the  period  of  the  first  manifestation  of  menstruation,  the  paroxysm  of 
epilepsy  coming  at  such  time  as  to  identify  it  uniformly  with  the  menstrual 
flow.  With  some  the  epileptic  paroxysm  will  immediately  precede  the 
commencement  of  the  monthly  sickness;  in  others  it  occurs  during  the  prog- 
ress of  the  flow  but  in  the  larger  number,  the  attacks  develop  from  one  to 
three  days  after  the  cessation  of  the  flow.  When  the  disease  occurs  in  con- 
nection with  the  monthly  flow,  and  its  paroxysms  are  rarely  noticed  to  oc- 
cur in  the  intermediate  time,  it  is  fair  to  presume  that  there  is  some  morbid 
sensitiveness  in  the  uterus  or  its  appendages,  that  is  increased  by  the  de- 
termination of  blood  and  greater  fullness,  as  the  menstrual  flow  approaches, 
untd  it  extends  a  reflex  influence  through  the  spinal  cord  to  the  base 
of  the  brain,  and  thus  develops  an  epileptic  paroxysm.  In  the 
male  it  is  supposed  that  the  practice  of  self-abuse  and  excessive  sexual 
indulgence  in  any  mode,  during  the  period  intervening  between  fifteen 
and  twenty  years,  is  liable  to  constitute  an  exciting  cause  of  epilepsy. 
I  am  not  satisfied,  however,  that  any  cases  have  occurred  under  my  own 
observation,  in  which  this  was  the  primary  cause.  I  have  no  doubt, 
however,  from  observation,  that  where  the  predisposition  exists  and  where 
the  disease  has  already  been  established,  that  excessive  sexual  excitement  of 
any  kind  has  a  decided  influence  in  increasing  the  frequency  of  the 
paroxysms,  and  aggravating  the  disease.  Another  not  infrequent  cause  of 
epilepsy,  is  injury  to  peripheral  nerves  by  mechanical  violence.  There 
are  many  cases  on  record,  where  from  injuries  of  various  kinds,  and  some- 
times surgical  operations,  a  sentient  nerve  has  been  included  in  the  cica- 
trix, left  by  the  healing  of  a  wound,  in  such  a  way  as  to  cause  a  reflex  influ- 


730  EPILEPSY. 

eiice  to  be  extended  to  the  nervous  centers,    and  to  be  a  direct  exciting 
cause  of  epileptic  paroxysms. 

Amona:  the  most  common  of  the  injuries  which  result  in  epilepsy,  are 
those  inflicted  upon  the  scalp,  or  upon  the  bones  of  the  cranium.  I  have 
seen  several  instances  where  mere  scalp  wounds,  after  they  had  healed 
and  appeared  to  be  entirely  well,  were  found  to  exhibit  a  certain  degree 
of  tenderness  on  pressure,  and  the  patients  became  subject  to  paroxysms 
of  epilepsy,  and  the  complete  removal  of  the  cicatrix  has  been  followed 
by  cure  of  the  disease.  Fractures  of  the  cranium  that  occur  from 
blows  or  severe  mechanical  violence,  though  not  displacing  the  whole 
thickness  of  bone  sufficient  to  produce  compression  of  the  brain,  may  so 
far  shatter  the  inner  table  of  the  skull  as  to  cause  a  little  spicula  of 
bone  to  be  depressed  inward,  in  such  a  way  as  to  have  its  point  rest  upon 
the  dura  mater  and  become  a  source  of  irritation,  and  to  be  followed  by 
the  development  of  epileptic  paroxysms,  usually  of  considerable  severity. 
That  the  efi'ect  of  the  bony  fragment,  in  irritating  the  membrane  and 
surface  of  the  brain,  was  the  true  cause  of  the  epilepsy,  would  seem  to  be 
proven  by  the  fact  that  when  the  scalp  has  been  laid  open,  and  the  in- 
jured portion  of  bone  removed  with  the  trephine,  the  patient  ceased  to 
have  any  further  paroxysms  of  epileptic  disease,  and  in  many  instances 
recovered  good  health.  You  will  see  from  the  tenor  of  what  I  have  said, 
that  so  far  as  the  etiology  of  epilepsy  is  concerned,  the  causes  may  be 
divided  into  two  classes,  namely,  those  that  aifect  primarily  the  periph- 
eral extremity  of  sentient  nerves,  producing  epileptiform  disease  only 
by  reflex  action  upon  the  nervous  centers,  to  which  belong  the  cases  that 
arise  from  uterine  and  ovarian  irritations,  intestinal  disturbances,  wounds, 
cicatrices,  and  fractures  of  the  skull,  and  which  are  properly  denominated 
reflex  cases  of  epilepsy.  The  other  class  of  causes  act  directly  upon  the 
cerebral  hemispheres  and  ganglia  at  the  base  of  the  brain,  producing 
primary  changes  there,  and  consequently  they  are  not  reflex  but  direct  in 
the  order  of  phenomena,  the  causes  being  such  as  produce  some  modifi- 
cation of  the  properties  and  functions  of  the  cerebral  substance,  instead  of 
acting  upon  the  peripheral  extremity  of  nerves.  Following  this  division 
of  causes,  some  writers  have  divided  epilepsy  into  two  groups  of  cases; 
one  of  which  they  denominate  cerebral,  and  the  other  peripheral,  or 
centric  and  excentric.  By  the  first,  they  mean  those  cases  which 
originate  from  primary  irritation,  or  morbid  action  in  the  nervous 
centers,  generally  in  the  ganglia  at  the  base  of  the  brain,  or  in  the 
surface  of  the  hemispheres,  or  both.  While  by  peripheral  cases  are 
meant  those  in  which  the  primary  point  of  irritation  involves  some  sen- 
tient nerve  at  its  extremity,  as  I  have  explained  only  a  few  moments 
since.  It  is  well  to  keep  in  mind  these  two  classes  of  cases,  as  it  will  aid 
3'ou,  both  in  devising  rational  modes  of  treatment  for  individual  cases, 
and  in  judging  of  the  prospects  of  amelioration  or  cure.  As  a  rule, 
peripheral  or  reflex  cases  of  epilepsy  are  for  the  most  part  curable,  if  the 
treatment  is  commenced  at  an  early  period  in  the  progress  of  the  disease, 
and  judiciously  continued  for  a  considerable  period  of  time,  while  in  the 
great  majority  of  cases  of  central  epilepsy,  or  such  as  have  their  origin 
from  direct  irritation  of  the  sentient  portions  of  the  base  of  the  brain,  and 
periphery  of  the  hemispheres,  the  prognosis  is  not  favorable;  neither  is 
it  necessarily  and  uniformly  unfavorable;  but  the  number  of  cases  of  this 
class  that  recover  is  small,  compared  to  the  whole  number  that  occur. 
And  while  the  prognosis  in  cerebral  epilepsy  is  very  generally  unfavor- 
able so  far  as  relates  to  the  ultimate  recovery  of  the  patient,  it  is  not  un- 
favorable so  far  as  relates  to  any  immediate  danger  to  life;  for  life  may  be 


ANATOMICAL   CHANGES.  731 

prolonged  through  many  years,  as  I  have  previously  explained,  or  until 
the  patients  have  become  imbecile,  or  even  idiotic,  from  impairment  of 
the   cerebral  structure,  instead  of  being  cut   off  by  any  acute  disease. 


LECTURE   LXXIII. 

Epilepsy  continued  —Its  Anatomical  Changes,  Diagnosis,  Prognosis  and  Treatment. 

GENTLEMEN:  lu  considering  the  anatomical  changes  accompanying 
epileptic  disease,  it  must  be  remembered  that  uncomplicated  epilepsy 
seldom  terminates  fatally  in  any  of  the  earlier  stages  of  the  disease, 
consequently  opportunities  for  post-mortem  examination  of  patients  in 
the  early  periods  of  the  progress  of  the  disease,  are  afforded  only  by  acci- 
dent or  through  death  from  some  other  cause.  When  such  opportuni- 
ties have  occurred,  in  most  instances  the  changes  apparent  to  the 
eye,  in  any  part  of  the  nervous  system,  are  not  sufficiently  distinctive 
to  indicate  any  special  anatomical  lesion  as  belonging  to  this  disease.  If 
the  disease  lias  existed  for  a  long  period  of  time,  examinations  usually 
show  some  degree  of  dilatation  of  the  blood  vessels  in  some  part  of  the 
medulla  oblongata,  or  pons  varolii,  and  occasionally  in  other  portions  of 
the  cerebral  structure.  In  cases  where  the  disease  has  existed  for  a  long 
series  of  years,  as  in  those  subject  to  the  disease  from  childhood  to  the 
middle  and  later  periods  of  adult  life,  some  portions  of  the  medulla,  cru- 
ra-cerebri  and  parts  of  the  base  of  the  brain  have  been  found  denser 
than  natural,  the  convolutions  somewhat  atrophied,  giving  to  the  lower 
part  of  the  anterior  lobes  less  transverse  diameter  than  is  natural.  These 
extreme  changes  are  usually  seen  only  in  cases  which  have  existed  from 
childhood,  and  are  the  result  of  relatively  diminished  growth  or  develop- 
ment, leaving  the  patient  in  a  state  of  more  or  less  dementia  or  mental 
imbecility.  Such  cases,  before  death,  present  an  unusual  smallness  of  the 
anterior  portion  of  the  cranium,  particularly  through  the  base  and  lower 
part  of  the  anterior  portion,  while  the  cerebellar  and  occipital  regions  and 
posterior  parietal  parts  maintain  m,ore  nearly  their  natural  size  and  per- 
fection of  nuti-ition.  Notwithstanding  all  the  investigations  of  the  emi- 
nent neurologists  of  the  present  day,  it  can  hardly  be  said  that  any  lesion 
of  the  nervous  centers,  or  anatomical  changes  have  been  found  sufficiently 
constant  to  justify  their  being  regarded  as  peculiar  to,  or  especially  char- 
acteristic of  the  epileptic  form  of  disease.  Such  experimental  physiol- 
ogists as  Marshall  Hall,  Brown-Sequard,  Charcot  of  Paris,  and  not  a  few 
in  our  own  country,  have  thrown  much  light,  by  their  experimentations 
upon  animals,  upon  what  we  might  denominate  the  mechanism  of  epi- 
lepsy, or  the  different  causes  by  which  the  paroxysms  maybe  induced,  and 
have,  perhaps^,  pointed  out  more  nearly  and  accurately  the  particular  por- 
tions of  the  nervous  centers  that  are  usually  involved  functionally.  And 
yet  they  have  not  arrived  at  a  satisfactory  development  of  any  peculiar 
anatomical  lesion.  While  there  may  be  no  special  structural  changes,  how- 
ever, which  can  not  be  found  in  connection  with  other  manifestations  of  dis- 
ease besides  that  of  epilepsy,  the  special  nature  of  the  morbid  process, 
which  essentially  constitutes  the  epileptic  disease,  may  be  defined  to  be  a 
morbidly  excitable  condition  of  the  medulla  oblongata  and    the    common 


732  EPILEPSY. 

center  of  voluntary  motion  at  the  base  of  the  brain,  coupled  with  im- 
pairment of  the  normal  control  of  the  cerebral  hemispheres  over  the 
involuntary  or  excito-motory  functions  of  these  central  parts.  The  con- 
stant morbid  condition  belonging  essentially  to  the  pathology  of  the  dis- 
ease, is  undoubtedly  an  undue  or  exaggerated  excitability  or  susceptibil- 
ity of  the  nervous  centers  of  voluntary  motion.  This  morbid  excitability 
of  the  structure  places  it  in  a  condition  favorable  for  the  action  of  any 
exciting  cause,  whether  acting  through  the  mental  faculties  in  direct  con- 
nection with  the  cerebral  hemispheres,  or  by  an  excito-motory  or  reflex 
influence,  from  irritation  transmitted  from  some  morbid  condition,  or  irri- 
tant action,  at  the  peripheral  extremity  of  the  sentient  nerves. 

And  if  the  expression  of  Hughlings  Jackson,  that  the  active  paroxysms 
of  the  disease  were  the  result  of  irreg-ular  discharges  of  nerve  force  in 
the  cerebral  centers,  is  meant  to  convey  the  idea  that  the  transmission  of 
some  exaggerated  impression,  either  through  the  mind  or  through  periph- 
eral nerves  to  the  cerebro-spinal  axis,  previously  in  the  state  of  morbid 
excitability  that  I  have  mentioned,  and  in  consequence,  carryingthe  motor 
function  beyond  the  control  of  the  mind  or  cerebral  hemispheres,  and 
thereby  inducing  involuntary,  clonic,  uncontrollable  spasmodic  action, 
together  with  loss  of  consciousness,  as  exhibited  in  ep'leptic  paroxysms,  I 
can  assent  to  the  explanation.  While  I  would  regard  the  morbid  sensi- 
tiveness of  the  portion  of  the  cerebro-spinal  axis  to  which  I  allude  as 
the  essential  and  constant  pathological  condition  constituting  the  epilep- 
tic disease,  it  is  true  that  the  coincident  conditions  of  other  functions 
differ  widely  in  different  patients.  In  one,  morbidly  excitable  nervous 
centers  may  co-exist  with  a  sanguine  temperament,  a  well  nourished  con- 
dition of  the  system,  full  development  of  the  muscular  structures  of  the 
body,  and  in  all  respects  vigorous  physical  health,  and  may  produce  in 
such  epileptics,  convulsions  at  the  usual  periods  with  as  much  violence  as 
in  any  other  class  of  cases  with  which  I  have  come  in  contact.  In  a 
much  larger  number,  however,  this  morbid  condition  of  the  cerebro- 
spinal center  is  associated  with  a  condition  of  the  physical  system  more 
especially  marked  as  the  nervous  temperament,  deficient  rather  in  the 
performance  of  the  assimilative  and  nutritive  functions,  leaving  the 
blood  below  the  normal  proportion  of  red  corpuscles,  tissues  generally 
pale  or  inclined  to  moderate  emaciation  and  thinness  of  flesh.  And  this 
tendency  to  paleness  or  anaemia  and  diminished  nutrition  appear  to  in- 
crease slowly  with  the  increase  in  the  duration  of  the  disease. 

Treatment — Epilepsy  being  a  disease  which  has  attracted  the  attention 
of  the  physician  from  a  remote  period  of  antiquity,  and  in  the  early  ages 
not  infrequently  regarded  as  the  manifestations  of  demonism,  the  remedies 
which  have  been  brought  into  requisition  for  its  treatment  are  perhaps  more 
numerous  and  have  been  applied  more  empirically,  than  in  the  treatment  of 
any  other  disease  in  the  whole  catalogue  of  human  ailments.  I  shall  not, 
however,  tax  your  time  by  enumerating  the  long  list  of  remedies  that 
have  been  tried,  recommended  and  abandoned  in  turn,  but  will  simply 
give  you  such  as  the  modern  investigations,  and  my  own  experience  in 
the  treatment  of  this  variety  of  disease  lead  me  to  regard  as  most  impor- 
tant. At  the  time  I  entered  upon  the  practice  of  medicine,  little  less  than 
half  a  century  since,  the  two  leading  remedies  for  the  treatment  of 
epilepsy  were  nitrate  of  silver  and  sulphate  of  zinc.  The  former,  more 
especially,  was  very  extensively  used,  and  at  that  time  it  was  not  very  un- 
common to  meet  with  cases  in  which  it  had  been  administered  for  such  a 
length  of  time,  and  in  such  doses,  that  it  had  foiuid  its  way  through  the 
blood  to   the  cutaneous   surface,  where,  acted  upon   by  oxygen  and  light, 


TREATMENT.  733 

it  had  produced  a  noticeable  change  of  color  in  the  skin.  But  the  most 
ample  experience  has  demonstrated  that  the  nitrate  of  silver,  sulphate  of 
zinc,  and  a  long  list  of  other  agents  heretofore  used  more  or  less,  are 
altogetlier  useless,  or  productive  of  no  curative  results.  Since  the  more 
recent  stud  es  concerning  the  nature  and  phenomena  of  epilepsy  has 
seemed  to  establish  the  fact  that  the  disease  is  one  primarily  of  morbid 
excitability  of  the  nervous  centers,  the  attention  of  the  profession  has 
been  turned  almost  exclusively  to  the  use  of  those  agents  which  are  prop- 
erly styled  nervous  sedatives;  such  as  the  bromide?,  physostigmn, 
digitalis,  gelseminum,  chloral  hydrate,  etc.  Cases  are  met  with  in  wiiich 
all  these  remedies  exercise  a  certain  amount  of  influence  in  rendering  the 
active  paroxysms  of  the  disease  less  frequent  and  less  severe,  at  least  for 
a  considerable  period  of  time;  and,  yet,  in  only  a  small  proportion  of  tiie 
whole  number  are  they  found  to  produce  any  permanent  interruption  ol 
the  paroxysms,  or  to  make  a  final  cure  of  the  disease. 

Formerly,  it  was  the  habit  to  speak  of  the  treatment  of  the  disease  un- 
der two  divisions:  one  appropriate  in  the  paroxysms,  or  during  the  period  ot 
active  convulsive  movements,  and  the  other,  required  in  the  intervals,  with 
a  view  of  preventing  the  recurrence  of  the  paroxysms.  But,  practically, 
there  is  no  need  of  medical  treatment  or  attempted  medical  treatm.  nt 
during  paroxysms  of  epilepsy.  As  I  have  stated,  when  speaking  of  the 
symptoms  and  clinical  history  of  the  disease,  the  convulsive  paroxysms 
are  always  temporary  in  their  duration.  Just  so  soon  as  by  the  arrest  of 
respiration,  the  oxygenation  and  decarbonization  of  the  blood  is  inter- 
rupted long  enough,  it  renders  that  fluid  sedative  to  the  excitability  of 
the  brain,  and  consequently  the  active  convulsive  movements  of  the  par- 
oxysms seldom  continue  more  than  from  two  to  five  minutes.  There  is, 
therefore,  neithe.-  time  nor  necessity  for  any  active  treatment  of  the  par- 
oxvsms.  Placing  the  patient  in  a  recumbent  or  inclined  position, 
with  the  clothes  loosened  sufficiently  to  prevent  any  undue  pressure  upon 
the  chest  or  interference  with  the  respiration,  by  opening  the  collar  atid 
necktie,  leaving  the  neck,  larynx  and  throat  bare,  and  free  access  of  air  for 
the  patient  to  breathe,  constitute  the  only  measures  of  any  value  during 
the  active  convulsive  paroxysms.  When  the  paroxysm  has  ceased,  it 
should  not  be  assumed  that  there  is  nothing  to  be  done  but  simply  to 
prescribe  some  favorite  remedy  which  is  supposed  to  exert  a  specific  influ- 
ence over  the  nervous  excitabdity.  This  is  too  much  the  habit  of  a  large 
proportion  of  the  profession  at  the  present  day.  Epileptic  patients,  on 
the  contrary,  need  to  be  examined  as  carefully,  and  to  be  prescribed  for 
as  fully,  not  merely  in  relation  to  medicines  to  be  taken,  but  in  relation 
to  their  diet,  dress,  exercise  and  all  the  habits  of  life,  as  patients  laboring 
under  any  other  form  of  disease.  If  this  attention  is  given  them,  and  the 
treatment  commenced  early,  while  the  intervals  between  one  paroxysm 
and  another  is  still  long,  and  the  measures  persevered  in  for  a  number  of 
months,  a  considerable  proportion  of  cases  can  be  cured,  or  at  least  all 
active  phenomena  of  the  disease  suspended  for  a  series  of  years.  It  is 
very  important,  when  taking  charge  of  any  case  of  epilepsy,  that  careful 
inquiry  be  made  in  regard  to  the  condition,  or  habitual  performance  of 
the  functions  connected  with  the  digestive  organs,  and  such  measures  as 
may  be  necessary  should  be  instituted  and  carefully  carried  out  for  keep- 
ing the  movements  of  the  bowels  as  near  the  healthy  standard  as  possible, 
neither  allowing  constipation  on  the  one  hand,  or  active  purgation  on  the 
other,  but  such  use  of  laxative  and  tonic  medicines,  and  such  articles  of 
diet,  as  will  promote  most  nearly  a  strictly,  regular,  healthy  condition, 
both    of  digestion,  secretion   and  evacuations.     And    in    this    connection 


734  EPILEPSY, 

more  attention  also  should  be  given   to  the  function  of  the  kidneys  than 
is  ordinarily  done. 

In  some  instances  it  will  be  found  that  the  skin  and  kidneys  are  defi- 
cient in  eliminating  waste  material,  and  that  one  needs  prompting  by 
diuretics,  and  the  other  by  a  warm  alkaline  bath  twice  a  week,  followed 
each  time  by  brisk  active  friction  with  dry  flannel.  The  exercise  of 
this  class  of  patients  also  should  be  regulated  in  such  a  manner  as  to  se- 
cure a  good  degree  of  outdoor  daily  exercise,  but  without  violent  or 
protracted  exertion.  Mental  application  also  should  be  carefully  regu- 
lated, avoiding  intensity  of  study  or  mental  exercise  in  the  young,  or  in- 
tensity of  business  application  and  anxieties  in  those  in  mature  life. 
And  yet  equally,  if  possible,  avoid  leaving  the  mind,  either  of  the  young 
or  middle  aged,  unoccupied.  Both  excessive  mental  activity,  especially  if 
accompanied  with  mental  anxiety  and  depressing  influences,  and  mental 
ennui  or  want  of  employment  or  occupancy,  are  unfavorable  and  directly 
calculated  to  increase  and  perpetuate  the  disease.  Another  item  perhaps 
of  quite  as  much  importance  even  as  a  most  careful  selection  of  medi- 
cines, is  the  regulation  of  the  diet.  Many  years  since,  the  elder  Dr.  Jack- 
son, of  Boston,  if  I  remember  rightly,  mentioned  in  some  of  his  writings 
that  the  avoidance  of  meat,  and  adherence  to  a  milk  and  farinaceous  or 
vegetable  diet  was  desirable  and  sometimes  at  least  very  beneficial  in 
lessening  the  frequency  of  the  epileptic  paroxysms.  Through  the  many 
years  that  have  since  passed,  I  have  had  occasion  to  note  the  influence 
exerted  by  using  meat  freely  as  an  article  of  diet,  and  also  by  abstaining 
from  it,  in  various  stages,  in  the  progress  of  this  disease.  I  am  fully  satis- 
fied from  such  observation,  that  in  a  large  proportion  of  epileptics,  all  of 
them  in  fact,  except  those  that  are  most  angemic,  it  is  decidedly  advan- 
tageous to  have  them  abstain  either  entirely  from  the  use  of  flesh  meat  as 
food,  or  to  allow  only  a  very  limited  amount  at  the  dinner  hour  each  day. 
I  remember  one  case  of  well  marked  epilepsy,  which  had  continued,  the 
paroxysms  gradually  increasing  in  their  frequency,  for  more  than  three 
jears,  in  the  person  of  a  young  man  of  a  nervous  temperament,  neither 
strongly  anaemic  nor  plethoric,  who  h^d  been  treated  during  much  of  the 
three  years,  with  the  usual  degree  of  skill,  so  far  as  medicines  were  con- 
cerned, by  a  number  of  physicians  of  good  standing,  but  without  any 
apparent  progress  in  ameliorating  the  condition  of  the  patient,  or  in 
lessening  the  frequency  of  the  paroxysms  of  the  disease.  He  was  tired  of 
taking  medicine,  protested  against  its  continuance,  and  I  suggested  that 
he  at  least  adopt  a  moderate  and  regular  daily  roatine  of  outdoor  exer- 
cise, taking  pains  to  exercise  the  arms  and  muscles  of  the  chest,  with 
sufficient  mental  occupation  to  furnish  the  mind  with  at  least  diversion 
and  occupancy,  but  without  any  severe  tax  upon  its  activitv,  take  no  med- 
icine and  omit  entirely  the  use  of  meat  from  his  diet.  He  was  allowed 
as  much  as  his  appetite  required,  of  milk,  different  varieties  of  bread, 
ordinary  variety  of  vegetables,  but  avoided  all  stimulating  drinks  of 
every  kind  fermented  and  distilled,  as  well  as  tea  and  coffee. 

He  followed  the  advice  faithfully,  and  after  the  first  four  months  he 
ceased  to  have  any  recurrence  of  his  epileptic  paroxysms,  and  although  his 
future  progress  was  noted  through  a  period  of  five  or  six  years,  he  con- 
tinued to  have  good  health  and  entire  freedom  from  any  recurrence  of 
epileptic  paroxysms.  It  is  not  the  object,  you  will  perceive,  to  confine 
patients  to  a  low  diet,  in  the  proper  sense  of  the  word,  for  we  allow  full 
liberty  to  use  what  the  appetite  demands,  and  that  of  a  sufficiently  wide 
range  or  variety  in  its  constituency;  but  simply  exclude  meat  and  those' 
drinks  which  are  known  to  increase   the   excitability  of  the   nervous    syi- 


TflEATMENT.  735 

torn.  There  are  some  cases,  however,  of  epilepsy  in  which  the  patients 
have  already  become  decidedly  anasinic,  with  cold  extremities,  tempera- 
ture habitually  one  or  two  degrees  below  the  natural  standard  of  health, 
pulse  soft,  weak,  and  yet  subject  to  epileptic  paroxysms  of  more  or  less 
frequency  and  severity.  In  such,  instead  of  prohibiting  entirely  the  use 
ot  meat,  I  think  it  advisable  simply  to  regulate  the  amount,  causing  them 
to  take  but  a  moderate  proportion  of  the  more  nutritious  and  easily 
dicrestible  varieties  of  meat  with  their  breakfast  and  dinner,  omitting  it  a1 
the  evening  meal.  In  this  class  of  subjects,  wherever  it  can  be  done 
with  sufficient  decree  of  perseverance  to  render  it  worthy  of  trial,  I  re- 
crard  the  use  of  electricity,  or  rather  galvanism,  with  some  degree  ol 
friction  or  massage,  as  an  important  part  of  the  treatment.  The  galvanic 
(U.-rcMit  should  never  be  communicated  to  them  with  sufficient  intensity  tc 
c.iusft  shocks  or  direct  excitement,  but  in  the  way  best  calculated  tc 
promote  general  nutrition  by  its  influence  in  quickening  the  functions  of 
what  a'^e  termed  the  trophic  or  vaso-motor  nerves,  and  the  inherent  affinit_y 
of  the  primary  molecules  that  enter  into  the  structure  of  the  tissues  oi 
the  body.  To  make  this  available  in  the  greatest  degree,  the  remedv 
should  be  used  from  five  to  twenty  minutes  once  a  day,  or  at  least  everv 
alternate  day.  You  will  note  that  this  recommendation  in  reference  tc 
electricity  or  galvanism,  with  friction  and  massage,  is  only  made  as 
applicable  to  those  cases  that  have  become  antemic  and  deficient  in  gen- 
eral nutrition.  For  many  epileptics  are  abundantly  nourished,  and  eight 
out  of  ten  of  all  of  them  have  voracious  appetites,  and  especially  appetites 
for  beefsteak  and  other  items  of  rich  food.  In  regard  to  remedial  agents, 
none  will  be  of  much  value  except  such  as  I  have  alluded  to  for  regulat- 
ing secretions,  promoting  a  healthier  condition  of  functions  that  may  be 
defective,  unless  they  be 'used  with  steadiness  for  a  long  period  of  time. 
And  this  is  one  of  thegre  itest  sources  of  failure  in  the  treatment  of  this  class 
of  cases.  The  disease  manifests  its  active  phenomena  only  in  paroxysms. 
In  the  earlier  stages  of  their  progress,  they  come  not  oftener  than  once  in 
every  four,  six  or  eight  months.  In  the  intervals,  much  of  the  time,  the 
patient  has  the  appearance  of  entire  good  health.  It  is  extremely  difficult 
in  such  instances  to  have  either  parents,  in  reference  to  their  children,  or 
adult  patients  themselves  realize  that  there  is  any  necessity  for  using  reme- 
dies from  day  to  day,  while  apparently  as  well  as  any  of  those  around  them. 
A  I  are  ready  enough  to  take  medicine  when  the  paroxysms  of  convul- 
sion come,  and  to  follow  it  up  for  a  week  or  possibly  two  or  three  weeks 
after  it  has  passed  by;  but  to  persevere  in  all  these  matters  judiciously, 
from  month  to  month,  is  what  the  large  proportion  of  them  will  utterly 
fail  to  do,  notwithstanding  your  most  careful  explanation  of  the  nature  ol 
the  disease  and  the  necessity  for  such  perseverance.  These  remarks  are 
especially  applicable  to  the  treatment  of  the  earlier  stages  of  the  disease. 
There  are  many  cases,  after  they  have  continued  five,  six  or  a  dozen 
years,  and  increased  in  the  frequency  of  their  paroxysms  from  once  or 
twice  in  the  year  to  a  paroxysm  every  week,  with  visible  impairment  of 
the  mental  faculties,  in  which  the  anxious  parents  and  friends  will  often 
persevere  in  the  use  of  medicine  until  the  system  may  be  saturated  even 
to  an  injurious  extent.  But  at  such  advanced  stage  of  progress,  most 
cases  of  epilepsy  prove  to  be  absolutely  incurable.  They  are  often 
palliated  and  the  paroxysms  postponed  to  longer  intervals  between  their 
recurrence.  And,  although,  a  great  many  of  these  confirmed  cases  have 
come  under  my  observation,  I  have  known  but  very  few  in  which  the 
disease  has  been  permanently  interrupted.  If  the  disease  is  taken  in 
charge  in  young   subjects  anywhere  from   infancy  to  five   or  six  years  of 


7ob  EPILEPSY. 

a^e,  and  before  structural  lesions  or  partial  arrest  of  nutrition  in  the 
cerebral  centers  has  actually  taken  place,  a  considerable  percentage  may- 
be cured.  I  speak  the  more  positively,  that  a  proportion  of  them  may  be 
cured,  as  I  have  known  some  long  enough  to  know  personally  that  the 
disease  had  remained  without  any  recurrence  from  childhood,  at  least,  to 
the   middle  period  of  adult  life. 

I  do  not  yet  think  there  is  a  specific  remsdy  for  the  cure  of  epilepsy; 
but  the  particular  combination  which  has  proven  more  serviceable  in  my 
own  hands  than  any  other,  although  I  have  tried  a  great  variety — is  that 
of  one  of  the  bromides,  given  in  connection  with  the  fluid  extract  of  g  ilium 
alba,  and  a  certain  proportion  of  digitalis.  I  say  one  of  the  bromides,  be- 
cause I  think  as  a  general  rule,  there  is  no  advantage  in  combining  the 
different  bromides  together,  but  there  are  some  patients  that  will  be  bene- 
fited to  a  greater  degree  by  the  bromide  of  potassium,  others  by  the 
bromide  of  ammonium,  and  still  others  by  the  bromide  of  lithium.  It  is 
not  easy  to  determine  which  of  these  will  do  most  good  to  the  patient 
until  they  are  tried.  I  have  thought  this  rule  applicable:  that  in  those 
cases  where  there  is  a  tendency  in  connection  with  the  disease  to  inactivity 
of  the  kidneys,  inclining  the  patient  habitually  to  scantiness  of  urine,  the 
bromide  of  lithium  was  found  most  beneficial.  And  in  such  I  also  give 
in  connection  with  the  bromide  and  galium,  such  doses  of  the  wine  of 
colchicum  root  as  can  be  borne  without  disturbing  the  bowels,  instead  of 
digitalis.  But  in  the  large  majority  of  cases,  I  have  thought  the  bromide 
of  potassium  the  more  efficient  article  of  this  group.  The  formula  which  I 
have  used  much  for  the  last  twenty  years  consists  of  the  bromide  of  potas- 
sium twenty-five  grams  (3^'i)  tincture  of  digitalis,  twenty-five  c.  c.  (fl3vi) 
fluid  extract  of  galium  alba,  ninety  c.  c.  (fl  fiii),  and  simple  elixir  thirty 
c.  c.  (fl  3i).  To  an  adult  or  person  above  the  period  of  puberty,  I  have  usually 
given  of  this  formula,  four  cubic  centimeters  (fl  3i)  before  breakfast  and 
supper,  and  six  cubic  centimeters  (fl  3'ss)  at  bed  time.  If  the  paroxysms 
of  the  disease  recur  at  long  intervals,  it  is  sufficient  in  many  instances  to 
give  but  two  doses  a  day,  i-  e.  four  cubic  centimeters  (fl  3i)  in  the  morning 
and  six  (fl  3iss)  in  the  evening.  I  have  found  it,  however,  advantageous, 
whenever  the  paroxysms  of  the  disease  have  been  found  to  recur  with 
a  sufficient  degree  of  regularity  so  that  it  could  be  known  about  when 
the  next  paroxysm  was  to  be  expected,  that  the  patient  should  com- 
mence at  least  a  week  before  the  time,  to  increase  the  medicine  to  three 
doses  every  day  instead  of  two,  and  continue  it  at  that  rate  till  the  time  of 
the  expected  paroxysm  had  passed  by.  Then  recede  again  to  a  dose 
morning  and  evening.  In  prescribing  for  younger  persons  the  same  com- 
bination may  be  used,  but  the  dose  must  be  diminished  at  the  ordinary 
ratio  to  keep  the  proportion  appropriate  for  the  age  of  the  patient.  The 
reason  for  giving  larger  doses  at  night  is,  that  a  large  proportion  of  epilejD- 
tic  patients  have  their  paroxysms  come  either  in  the  night  or  early  morn- 
ing. One  important  objection  to  the  protracted  use  of  the  bromides,  is 
their  tendency  to  produce  cutaneous  eruptions,  and  sometimes  to  impair  in 
some  degree  the  nutritive  functions.  The  tendency  to  induce  cutaneous 
eruptions  can  in  some  instances  be  obviated  for  a  considerable  period  of 
time,  by  adding  a  small  proportion  of  the  liquor  potassii  arsenitis  to  the 
foi'mula  that  I  have  just  mentioned;  making  the  proportion  such  that  an 
adult  would  get  from  two  to  four  minims  of  the  arsenical  preparation  in 
each  dose.  Guided  by  my  own  experience,  I  should  say  next  in  value  to 
the  combination  that  I  have  just  given  you,  is  valerianate  of  zinc  in  com- 
bination with  such  doses  of  the  extract  of  stramonium,  or  conium,  as  will 
be  borne  without  producing  noticeable  dryness  of  the  fauces,  or  dilatation 
of  the  pupils  of  the  eyes. 


TEEATMENT.  737 

Recently,  bromine  itself  has  been  recommended,  I  think,  by  Dr.  Ham- 
mond, as  a  remedy  quite  as  efficient  in  ameliorating  the  epileptic  condi- 
tion as  any  of  the  bromides.  For  administration,  one  cubic  centimeter 
(fl  3^)  of  the  bromine  may  be  put  into  two  hundred  and  sixty  cubic 
centimeters  (fl  ^viii)  of  water,  with  three  or  four  grammes  (3i)  of  the 
bromide  of  potassium,  to  render  the  solution  of  the  bromine  in  the  water 
more  perfect.  Of  this  solution,  four  cubic  centimeters  (fl  3i)  may  be  given 
further  diluted  with  water,  or  sugar  and  water  at  the  time  of  adminis- 
tration, three  times  a  day.  I  have  not  had  sufficient  clinical  experience 
with  this  remedy  to  express  any  opinion  as  to  its  value,  although  I  should 
anticipate  its  eifects  would  be  very  similar  to  that  of  the  bromides,  which 
have  been  so  long  and  thoroughly  tested.  As  I  remarked  before,  so  in 
closing  this  subject,  I  must  remind  you  that  a  large  part  of  your  success 
in  the  management  of  cases  of  epilepsy  will  depend  upon  bringing  them 
under  treatment  at  an  early  period  after  the  disease  has  commenced, 
paying  close  attention  to  a  judicious  regulation  of  the  diet,  exercise  men- 
tal and  physical,  and  to  the  careful  maintenance  of  a  healthy  activity  in  all 
the  important  functions  of  the  body.  What  1  have  thus  stated  in  regard 
to  the  treatment  applies  to  the  disease  as  ordinarily  presented  to  us  for 
treatment,  unconnected  with  any  traumatic  influence  in  producing  it. 
As  a  matter  of  course,  wherever  cases  of  epilepsy  are  met  with  of  a  reflex 
character,  and  the  primary  seat  of  irritation  can  be  determined,  whether 
it  involves  the  sentient  nerves  of  the  scalp,  or  any  other  part  upon  the 
exterior  of  the  body,  or  a  fracture  or  partial  fracture  of  the  bones  of 
the  cranium,  or  the  existence  of  an  irritable  or  diseased  uterus,  or  irri- 
tating substances  in  the  alimentary  canal,  in  such  cases  I  say,  as  a  mat- 
ter of  course,  the  leading  object  of  treatment  must  be  the  removal  of  the 
primary  seat  of  irritation,  with  whatever  remedies  are  necessary  for  that 
purpose.  Traumatic  cases  usually  are  to  be  remedied  by  surgical  inter- 
ference, for  the  removal  of  spicules  of  bone,  cicatrices  and  badly  healed 
stumps  after  amputations,  while  diseases  in  the  alimentary  canal  or 
in  the  viscera  of  the  pelvis,  male  and  female,  or  unusual  sexual  indul- 
gence, must  be  treated  and  controlled  by  the  practitioner,  by  the  use  of 
such  remedies  as  each  individual  case  calls  for.  I  apprehend  that  if  we, 
as  practitioners  of  medicine,  should  study  the  individual  cases  of  epi- 
lepsy that  come  under  our  care,  especially  those  that  are  presented  in  the 
early  stage  of  their  progress,  more  carefully  in  relation  to  the  particular 
cause  or  causes,  and  make  a  more  intelligent  and  thorough  effort  to  re- 
move every  point  of  irritation  on  the  Drinciples  that  I  have  laid  down,  a 
much  larger  number  of  cases  of  the  disease  would  be  permanently 
cured  than  have  been  heretofore.  And  yet  I  must  admit,  as  I  have  already 
done,  that  after  the  disease  has  become  of  long  duration  or  the  habitual 
recurrence  of  paroxysms  well  established  through  a  period  of  several 
years,  it  is  really  rare  that  any  mode  of  treatment,  however  perseveringly 
followed,  has  succeeded  in  making  a  permanent  cure  or  accomplish- 
ing more  than  a  temporary  amelioration  of  the  condition  of  the  patient. 
47 


738  CHOEEA. 


LECTURE  LXXIV. 


Chorea— Its  Causes,  Clinical  History,  Pathology,  Diagnosis,  Prognosis  and  Treatment. 

GENTLEMEN:  The  disease  denominated  chorea,  sometimes  popular- 
ly called  St.  Vitus  Dance,  is  met  with  most  frequently  in  children 
between  the  ages  of  five  and  fifteen  years.  It  may  occur  earlier  than 
five,  and  sometimes  between  fifteen  and  twenty-five.  But  probably  eight 
out  of  ten  of  all  the  cases  of  chorea  that  occur,  have  their  commencement 
within  the  ages  first  named. 

Causes. — A  variety  of  causes  have  been  alleged  to  be  capable  of  in- 
ducing chorea,  some  holding  the  relation  of  predisposing,  others  that 
of  exciting  causes.  Of  the  first,  perhaps,  an  excitable  temperament 
coupled  with  timidity  of  mind  in  children,  constitute  the  most  constant 
predisposing  conditions.  A  very  large  majority  of  all  the  cases  that 
come  under  my  observation  are  in  a  class  of  children,  embracing  both 
males  and  females,  of  a  rather  aniemic  or  delicate  physical  condition  and 
a  decidedly  timid,  diffident  condition  mentally.  Yet,  these  conditions  are 
not  present  in  all  cases  of  chorea,  for  I  have  met  with  some  children  of 
apparently  sanguine  temperament,  hardy,  well  nourished  and  without  any 
special  mental  trepidation  or  timidity.  As  a  general  rule,  girls  are  more  dis- 
posed to  the  disease  than  boys,  and  I  have  known  a  number  of  instances 
in  which  season  of  the  year  appeared  to  exert  an  influence,  the  pa- 
.tients  having  their  attacks  renewed  in  some  instances  every  autumn,  for 
two  or  three  years  in  succession,  apparently  coincident  with  the  occur- 
rence of  cold,  damp,  and  changeable  weather.  But  in  a  large  majority, 
it  is  not  easy  to  trace  any  influence  from  the  seasons  of  the  year,  or  any 
particular  diet  or  mode  of  life.  Of  the  exciting  causes,  none  are  more 
prolific  in  developing  the  disease  into  activitj?^  than  fear,  coupled  with 
mental  anxiety.  Children  going  to  school  between  the  ages  of  seven  and 
ten  years,  of  a  temperament  such  as  1  have  indicated,  find  it  a  little  diffi- 
cult to  get  their  lessons  to  the  satisfaction  of  their  teachers,  and  are  in 
consequence  placed  each  day  in  a  state  of  continual  dread  or  apprehen- 
sion, which  renders  it  still  moi'e  difficult  for  them  to  make  progress  in  their 
studies;  and  in  a  few  weeks,  or  months  at  longest,  of  this  regular  daily  men- 
tal trepidation  and  anxiety,  coupled  with  fear  of  punishment,  and  perhaps 
aided  by  the  jeers  of  their  comrades  in  the  same  classes,  they  are  discov- 
ered to  be  subject  to  certain  muscular  movements  of  the  face  and  of  the 
voluntary  muscles  of  the  hands  and  arms,  which  at  first  are  not  infre- 
quently mistaken  for  willful  motions,  and  thus  bring  more  scolding, 
more  jeers,  and  add  directly  to  the  unhappy  condition  of  the  sufferer  till 
the  disease  is  fully  developed. 

The  same  mental  conditions  may  arise  in  families  without  the  child 
having  any  connection  with  the  school  room.  In  fact,  any  train  of  cir- 
cumstances which  tends  to  keep  the  child  in  a  state  of  mental  apprehen- 
sion, coupled  with  more  or  less  fear,  strongly  acts  as  an  exciting  cause  of 
this  variety  of  nervous  disease.  Another  class  of  cases  has  been  plainly 
traced  to  the  influence  of  cold  and  damp  air  or  sudden  checking  of  per- 
spiration. Indeed,  not  infrequently,  the  choreic  movements  have  been 
associated  with  a  moderate  degree  of  rheumatic  fever  and  soreness  in 
different  parts  of  the  system,  rendering  it  unmistakably  a  case  of  rheu- 
matic oriofin.     One  of  the  earliest  well-marked  cases  of  chorea  that  came 


SYMPTOMS.  739 

under  my  care  after  enterinor  upon  the  practice  of  medicine,  more  than 
forty  years  since,  was  in  a  hardy,  well-nourished  boy  of  twelve  or  four- 
teen years  of  age,  who,  after  working  with  other  members  of  the  family 
in  the  woods,  chopping  wood,  on  an  early  spring  day,  with  the  coat  off, 
incautiously  went  hotne  without  putting  his  coat  on  and  became  some- 
what chilled.  This  was  followed  during  the  two  succeeding  days  by  a 
well-marked  rheumatic  fever,  which  abated  somewhat  during  the  follow- 
ing two  days.  But  as  the  rheumatic  fever  diminished,  severe  choreic 
symptoms  immediately  followed,  and  proved  quite  persistent  in  its  dura- 
tion. It  is  probable  that  the  cases  to  which  I  have  alluded  as  recurring 
at  certain  seasons  of  the  year,  particularly  in  spring  and  autumn,  are 
usually  of  the  class  that  might  be  styled  rheumatic  cases,  or  such  as 
originate  from  imperfect  eliminations  through  the  skin  and  kidneys,  and 
consequent  retention  of  the  products  of  tissue  metamorphosis  until  thev  act 
upon  certain  portions  of  the  nervous  centers,  producing  choreic  symptoms, 
instead  of  upon  the  muscular  and  fibrous  tissues,  which  would  constitute 
ordinary  rheumatism.  Other  cases  have  been  alleged  to  originate  from 
drying  up  of  suppurative  sores,  such  as  ulcers,  and  still  more  by  the 
sudden  and  rapid  disappearance  of  chronic  cutaneous  eruptions.  Long 
standing  eruptions,  like  chronic  eczama  of  the  scalp  and  other  parts  of 
the  system,  on  suddenly  disappearing,  have  been  followed,  though  not 
very  frequently,  by  choreic  symptoms.  Still  other  cases  have  been  sup- 
posed to  originate  from  irritation  in  the  alimentary  canal,  either  from  in- 
testinal worms  or  indigestible  food.  It  is  proper  to  remark,  however,  that 
though  I  have  observed  a  very  large  number  of  cases  of  chorea,  I  have  no 
recollection  of  a  single  case  that  was  connected  either  with  intestinal 
worms  or  habitual  indigestion;  and  I  think  not  more  than  three  or  four 
in  which  there  was  any  reliable  evidence  that  the  disease  had  originated 
from  sudden  drying  up  of  ulcers,  or  the  disappearance  of  cutaneous 
eruptions.  But  from  impressions  of  cold  and  damp,  I  have  met  with  a 
considerable  number,  while  eight  out  of  ten  of  all  cases  have  been  trace- 
able to  mental  impressions  of  a  depressing  character  coupled  with  fear,  or 
from  sudden  and  severe  fright. 

Clinical  History. — In  most  cases  the  disease  develops  rather  gradually, 
without  any  regular  premonitory  symptoms  or  warning,  or  any  noticeable 
febrile  stage.  The  first  deviation  from  the  natural  condition  noticed  is 
usually  the  irregular  movements  of  the  muscles  of  one  or  both  sides  of  the 
face.  At  first  it  may  be  merely  an  irregularly  recurring  spasmodic 
action  or  jerking  of  a  particular  muscle,  either  drawing  the  eyebrows  up 
and  forcing  the  eyelids  together  like  a  forcible  wink,  or  more  frequently, 
lifting  one  angle  of  the  mouth.  In  a  day  or  two  after  observing  these 
slight  spasmodic  movements  in  some  of  the  muscles  of  the  face,  the  hand 
will  be  noticed  to  move  irregularly,  and  sometimes  when  attempting  to 
take  hold  of  something  it  will  be  jerked  suddenly  in  another  direction. 
The  feet  may  be  moved  in  the  same  way.  But  if  these  symptoms  have 
attracted  attention  or  elicited  inquiry,  or  if  they  are  mistaken  for  volun- 
tary movements,  and  any  chiding  or  reproof  is  administered,  it  usually 
directly  increases  the  difficulty,  rendering  the  spasmodic  action  much 
more  frequent  and  violent  than  it  was  before.  Some  cases  hardly  go 
beyond  the  slight  symptoms  I  have  named.  There  is  no  disturbance  of 
the  pulse,  no  increase  of  temperature,  indeed  no  particular  development 
of  other  symptoms,  but  simply  these  slight  and  variable  involuntary 
spismodic  movements  of  particular  muscles,  either  of  the  face  or  extremi- 
ties, or  of  both.  But  in  most  instances  where  no  remedies  are  inter- 
posed, the  disease  increases  from  day  to  day,  and  in  about  one  week  after 


740  CHOEEA. 

the  first  noticeable  irregular  muscular  movements,  they  will  have  ex- 
tended to  nearly  all  the  voluntary  muscles  of  the  face,  neck,  and  both 
upper  and  lower  extremities;  not  that  they  will  all  be  in  motion  at  one 
time,  but  alternately  and  with  entire  irregularity;  the  muscles  of  the  arm 
moving  one  second,  and  next  a  twitching  in  the  muscles  of  the  face  or  in  the 
neck,  shoulders  or  feet,  rendering  the  various  muscular  movements  entirely 
unsteady  and  without  an}'-  successive  order,  and  sometimes  throwing  the 
patient  into  the  most  grotesque  and  ludicrous  attitudes.  During  the 
second  week  in  a  majority  of  ordinary  cases,  the  disease  reaches  its  climax 
of  development,  when  the  muscular  movements  become  so  severe  and 
frequent  that  the  patients  can  make  no  steady  progress  in  walking;  the 
legs  are  jerked  in  such  an  irregular  manner  as  to  render  walking  imprac- 
ticable, while  the  hands  and  arms  are  so  suddenly  and  severely  moved 
as  to  cause  the  dropping  or  throwing  whatever  may  be  in  the  hands,  and 
rendering  them  incapable  of  even  feeding  themselves.  Everything  is 
thrown  irregularly  out  of  their  hands,  and  they  are  sometimes  not  able  to 
keep  themselves  in  bed — the  muscular  movements  of  the  trunk  of  the  body 
as  well  as  the  extremities,  throwing  them  from  side  to  side  until  they  will 
be  dashed  either  against  the  walls  along  the  bed,  or  out  of  the  bed  upon 
the  floor.  Where  the  disease  becomes  thus  violent,  there  is  usually  con- 
siderable dilatation  of  the  pupil  of  the  eye,  there  is  much  difficulty  in  deglu- 
tition, and  almost  entire  inability  to  talk,  on  account  of  the  irregular 
movements  affecting  the  muscles  concerned,  both  in  speech  and  deglutition. 
I  have  seen  a  few  instances,  where  the  spasmodic  action  during  the  par- 
oxysms was  so  violent,  that  it  required  the  constant  attention  of  one  or  two 
persons  to  keep  the  patients  on  the  bed,  and  prevent  them  from  suffering 
more  or  less  personal  injury  by  the  uncontrollable  and  irregular  muscular 
movements.  It  is  very  rare  that  the  muscular  movements  involve  the 
sphincters  of  the  body,  but  in  a  few  instances  the  patients  have  been  un- 
able to  control  either  their  water  or  fasces.  There  is  a  decided  parox- 
ysmal character  to  the  irregular  movements  in  almost  all  the  oases  of 
chorea.  There  are  periods  of  a  few  minutes  at  a  time  in  which  the  irreg- 
ular or  spasmodic  muscular  movements  will  be  very  violent,  extending 
over  most  of  the  voluntary  muscular  system,  and  then  an  interval  of  compar- 
ative quiet,  sometimes  lasting  not  more  than  two  or  three  minutes,  while 
at  other  times  the  intermissions  between  the  paroxysms  will  be  from 
fifteen  to  thirty  minutes  of  almost  entire  repose.  But  in  nearly  all  in- 
stances during  sleep,  the  irregular  muscular  movements  cease,  and  many 
of  the  choreic  patients  sleep  as  quietly  as  though  they  were  in  perfect 
health,  I  have  noticed  only  a  few  exceptions  to  this  rule,  in  which  some 
slight  degree  of  spasmodic  action  continued  during  sleep.  The  natural 
tendency  of  the  disease,  as  I  have  just  remarked,  is  to  reach  the  climax  of 
its  development  during  the  latter  part  of  the  second  week,  continuing  with 
but  little  change  until  toward  the  middle  or  latter  part  of  the  third  week, 
when,  in  most  cases,  there  begins  to  be  a  decline  or  an  apparent  tendency 
to  spontaneous  recovery  between  the  end  of  the  fourth  and  that  of  the 
sixth  week.  Mild  cases  have  terminated  earlier,  and  the  severer  ones 
sometimes  have  been  protracted  not  only  six  weeks  but  as  many  months. 
As  an  ordinary  rule,  during  the  whole  progress  of  the  disease  the  patient 
retains  a  moderately  fair  appetite,  the  evacuations  remain  nearly  regular, 
though  sometimes  inclined  to  costiveness,  the  urine  usually  of  rather 
high  specific  gravity,  and  perhaps  less  in  bulk  than  natural,  although  this 
varies  with  different  cases.  A  few  that  have  come  under  my  observation 
made  larger  quantities  of  limpid  urine  than  in  health.  Patients  with  this 
disease   are  usually  also  free  from  pain,  except  such   as  are  of  rheumatic 


PATHOLOGY.  741 

orlo-in.  These  usually  complain  of  more  or  less  severe  headache,  and 
general  muscular  soreness  or  hyperassthesia;  and,  so  far  as  I  have  ob- 
served, the  urinary  secretion  is  less  than  natural  and  of  a  deeper  red  color. 
During  the  first  week,  there  is  slight  elevation  of  temperature  and  ac- 
celeration of  pulse.  But  aside  from  this,  I  have  noticed  no  general 
febrile  phenomena,  or  any  considerable  pain  connected  with  the  disease. 
In  the  severer  cases,  where  the  paroxysms  and  violent  muscular  move- 
ments combined  are  such  as  1  have  described,  the  patient  becomes 
exceedingly  weary,  apparently  through  voluntary  efforts  to  lessen  the 
uncontrollable  movements.  After  the  first  two  weeks  there  is  noticeable 
usually  some  loss  both  in  flesh  and  strength.  The  countenance  is 
usually  expressive  of  despondency,  and  the  color  of  the  Up  evidently  in- 
dicates impoverishment  of  the  red  corpuscles  of  the  blood. 

While  the  descriptions  I  have  given  from  the  lighter  class  of  cases  to. 
the  more  severe  as  they  are  usually  met  with,  apply  to  those  of  most  fre- 
quent occurrence,  many  show  deviations  that  require  mention.  Among 
the  more  common  of  these  deviations  is  the  confinement  of  the  disease  to 
one  side  of  the  body,  particularly  one  side  of  the  face,  one  arm  or  one 
leo-.  In  a  few  instances  this  has  been  well  characterized,  the  muscles  of 
one  side  being  actively  involved  in  the  disease,  while  hardly  an  irregular 
movement  can  be  detected  upon  the  other.  In  other  instances,  the  dis- 
ease is  confined  entirely  to  some  limited  portion  of  the  voluntary  muscles, 
such  as  those  of  the  face  alone.  In  other  instances,  the  arms,  the  feet 
and  legs,  and  in  not  less  than  tiiree  cases,  I  have  found  the  patient  ap- 
parently afi'ected  only  in  the  muscles  of  the  diaphragm  and  the  anterior 
walls  of  the  abdomen  producing  very  marked  and  characteristic  in- 
terference with  the  regularity  of  the  respiratory  movements,  and  of  course 
with  the  regularity  of  the  speech.  One  of  these  cases  was  a  young  wo- 
man of  eighteen,  who  came  from  the  interior  of  the  State,  and  had  been 
previously  affected  by  the  disease  for  some  six  months.  It  was  limited 
entirely  to  the  muscles  of  the  trunk  and  diaphragm,  cutting  short  her 
words  at  irregular  intervals  when  conversing,  forcing  the  breath  suddenly 
out  or  stopping  the  respiratory  act  once  or  twice  in  its  progress.  In  an- 
other case  also,  a  young  woman  of  twenty  years,  the  disease  was  limited 
apparently  entirely  to  the  abdominal  muscles  and  diaphragm,  not  affect- 
ing the  muscles  of  the  chest  above  the  'diaphragm,  but  involving  the 
muscles  of  the  abdominal  walls  in  front  to  the  pubis.  But  you  must 
be  prepared  to  meet  with  irregular  choreic  action  in  almost  any  of 
the  muscles  of  the  body  or  extremities,  either  as  affecting  single  mus- 
cles or  associated    groups,  co-operating  in  certain  movements. 

Pathology. — As  uncomplicated  cases  of  chorea  rarely  terminate  fatally,, 
but  few  opportunities  have  occurred  for  post-mortem  examinations  or  for 
studying  the  structural  changes  that  might  be  supposed  to  occur  in  the 
cerebro-spinal  portions  of  the  nervous  system.  But  the  disease,  as  ordi- 
narily met  with,  is  so  purely  one  of  functional  or  temporary  disturbance, 
tending  toward  recovery,  that  it  is  not  probable  that  the  closest  scrutiny 
would  detect  any  structural  changes  in  the  cerebral  or  cerebro-spinal 
structures,  that  could  be  considered  as  characteristic  of  this  disease.  The 
essential  pathological  condition  connected  with  it,  is  undoubtedly  one  of 
a  peculiar  morbid  excitability  of  certain  tracts  of  nerve  matter  in  the 
cerebro-spinal  axis,  extending  perhaps  more  or  less  to  the  corpora-striata 
and  optic  thalami.  The  phenomena  of  the  disease  may  originate  in  two 
ways,  one  by  direct  radiation  of  irregular  nerve  force  upon  voluntary 
muscles,  bringing  them  into  irregular,  involuntary  action;  in  the  other, 
not  so  much  direct  radiation  of  irregular  nervous  influence,  as  the  loss  of 


742  CHOREA. 

the  power  of  the  cerebral  hemispheres  to  control  and  direct  voluntary 
movements.  The  latter  is  the  case  in  most  instances,  where  the  disease 
has  originated  from  mental  influences,  acting  upon  a  timid  nervous  tem- 
perament, while  the  former,  the  direct  establishment  of  irritative  influ- 
ence, is  the  predominating  pathological  condition  in  those  cases  which 
originate  from  exposure  to  cold,  wet,  and  other  causes,  which  would  favor 
the  development  of  the  rheumatic  irritation,  and  from  the  drying  up 
of  ulcers,  or  the  sudden  disappearance  of  cutaneous  eruptions.  There  is 
no  evidence  that  any,  except  well  marked  rheumatic  cases,  are  accompa- 
nied by  any  distinct  hyperEemia  or  increase  of  blood  in  the  nervous  cen- 
ters. On  the  contrary,  the  absence  of  fever  and  local  heat  in  the  head, 
the  predominance  of  paleness,  ansemia  and  dilatation  of  the  pupils,  as 
the  disease  becomes  more  severe,  all  indicate  rather  an  anasmic  condition 
of  nerve  centers,  than  anything  meriting  the  name  of  hyper^emia  or  full- 
ness. But  in  some  of  those  cases  which  originate  from  causes  tending  to 
suppress  either  natural  or  unnatural  secretions,  there  are  often  indications 
both  of  febrile  disturbance,  and  of  hypenemia  of  the  central  portion  of  the 
nervous  system. 

Diagnosis. — The  symptoins  of  chorea  after  they  have  been  once  ob- 
served are  so  characteristic  and  difl'ercTit  from  almost  every  other  variety 
of  irregular  muscular  action,  that  there  is  very  little  danger  of  mistakes 
in  diagnosis.  The  action  of  the  muscles  in  an  irregular  or  entirely  in- 
coherent manner,  at  no  time  obliterating  the  patient's  consciousness,  or 
wholly  obstructing  the  respiration,  so  as  to  produce  the  ordinary  phe- 
nomena of  convulsions,  the  recurrence  of  the  movements  every  few 
minutes,  all  tend  to  distinguish  it  from  any  form  of  general  convulsion. 
The  long  relaxation  of  the  muscles  in  the  intervals  between  the  short, 
spasmodic  jerking,  separate  it  at  once  from  all  forms  of  tetanic  rigidity, 
or  cerebral  disease  accompanied  by  ordinary  paralysis  with  a  rigidity  of 
muscles;  and  on  the  other  hand,  it  only  requires  the  observation  of  a 
single  case  to  see  a  b.oad  diflerence  between  the  muscular  movements  oc- 
curring irregularly,  first  in  one  place  and  then  in  another,  with  intervals 
of  rest  after  each  paroxysm,  and  the  steady  tremulous  shaking  of  paraly- 
sis agitans.  There  is  indeed  no  other  form  of  nervous  affection  that 
exhibits  phenomena  which,  in  their  aggregate,  have  any  near  resemblance 
to  those  of  chorea. 

Prognosis. — As  a  general  rule,  the  prognosis  in  chorea  is  favorable. 
Although  I  have  met  with  a  large  number  of  cases  of  this  disease,  and 
at  almost  all  stages  of  their  ordinary  progress,  and  in  all  grades  of 
severity,  I  have  known  no  cases  which  terminated  fatally,  and  I  think 
only  three  that  did  not  recover.  These  three  were  in  adults,  all  of  whom  be- 
fore coming  under  my  observation,  had  suffered  from  the  disease  for 
periods  varymg  from  fiiteen  to  twenty  years,  and,  at  the  time,  had  evi- 
dently become  complicated  with  symptoms  indicating  structural  change 
in  certairj  parts  of  the  spinal  cord  and  medulla  oblongata  somewhat 
similar  to  that  in  progressive  locomotor  ataxia.  Cases  that  are  brought 
under  oliservation  and  are  subject  to  proper  regulations  in  the  early 
stage,  will  always  end  in  recovery,  and  usually  within  a  period  of 
from  three  to  six  weeks. 

Treatment. — The  first  object  to  be  accomplished  in  the  treatment  of 
chorea  is,  so  far  as  possible,  to  remove  the  further  operation  of  all  such 
influences  as  might  have  constituted  exciting  causes,  or  more  properly, 
of  such  influences  as  might  have  contributed  to  the  development  of  the 
disease.  This  is  particularly  necessary  in  all  such  cases  as  have  origi- 
nated   mainly  from   mental  influences.      The  child,    if  attending  school, 


TREATMENT.  743 

should  be  at  once  removed,  if  for  no  other  reason  than  from  the  fact  that 
it  is  impossible  for  a  child  to  attend  school,  laboring  under  this  disease, 
and  not  attract  the  attention  of  the  other  scholars.  If  the  teacher  him- 
self suspects  the  nature  of  the  disease  and  treats  the  child  with  admitted 
judiciousness,  the  attention  of  other  children  will  be  constantly  attracted 
to  the  awkward  and  grotesque  movements,  and  their  observation  and  con- 
versation will  most  certainly  tend  to  perpetuate  the  disease  in  this  class  of 
patients.  Another  ol)jectioa  is,  that  there  are  liable  to  be  other  children 
of  temperaments  favorable  for  developing  the  same  disease,  and  the  pres- 
ence of  one  case  very  generally  creates  more  or  less  disposition  to  imitate 
it  on  the  part  of  others,  which  sometimes  actually  develops  the  disease  in 
the  imitators,  and  thereby  increases  the  number  of  cases  among  the 
children  thus  associated. 

After  removing  the  child  from  contact  with  other  children  as  far  as  is 
practicable,  both  in  the  school  and  in  the  neighborhood,  and  directing  that 
it  shall  be  provided  with  such  influences,  proportioned  to  its  age,  as  will 
divert  its  attention  and  promote  its  cheerfulness,  secure  for  it  some 
exercise  by  riding  and  outside  exposure,  always  in  company  with  some 
cheerful  attendant,  who  will  be  ready  to  pass  every  awkward  and  irregular 
movement  by  unnoticed.  And  the  parents  or  immediate  attendants 
should  be  strictly  enjoined  to  pass  all  irregular  movements,  blunders,  or 
accidents  that  the  child  may  make  with  as  little  notice  as  is  compatible 
with  the  sal'ety  of  the  patient,  and  that  all  mistakes  or  accidents  resulting 
from  spasmodic  movements,  either  in  attempting  to  feed  themselves  or 
to  hold  anything  in  their  hands,  should  be  overlooked  or  excused  with  a 
word  of  encouragement  and  cheerfulness.  I  speak  of  the  necessity  of 
thus  directing  the  management  of  patients  suffering  from  chorea  produced 
by  mental  influences,  from  having  frequently  observed  that  in  all  the 
working  classes  of  people,  and  indeed,  more  or  less  among  all  classes, 
there  is  great  proneness  to  a  directly  opposite  mode  of  management. 
The  anxiety  of  the  mother  causes  her  to  pay  attention  to  every  awkward 
movement,  and  in  the  earlier  stage  of  the  disease,  not  understanding  its 
nature,  until  it  has  been  aggravated  to  its  highest  degree  of  development 
by  her  chiding  and  upbraiding  or  liberally  scolding  for  almost  every 
awkward  movement  the  child  may  make.  For  the  more  the  patient  is 
scolded,  the  more  irregular  and  excited  its  movements  become.  Conse- 
quently, one  of  the  most  important  items  in  the  management  is  to  place 
the  patient  in  a  comfortable  condition  of  air  and  warmth,  a  plain  un- 
stimulating,  but  nutritious  diet,  and  in  the  immediate  care  of  judicious 
and  cheerful  companions  and  nurses.  Indeed,  this  alone  will  serve  tO' 
restore  the  larger  proportion  of  this  class  to  health  in  from  three  to  four 
weeks.  I  have  said  that  the  diet  should  be  plain,  unstimulating,  but 
sufficiently  nutritious  and  easily  digested.  The  patient  needs  a  fair 
amount  of  nutriment,  yet  the  digestive  organs  should  not  be  overtaxed, 
and  especially  with  indigestible  food.  Tea  and  coffee  should  be  either 
prohibited  or  used  sparingly;  and  no  other  so-called  stimulating  drinks 
should  be  allowed,  either  fermented  or  distilled.  Attention  should  be 
given  to  the  condition  of  the  evacuations,  both  from  the  bowels  and  the 
renal  organs,  sufficient  to  see  that  the  bowels  are  moved  naturally  and 
regularly,  but  without  the  debilitating  effects  of  physic,  and  that  the 
urinary  secretion  is  sufficiently  abundant  to  fully  separate  the  elements  of 
the  urine  from  the  blood.  In  most  instances  there  is  very  little  variation 
from  natural  in  either  the  digestive  organs  or  renal  function.  In  those 
cases  which  have  arisen  mostly  from  mental  influences,  the  medical  treat- 
ment should  have  two  objects  in  view.     One  mildly  tonic,  the  other  anti- 


744  CHOREA. 

spasmodic  or  quieting  to  irregular  nervous  action.  The  particular 
remedies  which  have  appeared  to  exert  the  most  reliable  control  over  the 
progress  of  the  disease  and  lead  to  the  earliest  recovery,  have  been 
valerianate  of  zinc,  and  liquor  potassii  arsenitis  or  Fowler's  solution.  To 
patients  between  the  ages  of  five  and  ten  years,  I  have  usually  given 
thirteen  centigrammes  (gr.  ii)  of  the  valerianate  of  zinc,  usually  in  the 
form  of  a  gelatine-coated  pill,  for  convenience  of  administration,  before 
each  meal  and  at  bed-time,  and  from  three  to  five  minims  of  the  liquor 
potassii  arsenitis  in  15  c.c,  or  a  tablespoonful  of  water  just  after  each  regular 
meal.  For  the  last  twenty  years  I  have  met  with  but  very  few  cases  of  the 
variety  of  chorea  to  which  I  am  now  alluding,  that  have  not  yielded  to  this 
treatment,  and  become  convalescent  in  from  two  to  three  weeks.  In  a 
few  instances  I  have  had  to  continue  it  four  weeks,  and  in  a  still  smaller 
number  of  cases  I  have  found  the  arsenical  preparation  to  produce  disturb- 
ance of  the  functions  of  the  stomach,  constituting  loss  of  appetite,  and  some- 
times griping  and  a  little  looseness  of  the  bowels,  and  have  been  obliged  to 
discontinue  it  on  that  account.  I  think,  perhaps,  in  two  or  three  cases  it  has 
interfered  with  the  action  of  the  kidneys,  and  led,  in  less  than  a  week 
from  the  time  it  was  commenced,  to  an  oedematous  condition  and  puffiness 
of  the  loose  tissue  under  the  eyelids  in  the  morning,  and  more  or  less  of 
oedema  about  the  tops  of  the  feet  and  ankles  during  the  afternoon 
and  evening.  Of  course  in  all  such  cases  it  was  immediately  discon- 
tinued. "When  the  arsenical  preparation  in  any  respect  disagrees  (and 
you  should  never  administer  it  without  taking  subsequent  care  to  note 
its  effects)  the  patients  frequently  will  recover  in  a  reasonable  time  under 
the  influence  of  valerianate  of  zinc  alone.  If  they  are  unusually  rest- 
less at  night,  one  moderately  full  dose  of  valerianate  of  ammonium  given 
at  bed-time,  will  both  secure  rest  during  night  and  contribute  to  steady 
the  irregular  muscular  action  during  the  following  day.  A  combination 
of  the  bromide  of  ammonium  and  hydrate  of  chloral,  in  doses  suited  to 
the  age  of  the  patient,  given  morning  and  evening,  has  sometimes  acted 
very  favorably  in  removing  the  irregular  muscular  movements,  and  at  the 
same  time  promoting  sleep  at  night.  In  those  cases  which  have  come  under 
my  observation  of  the  most  severe  character,  in  which  the  paroxysms  had 
rendered  the  patient  wholly  unable  to  walk  or  talk  or  even  to  swallow 
without  more  or  less  difficulty,  requiring  one  or  two  attendants  constantly 
to  keep  them  in  bed,  I  have  found  it  of  great  advantage  to  administer 
once  or  twice  in  the  day,  say  morning  and  evening,  a  warm  douche  upon 
the  occipital  region  and  back  of  the  neck.  The  mode  of  administration 
has  been  to  bring  the  patient's  head  and  iieck  out  from  the  front  edge  of 
the  bed,  horizontally  over  a  tub,  with  the  face  downward,  and  from  a 
pitcher  holding  one  or  two  quarts  of  warm  water,  not  hot,  but  simply 
warm  as  is  comfortable,  and,  holding  the  pitcher  from  one  to  two  feet 
above  the  head,  pour  a  continual  stream  upon  the  occipital  region  of  the 
head  and  neck.  The  position  is  such  that  the  water  runs  directly  off  into 
the  tub,  and  when  from  one  to  three  quarts  have  been  thus  poured  in  a 
steady  stream,  the  water  is  wiped  quickly  off  and  the  patient  laid 
back  upon  the  bed  to  rest.  In  most  instances  the  douche  is  followed  by 
one  or  two  hours  of  continuous  rest,  with  but  little  muscular  agitation. 
And  a  repetition  of  it  once  or  twice  a  day  during  the  week  that  the  disease 
is  at  its  climax,  or  while  it  is  approaching  its  climax,  has  seldom  failed  to 
greatly  facilitate  a  cure.  When  patients  are  very  antemic  they  may  be 
benefited  by  giving  more  or  less  of  those  preparations  which  are  regarded 
as  calculated  to  promote  nutrition,  and  especially  to  favor  the  formation 
of  red  corjouscles  of  blood.     With  such  the  arsenical  preparations  may  be 


TREATMENT.  745 

given  in  direct  conjunction  with  suitable  doses  of  the  lacto-phosphate  of  lime 
compound  syrup  of  the  hypo-phosphites,  or  with  the  compound  tincture 
of  cinchona,  which  perhaps  constitute  the  best  of  the  class  of  nutrient 
tonics  that  we  can  use  in  such  cases.  I  do  not  mention  the  preparations 
of  iron,  for  the  reason  that  in  a  majority  of  instances  in  which  I  have  tried 
them  they  have  seemed  to  me  either  to  produce  headache  after  a  few  days 
or  to  actually  increase  the  irregular  muscular  movements.  This  has  led 
me  to  think  that  iron  is  not  well  tolerated  in  that  peculiar  condition  of 
the  nervous  system  giving  rise  to  choreic  movements.  While  the  treat- 
ment that  I  have  now  mentioned  is  that  which  my  experience  has  shown 
most  successful  in  the  treatment  of  the  common  class  of  cases  of  chorea, 
those  arising  from  sudden  exposure  to  cold,  and  that  are  plainly  associated 
with  more  or  less  of  a  rheumatic  grade  of  irritation,  will  not  so  readily 
yield  to  the  same  remedies.  But  they  require  to  be  carefully  discrimi- 
nated and  early  subjected  to  the  influence  of  a  different  class  of  remedial 
agents.  Such  cases,  at  their  beginning,  while  there  is  some  feverishness, 
general  muscular  soreness,  some  degree  of  headache,  with  slight  accelera- 
tion of  pulse,  will  perhaps  be  more  promptly  benefited  by  a  solution  of  sali- 
cylate of  sodium  in  connection  with  tincture  of  cimicifuga  racemosa  and 
gelsemium,  than  by  any  other  remedies.  A  combination  of  these  three 
medicines  in  such  proportion  as  to  adjust  the  dose  of  each  to  the  age  of  the 
patient,  aiming  to  get  a  fair  but  not  exaggerated  influence,  and  given  once 
in  from  four  to  six  hours, will  usually  produce  decidedly  ameliorating  effects 
within  the  first  five  or  six  days,  and  sometimes  entire  relief  of  all  the  symp- 
toms. A  case  to  which  I  have  already  alluded  that  occurred  durino-  a 
very  early  period  of  my  practice,  in  a  boy,  who,  in  returning  frcm  his 
work  was  suddenly  chilled,  and  soon  after  attacked  with  very  severe 
chorea,  was  entirely  relieved  and  convalescence  established  bv  the  use  of 
the  warm  douche  applied  thoroughly  twice  a  day  for  the  first  three  days, 
once  a  day  afterwards,  and  the  internal  use  of  a  combination  of  the 
tincture  of  cimicifuga,  wine  of  colchicum  root  and  tincture  of  stramonium. 
Cimicifuga  has  been  recommended  by  many  in  the  treatment  of  chorea, 
but  I  am  satisfied  that  its  efficacy  is  restricted  almost  entirely  to  the 
rheumatic  class  of  cases.  And  in  those,  either  alone,  or  still  better  in  con- 
junction with  salicylate  of  sodium  and  moderate  doses  of  stramonium,  it 
will  certainly  produce  very  satisfactory  results.  Colchicum  is  particularly 
valuable  as  an  addition  to  the  treatment  in  such  cases  as  are  accompanied 
by  more  or  less  constipation  and  checking  of  the  urinary  secretion.  It 
may  be  pushed  until  it  produces  some  laxative  effect,  but  should  not  be 
carried  so  far  as  to  produce  hyper-catharsis  or  intestinal  irritation.  Many 
other  remedies  have  been  suggested  and  used  in  the  treatment  of  cases  uf 
chorea,  but  if  you  keep  in  mind  the  fact  that  the  disease  is  only  a 
functional  disturbance,  consisting  mostly  of  a  morbid  state  of  excitability 
coupled  with  a  tendency  to  ansemia,  impoverishment  of  blood  and  menta") 
depression,  and  that  your  remedies  are  to  be  adjusted  for  the  relief  of 
these,  you  will  seldom  be  at  a  loss  to  find  in  the  materia  medica  sufficient 
material  to  fulfill  the  indications  presented  by  the  disease.  You  should 
remember  that  the  earlier  cases  are  brought  under  proper  domestic  regu- 
lations, such  as  will  remove  them  from  all  causes  calculated  to  aggravate 
the  disease,  the  better  will  be  the  prospect  of  a  speedy  and  permanent 
cure.  Only  one  additional  word  in  relation  to  preventing  a  recurrence  of 
the  disease.  In  a  few  instances,  I  have  found  relapses  to  occur  by  allow- 
ing children  who  had  recovered  from  attacks  to  resume  their  school  duties 
early,  and  thereby  expose  them  to  the  same  influences  that  had  contributed 
to  develop  the  disease  at  first.     Care  should  be  exercised  in  this  re^nird, 


74:6  CATALEPSY. 

a".d  the  cliildron  either  not  allowed  to  return  to  school  till  such  time  as 
recovery  has  been  well  established,  or  what  is  better  by  far,  the  children 
should  be  placed  under  such  teachers  and  in  schools  of  such  select,  limited 
numbers,  as  will  enable  the  patients  to  enjoy  a  reasonably  judicious  men- 
tal training  and  development,  with  but  little  liability  to  exposure  to 
influences  that  would  provoke  a  return  of  the  disease. 


LECTUEE  LXXV. 


Catalepsy  and    Convulsions— Their    Clinical  History,  Pathological  Relations   and  Remedial 
Management. 

GENTLEMEN:  The  next  subject  to  which  I  will  direct  your  attention 
is  called  catalepsy.  It  is  one  of  the  most  infrequent  of  the  functional 
disturbances  of  the  nervous  system  possessing  the  characteristics  of  a  dis- 
tinct disease.  Although  occurring  very  rarely,  it  has  been  recognized  and 
described  from  a  remote  period  of  medical  history.  Ic  occurs  most  fre- 
quently during  the  period  of  youth  and  the  early  part  of  adult  life,  and 
seems  in  nearly  the  same  ratio  of  frequency  in  both  sexes.  The  causes 
of  the  disease  are  not  well  ascertained,  although  particular  cases  have 
been  found  to  originate  from  malarious  influences,  and  to  exhibit  distinct 
periodicity  in  the  recurrence  of  the  paroxysms;  others  have  been  apparent- 
ly developed  by  strictly  mental  influences,  such  as  strong  mental  emotions; 
and  in  others  no  direct  exciting  cause  has  been  traced.  An  excitable,  or 
what  is  recognized  as  a  nervous  temperament,  coupled  with  more  or  less 
anaemia,  or  impoverishment  of  blood,  and  also  such  mental  conditions  as 
cause  a  predominance  of  despondency  or  melancholia  are  regarded  as 
predisposing  causes.  This  disease,  though  presenting  symptoms  during 
Its  more  positive  manifestations  or  paroxysms,  somewhat  uniform  and 
characteristic,  is  evidently  closely  related  in  some  instances  to  hysteria, 
in  others  to  particular  forms  of  insanity,  while  in  other  and  very  rare  in- 
stances, it  seems  to  depend  upon  the  action  of  malaria  on  a  peculiar  prior 
condition  of  the  nervous  system.  And  hence  the  cases  met  with  in  prac- 
tice may  be  grouped  into  three  classes:  the  malarious,  hysterical  and 
psychical,  or  such  as  are  associated  more  or  less  with  mental  derana  ements. 
Symptoms. — Most  cases  of  catalepsy  occur  in  paroxysms,  entirely  irreg- 
ular as  to  the  time  of  their  recurrence,  and  generally  commence  sud- 
denly, with  no  well-marked  premonitory  or  prodromic  symptoms.  In  some 
of  the  cases,  however,  a  marked  development  of  symptoms  is  preceded 
for  one,  two  or  three  days  by  unusual  taciturnity  of  mind,  indisposition  i 
to  converse,  with  insomnia,  or  disturbed  sleep  at  night.  In  other  cases 
the  paroxysms  have  been  preceded  b}^  unusual  hilarity,  nervous  excitabil- 
ity, and  a  ra{)id  passage  of  emotions  from  one  extreme  to  another.  But 
in  the  larger  majority  of  cases  the  development  of  catalepsy  occurs  sud- 
denly, and  consists  mainly  in  a  suspension  of  cerebral  consciousness 
coupled  with  general  rigidity  of  the  voluntary  muscular  system,  leaving 
the  patient  in  a  condition  apparently  oblivious  to  surrounding  objects  or 
conditions,  manifesting  no  apparent  consciousness  either  to  the  touch  or 
to  the  infliction  of  external  injuries,  or  to  the  observation  of  conversations 
that  may  take  place  in  their  presence.     But  the  muscular  rigidity  is  of 


SYMPTOMS.  747 

such  a  character  that  the  flexors  and  extensors  are  usually  evenly  bal- 
anced, leavinor  the  patient  directly  in  the  attitude  in  which  the  attack 
supervened,  whether  standinjr,  sitting  or  recumbent,  as  though  the  mus- 
cular system  had  suddenly  assumed  an  entire  fixed  condition,  olFering  a 
certain  degree  of  resistance  to  all  attempts  to  move  the  patient  from  the 
attitude  in  which  the  attack  supervened.  Muscular  rigidity,  however,  will 
usually  yield  gradually  to  moderate  force,  allowing  the  limb  to  be  raised, 
lowered,  or  moved  in  any  direction,  not  suddenly  by  muscular  action,  but 
as  though  it  were  the  yielding  of  an  inelastic  body  to  superior  force,  and 
the  part  remains  in  whatever  position  it  may  be  placed  by  such  force. 
This  maintaining  its  position,  liowever,  in  any  particular  attitude  in  which 
a  part  may  be  placed  is  not  permanent.  For  instance,  if  the  arm  or  limb 
be  raised  or  extended  and  left  unsupported,  while  it  retains  its  position 
for  a  time,  usually  after  ten  to  twenty  or  tliirty  minutes  it  slowly,  without 
tremor  or  vacillation,  yields  to  the  force  of  gravity  until  it  reaches  a  point 
of  support.  But  for  a  brief  time  the  limbs  or  body  may  be  molded  into 
almost  any  shape,  and  they  retain  for  a  time  the  position  in  which  they  may 
be  placed.  In  two  cases  of  a  strongly  marked  cataleptic  character  occurring 
under  my  observation  in  the  Mercy  Hospital,  at  different  periods  of  time, 
the  rigidity  of  the  muscular  system  was  well  marked,  and  the  suspension 
of  consciousness,  or  incapability  of  receiving  external  impressions,  was 
such  that  no  manifestations  were  obtained  by  the  most  varied  efforts  and 
experiments;  and  the  house  physician  at  that  time,  although  expert  in 
devising  measures  for  testing  the  reality  of  the  apparent  suspension  of 
consciousness,  as  well  as  fixedness  of  the  musuclar  condition,  tried  many 
expedients,  including  electricity,  without  producing  the  slightest  apparent 
effect. 

In  these  cases  the  paroxysm  continued  in  one  five  or  six  days,  and  in 
the  other  between  two  and  three  weeks.  In  the  great  majority  of  cases, 
however,  the  paroxysms  of  unconsciousness  and  muscular  rigidity  are  of 
shorter  duration.  In  some  they  remain  only  for  a  few  minutes,  in  others 
one  to  three  hours  and  from  that  up,  as  I  have  intimated,  to  as  many 
weeks.  Of  course,  in  those  cases  where  the  suspension  of  consciousness  and 
rigidity  remain  more  than  a  single  day,  there  is  danger  of  progressive 
exhaustion  from  inability  to  nourish  the  patient  without  resorting  to  more 
or  less  forcible  means  for  that  purpose.  In  almost  all  cases  the  paroxysms 
of  this  unconsciousness  and  rigidity  cease  almost  as  suddenly  as  they 
supervene.  The  patients  often  appear  as  though  they  had  just  awakened 
out  of  a  profound  sleep,  and  not  infrequently  yawn  once  or  twice,  look 
about  them  as  though  in  a  strange  place,  and  present  all  the  expressions 
and  movements  of  those  who  had  recovered  wakefulness  directly  from  a 
protracted  state  of  oblivious  sleep.  They  usually  resume  their  move- 
ments, however  slowly,  and  exhibit  a  considerable  degree  of  feebleness 
during  the  first  few  hours,  and  sometimes  for  one  or  two  days,  if  the 
paroxysm  has  been  protracted.  There  are  various  degrees  of  severity  in 
the  paroxysms  of  catalepsy.  Some  of  the  cases  that  have  been  termed 
catalepsy,  and  (described  as  such,  might  better  have  been  termed  instances 
of  simple  trance,  being  temporary  suspensions  of  consciousness,  with 
little  or  no  true  muscular  rigidity.  While  in  the  cataleptic  paroxysms 
the  muscular  rigidity  is  restricted  essentially  to  the  nerves  and  muscles  of 
voluntary  motion;  there  is  at  the  same  time  a  diminished  action  in  some 
of  the  involuntary  movements.  Respiration,  for  instance,  is  usually  per- 
formed much  less  efficiently  than  in  the  natural  condition.  In  those  cases 
that  have  come  under  my  own  observation  the  ordinary  respiratory  move- 
ments in  the   paroxysms  have   been  so  inefficient  that   it  required  close 


748  piAGNOSis*> 

watching  to  observe  any  expansion  and  contraction  of  the  chest,  or  the. 
ordinary  motions  of  inspiration  and  expiration.  While  this  was  the  case, 
however,  with  the  ordinary  respirations,  every  few  minutes  this  inefficiency, 
was  compensated  for  by  a  single,  slow,  long  inspiration,  resembling  a  sigh. 
And  this  sigh  or  extra  respiratory  movement  constituted  the  strongest  in-, 
dication  of  the  patient's  capacity  to  move  that  was  observable  during  the 
paroxysm.  The  face  is  usually  pale,  the  extremities  cool,  pulse  soft  and 
easily  compressed,  but  nearly  of  the  natural  frequency.  In  those  cases 
which  are  dependent  for  a  direct  exciting  cause  upon  malaria,  the  ter- 
mination of  the  paroxysm  is  usually  accompanied  by  temporary  sweating,, 
and  sometimes  it  is  begun  by  a  noticeable  coldness  and  blueness  of  the 
lips  and  nails,  as  though  there  was  a  slight  semblance  of  a  chill. 

Pathology. — Catalepsy  being  a  very  rare  disease,  and  the  cases  that 
have  occurred  rarely  terminating  fatally  unless  when  associated  with  cere- 
bral disease,  or  some  of  the  forms  of  insanity,  there  have  thus  far  been  dis- 
covered no  characteristic  appreciable  lesions  of  the  nervous  centers,  on 
which  the  phenomena  could  be  said  to  depend.  And  it  is  probable  that 
uncomplicated  catalepsy  is  purely  a  functional  disturbance  of  the  nervous 
centers,  consisting  in  the  temporary  loss.of  cerebral  recognition,  or  mental 
perception  of  outward  impressions,  with  coincident  radiation  of  sufficient 
nervous  influence  through  the  nerves  connected  with  the  voluntarj'  mus- 
cular system  to  hold  that  system  in  a  state  of  rigidity,  in  equipoise,  or 
fixedness.  Some  writers  have  suggested  that  contraction  of  the  muscular 
fibers  was  the  natural  condition  of  that  structure,  and  style  rigidity  as  the 
natural  muscular  tonus,  and  endeavor  to  explain  the  general,  equal  rigid- 
ity of  the  whole  voluntary  muscular  system,  on  the  supposition  that  the 
nervous  force  commanding  muscular  movements  and  muscular  action  is 
like  that  of  the  cerebral  function,  suspended.  And,  instead  of  the  nerv- 
ous impression  commanding  muscular  rigidity,  it  is  simply  a  withdrawal 
or  temporary  suspension  of  all  nervous  influence,  allowing  the  muscular 
structures  to  resume  their  supposed  natural  tonus,  in  a  fixed  or  rigid  state. 
The  difficulty,  however,  with  this  theory  is,  that  the  fundamental  proposi- 
tion of  the  existence  of  a  natural  muscular  tonus  has  no  adequate  proof. 
It  must  be  confessed  that  it  is  difficult  in  the  present  state  of  our  knowl- 
edge, to  furnish  a  satisfactory  explanation  of  all  the  phenomena  or 
symptoms,  which  constitute  an  attack  of  catalepsy.  That  it  is  a  functional, 
disturbance,  not  involving  necessarily  structural  changes,  is  quite  evident 
from  the  readiness  with  which  paroxysms  come  on,  and  the  equal  readiness 
with  which  they  pass  ofi",  and  the  almost  universal  tendency  to  recovery, 
or  at  least  to  avoid  fatal  consequences. 

Diagnosis. — The  simple  description  of  the  symptoms  which  I  have  given 
you  furnishes  the  best  means  for  diagnosis.  There  is  no  other  form  of 
disease  that  gives  the  same  assemblage  of  symptoms,  namely,  the  coinci- 
dence of  suspended  cerebral  recognition  of  impressions  from  without, 
with  a  steadily  balanced  and  continuous  state  of  rigidity  of  the  voluntary 
muscular  system.  Tetanus,  hysteria,  and  all  the  various  forms  of  irreg- 
ular muscular  action,  are  more  particularly  paroxysmal,  and  are  associated 
with  other  coincident  phenomena,  entirely  difi"erent  from  that  of  cat- 
alepsy. In  simple  trance,  and  in  the  various  conditions  of  peculiar  mental 
emotion  that  are  sometimes  observed,  there  is  lacking  the  muscular  tonus, 
or  rigidity,  which  belongs  to  the  cataleptic  state. 

Prognosis. — As  I  have  already  stated,  the  prognosis  having  reference, 
to  the  amount  of  danger  to  the  life  of  the  patient,  may  be  said  to  be  favor- 
able in  all  cases  that  are  not  complicated  with  mental  diseases,  or  some 
form  of  insanity;  but,  so  far  as  relates  to  the  prospect  of  recovery  in  the 


TREATMENT.  749 

sense  of  being-  exempt  from  liability  to  recurrence  of  paroxysms  from  time 
to  time,  the  prognosis  is  not  so  favorable;  there  being  a  strong  tendency 
in  the  disease  to  an  irregular  recurrence  of  attacks,  in  some  at  long  inter- 
vals and  in  others  more  frequently,  especially  when  the  patient  has  passed 
the  period  of  puberty.  If  it  is  certain  that  the  paroxysms  depend  for  their 
exciting  cause  upon  malarious  influence,  the  prognosis  is  decidedly  favor- 
able. Such  cases  are  usually  permanently  cured,  first,  by  antiperiodics  to 
interrupt  the  paroxysms,  and  subsequently  by  proper  attention  to  the  im- 
provement of  the  general  health  and  tone  of  the  nervous  system.  When 
they  occur  at,  or  before  the  period  of  puberty,  proper  attention  to  their 
physical  and  mental  training  continued  for  one,  two  or  three  years  will 
usually  destroy  their  liability  to  recurrence  of  attacks  and  secure  for  them 
a  permanent  recover3^ 

Treatment. — The  treatment  evidently  divides  itself  into  two  parts: 
that  which  is  required  during  the  paroxysm,  or  the  continuance  of  the  at- 
tack, and  that  which  is  necessary  for  preventing  its  recurrence.  In  cases 
where  the  patient  has  already  passed  through  one  or  more  paroxysms,  and 
it  has  thus  been  ascertained  that  they  are  of  temporary  duration  it  is  not 
desirable  to  institute  decided  and  active  measures  of  treatment  till  the 
paroxysm  has  passed  by.  But  if  the  paroxysm  is  more  lasting,  extending 
any  period  beyond  twenty-four  hours,  some  measures  may  be  resorted 
to  with  the  hope  of  shortening  its  duration,  and  thus  restoring  the  patient's 
abilitv  to  take  nourishment  before  material  exhaustion  has  taken  place. 
Among  the  expedients  that  are  perhaps  most  likely  to  terminate  the 
paroxysm,  are  sudden  dashing  of  cold  water  upon  the  face  and  naked 
chest,  which  sometimes  will  bring  a  sudden  inspiratory  effort  coupled  with 
an  immediate  return  of  consciousness  and  ending  of  the  paroxysm.  Mod- 
erate electric  shocks  will  sometimes  succeed  in  producing  some  effect. 
Both,  however,  have  frequently  been  found  ineffectual,  and  all  other  simi- 
lar expedients.  Sometimes  the  administration  of  enemas,  containing  such 
remedies  as  assafoetida,  valerian,  camphor,  or  almost  any  of  this  class  of 
antispasinodics  and  stimulants,  have  been  found  sufficient  to  arouse  the 
patient,  and  end  the  paroxysm.  In  the  two  cases  to  which  I  have  alluded 
in  the  hospital  none  of  these  expedients  had  any  effect.  In  one  of  them, 
milk  or  any  item  of  liquid  food,  when  the  -underjaw  could  be  depressed 
sufficiently  by  a  moderate,  steady  pressure  to  allow  nourishment  to  be 
placed  far  back  upon  the  tongue,  would  be  swallowed  slowly,  but  some- 
times with  difficulty  and  some  danger  of  choking.  But  it  was  tedious 
and  difficult  to  administer  enough  to  adequately  sustain  the  patient. 
Enemas  of  milk  and  beef  tea  were  generally  retainetl  when  given  in 
quantities  not  exceeding  90  or  120  cubic  centimeters  (fl,  ^iii  to  riv)  at  a 
time,  and  constituted  the  principal  dependence  for  nourishment.  In  the 
patient  in  whom  the  paroxysm  continued  beyond  the  second  week  and 
symptoms  of  exhaustion  became  strongl}'  marked  notwithstanding  the 
efforts  to  nourish  him  by  enemas,  I  found  great  difficulty  in  getting  his 
mouth  sufficiently  open  to  place  anything  upon  the  back  part  of  the 
tongue.  It  appeared  to  me  that  it  was  one  of  the  cases  closely  allied  to 
insanity  as  it  had  been  preceded  for  a  considerable  time  by  melancholia. 
The  difficulty  of  administering  nourishment  by  the  mouth  appeared  to  be 
increased  by  some  voluntary  resistance  added  to  the  rigidity  constantly 
existing.  But  the  necessity  for  more  nourishment  became  so  urgent  that 
the  nurse  and  house  physician  proposed,  at  one  of  my  visits,  that 
we  forcibly  introduce  the  stomach  tube  and  pour  nourishment  into  the 
stomach.  Being  satisfied  from  what  I  could  learn  of  the  history  of  the 
patient  that  there  had  been  some  indication  of  mental  derangement,  it 


750  CATALEPSY. 

occurred  to  me  that  possibly  a  little  strateo^y  mi^ht  be  valuable,  and 
after  talking  freely  by  the  bedside  about  the  necessity  of  resorting  to  forci- 
ble administration  of  nourishment  in  the  manner  I  have  just  suggested, 
I  made  the  remark,  that  if  there  was  no  change  by  the  next  day  we  would 
resort  to  it,  but  would  postpone  it  that  long.  As  we  stepped  beyond  the 
hearing  of  the  patient,  I  instructed  the  nurse  to  do  as  he  had  been  in  the 
habit  of  d  )ing  every  day,  i.  e.,  bring  the  patient  nourishment,  make  some 
little  effort  to  feed  him,  but  without  much  persistence,  and  then,  as  if 
doing  it  carelessly,  or  by  accident,  in  the  evening  leave  a  bowl  of  milk 
upon  a  stand  directly  at  the  bedside  of  the  patient,  where  it  could  be 
easily  reached,  if  the  patient  were  disposed  to  reach  it  during  the  night. 
This  was  done,  and  the  next  morning  the  milk  was  gone,  with  reasonable 
certainty  that  no  one  else  had  meddled  with  it  but  the  patient.  For  three 
or  four  successive  evenings  the  milk  was  left  in  a  similar  way,  and  uni- 
formly disappeared  before  morning,  at  the  end  of  which  time,  the  patient 
was  found  early  in  the  morning  out  of  bed,  standing  motionless  as  a 
statue,  in  undress,  gazing  at  a  picture  upon  the  wall.  He  was  persuaded 
with  a  little  assistance,  again  to  resume  his  bed,  and  from  that  time  oii 
slowly  recovered  his  perceptions,  and  with  apparent  reluctance  took 
nourishment,  and  became  better  from  day  to  day,  and  in  about  four  weeks 
more  had  regained  a  fair  degree  of  strength.  And  although  decidedly  in- 
disposed to  talk  much,  he  left  the  hospital  apparently  sane,  and  in  a  pretty 
good  physical  condition.  The  treatment  which  is  required  in  the  inter- 
vals between  the  paroxysms  of  a  case  of  catalepsy  must  be  varied  to  suit 
each  individual  case.  Where  the  patient  is  under  malarious  influence,  the 
prompt  use  of  efficient,  though  not  exaggerated  doses  of  antiperiodics 
mild  tonics,  easily  digestible  food,  passive  exercise  in  the  open  air  by 
riding,  and  avoiding  direct  physical  fatigue,  constitute  the  means  which  will 
usually  speedily  restore  such  patients  to  entire  health.  In  those  instances 
that  prove  to  be  connected  with  mental  disease,  there  is  almost  always 
n)ore  or  less  structural  change  in  some  portion  of  the  brain,  and  usually 
all  treatment  proves  only  palliative,  so  far  as  restoring  the  patient's  health, 
and  the  cerebral  disease  goes  on  to  its  usually  fatal  result,  whether  the  cat- 
aleptic paroxysms  continue  to  recur  or  not.  The  treatment  of  such  cases 
must  be  governed  entirely  by  the  indications  afforded  by  the  accompanying 
form  of  cerebral  or  cerebro-spinal  disease.  There  are  cases,  however,  that 
are  neither  influenced  by  malaria,  nor  by  organic  structural  changes,  but 
are  more  allied  to  hysteria,  in  which  the  two  leading  objects  of  the 
treatment  in  the  intervals,  will  be  to  diminish  the  morbid  excitability  of 
the  nervous  system,  on  the  one  hand;  and  to  support  strength  and  func- 
tional regularity,  especially  in  reference  to  digestion,  assimilation,  nutri- 
tion and  regularity  of  excretory  actions,  on  the  other,  as  the  best  and 
surest  means  of  preventing  a  recurrence  of  the  cataleptic  paroxysms. 
Good  air,  moderate  outdoor  exercise  in  proportion  to  the  strength  of  the 
patient,  encouraging  and  cheerful  mental  influences  where  it  is  practica- 
ble, and  change  from  the  interior  to  the  sea-shore  in  the  summer,  and 
especially,  in  all  cases,  such  measures  as  tend  to  give  cheerfulness  and 
mental  courage,  and  light  but  varied  occupations,  will  be  found  of  much 
benefit. 

Co7ividsions. — Although  there  is  no  disease  of  the  nervous,  system 
which  can  be  properly  designated  convulsive,  or  justify  the  use  of  the 
word  convulsion,  to  indicate  any  particular  disease,  yet  a  few  words  in 
regard  to  convulsions  in  the  abstract  may  not  be  unprofitable.  General, 
irregular  muscular  contractions,  or  what  are  termed  clonic  spasms,  or  fits, 
are  simply  symptoms  of  some  prior  or  coincident   pathological   condition, 


CONVULSIONS.  7ol 

and  not  a  distinct  disease.  The  convulsive  affections  that  we  meet  with 
may  be  arranged  under  various  heads,  according  to  the  pathological  con- 
ditions, or  diseases  on  which  they  depend.  Most  writers  speak  of  infan- 
tile convulsions,  hysterical,  puerperal,  renal,  and  epileptiform  convulsions. 
The  latter  I  have  already  sufficiently  considered,  in  the  remarks  upon 
epilepsy.  The  renal  convulsions,  by  which  are  meant  convulsions  depend- 
ent upon  retention  of  the  elements  of  urine  acting  upon  the  nervous 
ce  iters,  I  have  also  sufficiently  considered  in  connection  with  inflamma- 
tory diseases  of  the  kidneys.  Puerperal  convulsions,  many  cases  of  which 
are  closely  allied  to  the  renal,  are  fully  considered  in  works  upon  gyne- 
cology and  obstetrics,  and  are  not  considered  as  within  the  domain  of 
practical  medicine.  The  hysterical,  will  be  more  appropriate  under  the 
head  of  hysteria,  to  which  I  shall  soon  direct  your  attention. 

This  leaves  me  only  what  has  been  styled  infantile  convulsions  for 
brief  consideration  at  the  present  time.  And  even  a  large  part  of  the 
cases  of  infantile  convulsions  may  be  traced  to  one  of  the  preceding 
classes.  Not  a  few  of  the  convulsions  that  occur  in  infancy,  although 
not  often  recognized  as  holding  that  relation,  are  nevertheless  strictly 
epileptic,  recurring  at  intervals  of  one,  two,  three,  or  six  months,  some- 
times in  single  paroxysms,  sometimes  in  two,  three,  or  four  paroxysms,  in 
quick  succession.  These  patients  speedily  recover,  and  go  on  again 
without  any  apparent  cerebral  lesion,  or  associate  morbid  condition. 
Consequently  parents  and  sometimes  the  physician  come  to  regard  them 
as  dependent  on  some  temporary  cause.  If  it  is  before  the  teeth  have 
all  come  through,  most  of  them  will  be  referred  to  the  supposed  progress 
of  some  one  or  more  teeth  that  are  crowding  upon  the  gums.  If  there  is 
no  opportunity  to  render  this  cause  available,  worms  will  be  called  into 
requisition  as  irritating  the  alimentary  canal;  yet  I  have  never  seen  a 
case  in  which  worms  were  procured  by  any  quantity  of  worm  medicines 
administered  to  this  class  of  subjects.  The  truth  is,  however,  that  the 
cases  to  which  I  now  allude,  and  that  begin  often  as  early  as  six  months 
of  age,  and  make  their  appearance  more  or  less  approximating  to  regu- 
larity once  in  three,  four,  or  six  months,  are  true  epileptiform  convulsions 
in  infancy  and  childhood.  Sometimes,  although  disappearing  from  the 
third  or  fourth  years  of  age  up  to  that  of  puberty,  and  re-appearing  at  pu- 
berty, the  spasms  then  are  for  the  first  time  recognized  as  epileptiform, 
and  in  many  of  the  cases  without  any  recollection  of  the  paroxysms 
suffered  in  infancy.  Such  cases  require  the  same  remedies,  adminis- 
tered under  the  same  general  principles  of  treatment  that  I  have  already 
given  you  as  applicable  to  cases  of  epilepsy  generally.  And  it  is  desirable 
that  you  pay  close  attention  to  every  case  of  convulsions  that  occurs  in 
young  children,  and  disappears  leaving  no  marked  symptoms  of  serious 
cerebral  lesion,  and  recurs  again  without  adequate  cause  at  some  stated 
period  of  time;  because,  if  recognized,  and  put  upon  such  regimen  and 
remedies  as  are  known  to  produce  the  most  effect  in  controlling  epileptic 
disease,  there  is  the  best  chance  of  effecting  a  permanent  cure.  There 
are  also  some  cases  in  childhood,  or  even  in  infancy,  in  which  convulsions 
depend  upon  inadequate  elimination  of  the  urinary  secretion,  and  are 
true  uraemic  convulsions. 

It  is  frequently  the  case  that  convulsions  have  occurred  for  the  first 
time  in  infants  and  young  children  during  the  period  of  convalescence 
from  attacks  of  the  eruptive  fevers.  Aside,  however,  from  these  cases,  we 
meet  with  convulsive  attacks  in  children  of  more  or  less  severity,  that  can 
not  be  referred  to  any  other  than  temporary  causes  acting  upon  a  peculiar 
susceptibility  of  the  cerebro-spinal   nervous  centers,  more  especially  that 


752  CONVULSIONS. 

jjart  of  the  cerebro-spinal  axis  which  is  related  to  the  voluntary  muscular 
system,  and  the  voluntary  nerves  of  sensation.  There  are  many  infants 
and  young  children  in  whom  there  is  undue  excitability  in  this  portion  of 
the  nervous  apparatus,  and  trifling  causes  of  an  irritative  or  exciting 
character  are  liable  to  bring  them  into  paroxysms  of  general  convulsive 
movements.  Children  born  of  scrofulous  or  tuberculous  parents,  are  per- 
haps more  liable  to  have  this  peculiar  excess  of  excitability  in  the  nervous 
system  than  any  others.  Next  to  these  are  children  born  of  parents  who 
are  themselves  subject  to  hysteria  or  epilepsy,  and  have  themselves  in- 
herited what  might  be  called  a  hysterical  temperament.  Those  born  of 
scrofulous  or  tuberculous  parents  in  addition  to  the  morbid,  excitability 
favoring  the  ready  development  of  convulsive  paroxysms,  present  also  a 
strong  tendency  to  more  or  less  permanent  hyperaemia  of  the  membranes 
and  surface  of  the  brain,  which,  if  not  carefully  and  persistently  counter- 
acted, is  liable  to  terminate  in  efPusion,  constituting  a  form  of  hydrocepha- 
lus, which  will  terminate  fatally  at  some  future  period,  either  with  or 
without  the  development  of  miliary  tubercles  in  the  membranes  and  surface 
of  the  brain.  Those  infants  and  young  children  that  possess  what  I  have 
styled  as  the  hysterical  excitability  of  the  nervous  system,  either  by  inherit- 
ance or  otherwise,  are  liable  to  be  attacked  with  general  convulsions  when- 
ever any  temporary  causes  are  brought  to  bear  sufficient  to  produce  fever  or 
increase  of  temperature  and  rapidity  of  circulation,  such  as  the  superven- 
tion of  scarlatina,  variola,  or  even  more  transient  fevers,  and  on  the  other 
hand  by  the  occurrence  of  any  causes  that  act  slowly  but  persistently  on 
the  peripheral  extremities  of  the  sentient  nerves,  whether  spinal  or 
ganglionic.  It  is  in  this  class  of  young  children  that  we  every  now  and 
then  find  a  paroxysm  of  violent  general  convulsions  on  the  first  develop- 
ment of  the  febrile  symptoms,  which  usher  in  any  one  of  the  eruptive  or 
general  fevers.  It  is  in  the  same  class  that  temporary  derangements 
of  digestion  from  taking  indigestible  food,  or  the  presence  of  worms  or  any 
species  of  irritative  influence  in  the  alimentary  canal,  acting  upon  the 
sentient  nerves  of  organic  life,  produce  convulsions. 

In  the  same  class  of  children  after  they  have  passed  the  period  of  in- 
fancy, between  three  and  five  or  six  years  of  age,  strong  mental  excite- 
ment, constant  fear,  injudicious  and  violent  chastisement,  will  not  in- 
frequently cause  the  development  of  convulsive  paroxysms.  Yet,  in  all 
this  class  of  cases  the  convulsions  are  usually  of  brief  duration,  and  not 
often  repeated,  or  more  than  one  paroxysm  at  a  time.  The  patient  usually 
recovers  quickly  and  fully  from  the  attack,  thus  distinguishing  them  from 
cases  that  depend  upon  cerebral  disease,  in  which,  when  the  convulsive 
paroxvsm  passes  away,  the  patient  is  still  left  with  moderate  fever,  and 
other  symptoms  of  cerebral  disturbance.  It  is  not  necessary  to  absorb 
your  time  with  a  description  of  what  is  usually  called  a  convulsion  or  fit. 
The  sudden  suspension  of  consciousness,  the  characteristic  irregular  mo- 
tions of  the  eyeball,  jerking  of  the  muscles  of  the  face,  choking  in  the  neck 
as  if  strangulating,  are  followed  in  a  few  seconds  by  general  clonic 
spasms.  The  suspension  of  respiratory  movements,  causes  the  lips  and 
face  to  become  turgid  with  dark  venous  blood,  finally  ending  in  a 
gradual  relaxation,  until  in  a  few  seconds  more  the  muscular  rigidity  is 
gone  and  the  patient  lies  as  if  in  a  sleep,  although  breathing  stertorously 
from  the  accumulation  of  phlegm  that  has  taken  place  in  the  mouth  and 
fauces  during  the  time  of  the  general  convulsive  movements.  So  strik- 
ing is  this  assemblage  of  symptoms  that  even  non-professional  persons  at 
once  style  them  a  convulsion  or  "  fit."  The  patient  left  alone  lies  as  if  in 
a  sleep  for  a  period  varying  from  a  few  minutes  to  half  or  three  quarters 


SYMPTOMS.  700 

of  an  hour,  hut  on  awakening,  speedily  recovers  from  d,ll  had  symptoms, 
unless,  after  the  hiooJ  has  again  become  well  oxygenized  and  decarbon- 
ized, a  second  paroxysm  should  supervene.  These  phenomena  are  so  fa- 
miliar and  characteristic,  as  constituting  a  convulsive  paroxysm,  that  it  is 
unnecessary  to  describe  their  variations  or  their  degrees  of  severity.  As 
you  will  infer  from  what  has  already  been  stated,  the  essential  patholog- 
ical condition  is  the  morbid  excitaljility,  or  susceptibility  of  the  cerebro- 
spinal nervous  centers,  acted  upon  by  some  temporary  excitino-  cause.  The 
treatment,  as  in  cases  of  catalepsy,  divides  itself  into  that  which  is  neces- 
sarv  during  the  paroxysms,  and  that  which  is  required  after  the  paroxysm 
lias  passed  by,  to  prevent  its  recurrence  and  restore  the  patient  more  fully 
to  a  normal  or  healthy  condition. 

Most  convulsions  are  so  temporary  in  their  duration,  so  completely  and 
necessarily  self-limited,  that  the  treatment  really,  during  the  convulsion, 
is  of  no  value.  But  the  terror  of  parents,  nurses,  and  attendants,  at  the 
primary  appearance  of  the  convulsive  movement  is  such,  that  the  most  rapid 
and  instantaneous  efforts  are  made  to  apply  remedies  with  the  expecta- 
tion of  relieving  the  patient.  Of  course,  with  most  of  the  people,  what- 
ever remedies  happen  to  be  in  use  at  the  time  the  paroxysm  subsides  gets 
the  credit  of  having  stopped  the  "fit,"  when  in  ninety-iiine  cases  in  a 
hundred  it  had  no  influence  whatever.  In  fact,  a  general  convulsion 
must  necessarily  be  self-limited  in  its  duration.  Suspending,  as  it  does, 
respiratory  movements,  checking  the  oxygenation  and  decarbonization  of 
the  blood,  the  rapid  accumulation  of  carbonic  acid  gas  in  the  blood 
and  the  exclusion  of  oxygen,  quickly  puts  the  blood  in  a  condition  capable 
of  producing  the  most  reliable  and  speedy  sedative  effect  upon  the  nerve 
excitability  that  could  be  found,  and  consequently  furnishes  its  own 
remedy,  so  far  as  the  continuance  of  the  convulsive  paroxysms  is  con- 
cerned. Still,  for  the  simple  effect  upon  the  attendants,  it  is  well  enough 
to  apply  cold  cloths  to  the  head,  warmth  to  the  feet,  sinapisms  to  the  cen- 
tral part  of  the  spine  between  the  shoulders,  and  near  the  junction  of 
the  back  with  the  neck,  and  on  the  center  of  the  epigastrium;  these  sina- 
pisms should  not  be  left  long  enough  to  actually  Ijlister,  but  simply  to 
produce  temporary  external  irritation.  If  the  convulsion  is  repeated  as 
soon  as  the  patient  has  fairly  recovered  consciousness  and  re-oxygenation, 
it  may  be  desirable  to  help  shorten  the  paroxysm  by  the  inhalation 
of  a  few  drops  of  chloroform,  or  some  other  anaesthetic.  And  yet 
even  this  is  deceptive  in  its  supposed  effects,  for  if  the  patient  can  breathe 
enough  to  take  efficiently  an  aneesthetic  into  the  lungs,  he  gets  breath 
enough  to  quickly  stop  his  paroxysm.  It  has  the  advantage  of  appear- 
ing to  be  doing  something,  and  earns  for  the  physician  the  confidence  of 
the  family,  by  having  it  appear  that  the  use  of  the  ansesthetic  was  quickly 
followed  by  a  subsidence  of  the  paroxysm  itself.  But  while  paroxysms 
of  convulsions  in  children,  especially  those  that  we  have  now  more  partic- 
ularly under  consideration,  not  dependent  upon  urgemic  poisoning  or 
retention  of  any  tox?emic  agents  in  the  blood,  but  dependent  directly 
upon  nervous  excitability  aggravated  by  some  temporary  exciting  cause, 
quickly  subside,  the  treatment  for  preventing  their  recurrence  has  two 
clear  objects  to  be  accomplished:  one  is  the  removal,  as  speedily  and  fully  as 
possible,  of  whatever  may  have  acted  as  a  direct  exciting  cause  of  the 
convulsion.  If  there  is  actually  a  swollen  and  tender  gum,  it  may  be 
incised  by  a  clear,  straight  cut  across  the  top  of  the  tooth,  sufficient  to 
completely  sever  the  gum  over  the  tooth.  But  in  my  experience  I  have 
found  very  few  instances  where  the  slightest  evidence  of  swollen  gums 
existed  as  the  exciting  cause  of  the  convulsion.     If  there  be  gastric    or 

4S 


754  CONVULSIONS. 

intestinal  irritation  or  derangement  from  any  cause,  tliis  should  be  care- 
fully corrected  as  early  as  practicable.  If  the  child  be  a  little  older,  and 
subject  to  undue  mental  excitement,  passions,  or  emotions  of  fear  from 
injudicious  management  on  the  part  of  parents,  or  anything  connected 
with  the  family  itself,  the  physician  should  point  it  out  and  require  it  to  be 
obviated.  Thus,  wherever  the  exciting  cause  can  be  traced  it  should  be 
as  accurately  and  fully  removed  as  circumstances  will  permit.  Having 
removed  the  exciting  cause,  the  next  and  equally  important  object  is  to 
overcome  the  undue  excitability  of  the  nervous  system,  which  constitute 
the  predisposition.  This  will  often  require  close  attention  on  the  part  of 
the  practitioner  and  a  full  explanation  to  the  parents,  in  order  to  secure 
the  necessary  attention  for  a  sufficient  length  of  time.  The  common  tend- 
ency in  all  such  cases  is  to  regard  the  patients  cured  as  soon  as  they 
cease  to  have  convulsions  and  are  able  to  take  their  usual  food,  and  are 
free  from  immediate  symptoms  of  disease.  Consequently  they  become 
speedily  careless  about  the  administration  of  medicine,  and  the  carrying  out 
of  good  hygienic  measures  which  may  be  essential  for  properly  overcoming 
the  constitutional  morbid  tendency.  Therefore,  to  secure  success  in  this 
part  of  the  treatment,  which  often  requires  to  be  pursued  for  months  or 
even  for  years,  an  intelligent  explanation  should  be  given  to  the  parents 
arid  a  proper  course  insisted  upon.  For  permanent  effect,  great  importance 
must  be  attached  to  the  mode  of  living,  including  diet,  exercise,  clothing, 
even  m.ore  than  to  the  administration  of  medicines. 

In  a  large  proportion  of  this  class  of  infants  and  especially  young 
children  after  they  have  reached  an  age  from  two  to  five  years,  there  is  the 
greatest  importance  to  be  attached  both  to  their  mental  and  physical 
training.  And  first  require  the  avoidance  of  all  those  mental  influences 
which  consist  in  encouraging  periods  of  extreme  excitement,  either  of 
hilarity,  boisterous  plays  carried  so  far  as  to  produce  weariness  and  much 
vascular  excitement  on  the  one  hand,  and  still  more  the  avoidance  of  in- 
tense excitement  of  the  passions,  sudden  fright,  mental  apprehension,  that 
often  are  perpetuated  almost  from  day  to  day  by  the  indulgence  on  the 
part  of  parents  and  nurses  of  fretful  and  violent  dispositions  in  their 
dealings  with  children,  thereby  begetting  in  the  children  themselves, 
equally  violent  dispositions  and  emotions;  while  the  opposite  kind  of 
trainins:,  characterized  by  gentleness  and  kindness,  if  properly  conducted, 
always  serves  to  maintain  better  discipline  than  the  most  peremptory  and 
violent  commands.  A  very  great  influence  can  be  exerted  in  overcoming 
the  morbid  nervous  excitability  in  young  children  simply  by  jiroper  men- 
tal influences  in  their  management.  For  physical  training,  take  them  fre- 
quently in  the  open  air  riding,  and  when  old  enough  to  run  about  with  any 
deo-ree  of  freedom,  walking  and  playing,  varying  the  exercises  so  as  to 
develop  the  chest  and  arms,  as  well  as  the  legs,  but  avoiding  all  excesses 
or  unduly  protracted  exercise.  Another  thing  that  is  very  generally  over- 
looked, and  yet  of  much  importance  to  this  class  of  subjects,  is  to  secure 
for  the  patient,  good,  pure  air  during  the  night.  Nothing  tends  more  to 
debilitate,  and  at  the  same  time  increase  the  excitability  of  the  nervous 
system,  than  sleeping  in  close,  poorly  ventilated  rooms  particularly  if 
they  are  kept  at  an  elevated  temperature.  Confined  warm  air  without 
sufficient  ventilation  to  prevent  it  from  being  contaminated  by  repeated 
inhalations,  is  one  of  the  most  injurious  of  all  our  domestic  errors.  There 
are  many  families  in  which  the  careful  mothers,  in  their  anxiety  to  prevent 
colds  and  protect  their  young  children,  keep  them  every  night  in  an  at- 
mosphere that  is  absolutely  impure  during  all  the  last  half  of  the  night, 
from  want  of  chang-e  or  ventilation.     So  far  as  the  administration  of  med- 


HYSTEKIA.  755 

icine  is  concerned  we  can  only  lay  down  this  general  rule:  that  no  medi- 
cine is  required  other  than  that  which  is  frequently  needed  to  properly 
regulate  the  secretions  and  evacuations,  using  such  a  combination  as  will 
produce  a  soothing,  quieting  and  tonic  effect.  All  so-called  stimulants 
should  be  avoided.  AH  nervous  excitants,  such  as  tea  and  coffee,  should 
also  be  avoided  or  used  very  sparingly.  It  is  very  desirable  to  avoid  the 
use  of  the  opiate  class  of  narcotics,  not  only  because  they  tend  to  consti- 
pate and  interfere  with  secretions,  but  on  account  of  the  fact  that  they 
speedily  subject  these  nervously  excitable  patients  to  the  impression 
which  calls  for  their  repetition,  and  the  habit  of  taking  them  is  general  y 
induced.  Temporary  quiet  is  obtained  in  such  cases  at  the  expense  of 
permanent  and  serious  impairment  of  the  tone  of  the  nervous  system. 
The  bromides  in  connection  with  tonics,  either  of  the  bitter  class,  such  as 
preparations  of  cinchona,  or  those  more  directly  nutrient,  as  the  hypo- 
phosphites,  lactophosphates,  and  sometimes  preparations  of  iron,  will  be 
found  advantageous.  But  the  particular  remedy  must  be  selected  for  each 
individual  patient,  and  the  dose  adapted  to  the  age,  always  remembering 
that  to  overcome  a  predisposition  or  constitutional  tendency  of  any  kind, 
requires. time,  patience  and  steady  perseverance.  And  with  these  three 
qualities,  time,  patience,  steadiness  of  purpose,  with  a  reasonably  judi- 
cious exercise  of  judgment  in  selecting  the  particular  hygienic  meas- 
ures and  remedial  agents,  almost  all  cases  of  the  character  we  have  been 
considering  can  be  conducted  to  so  full  a  recovery  that  on  their  arrival  at 
puberty,  or  adult  life,  they  will  be  free  from  the  predispositions  of  child- 
hood, or  the  defects  of  hereditary  tendencies. 


LECTURE  LXXVI. 


Hysteria— Its  Varieties,  Causes,  Clinical  History,  Pathology,  Diagnosis,  Prognosis  and  Treatment. 

GENTLEMEN:  Hysteria  is  a  name  which  has  long  been  applied  to 
certain  conditions  of  the  nervous  system  presenting  symptoms  more 
or  less  similar,  and  yet  varying  widely  in  different  cases,  and  very  gener- 
ally regarded  as  limited  to  the  female  sex.  Indeed,  the  name  hysteria 
was  chosen,  not  only  because  of  the  supposition  that  the  disease  was 
limited  to  the  female  sex,  but  that  it  was  connected  essentially  with  some 
disturbance  or  morbid  condition  of  the  uterus  or  ovaries.  It  is  certain, 
however,  that  this  idea  of  the  restriction  of  the  disease  to  one  sex  is  erro- 
neous. Although  occurring  much  more  frequently  in  females,  cases  of  a 
well-marked  character  have  been  observed  not  very  infrequently  during 
the  early  period  of  adult  life  in  the  opposite  sex.  And  even  in  females 
there  is  ample  evidence  that  many  cases  presenting  hysterical  phenomena 
have  no  necessary  connection  with  the  uterus  or  with  ovarian  disorders. 
Indeed,  it  is  probable  that  the  latter  class  of  disorders  simply  act  as  ex- 
citing influences,  tending  to  aggravate  the  nervous  affection,  when  there 
is  already  existing  a  predisposition  to  it,  or  an  actual  existence  of  the  dis- 
ease, and  that  the  group  of  symptoms  which  are  denominated  hysterical, 
are  in  no  way  necessarily  connected  with  the  functions  of  the  ovaries  or 
uterus.  It  is  a  form  of  disease  'which  has  been  known  and  described 
from  a  very  early  period  of  medical  history,  and  is  probably  capable  of 


756  HYSTERIA. 

assuming  a  greater  number  of  variations  in  its  symptoms  and  immediate 
manifestations  than  any  other  disease  to  which  the  human  system  is  liable. 
In  one  direction  it  has  a  close  relationship  to  epilepsy,  in  another  to  certain 
forms  of  mental  derangement,  while  the  great  majority  of  cases  appear  to 
•  consist  almost  exclusively  in  an  excessive  or  morbid  excitability  of  the 
cerebro-  spinal  system  of  nerves  and  nervous  centers,  coupled  with  a  decided 
loss  of  balance,  or  co-ordination  in  the  controlling  functions  of  the  cerebral 
hemispheres.  As  alreadv  stated,  it  occurs  most  frequently  in  the  female  sex 
and  between  the  ages  of  fifteen  and  twenty-five  years,  though  well-marked 
instances  are  occasionally  observed  at  an  earlier  period,  and  of  those  that 
become  subject  to  the  disease  during  the  period  named,  very  many  con- 
tinue during  the  whole  period  of  adult  life.  Very  few  cases,  however,  are 
observed  m  old  age. 

Causes. — I  may  say,  the  predisposing  causes  consist  of  almost  any  influ- 
ence which  is  made  to  act  continuously  through  consideraljle  periods  of 
time  and  of  such  a  nature  as  to  increase  ordinary  susceptibility  of  the  nerv- 
ous structures.  The  confinement  of  young  persons,  from  ten  to  fifteeii  and 
twenty  years  of  age,  much  in  warm  rooms,  poorly  ventilated — either  in 
school-rooms,  in  their  sleeping  apartments,  or  any  other  establishment, 
and  especially  if  such  confinement  is  coupled  with  active  mental  training, 
or  any  circumstances  that  are  calculated  to  produce  frequent  mental  ex- 
citements, such  as  the  reading  of  novels,  exciting  stories,  or  any  writings 
that  intensely  occupy  the  mind  of  such  persons,  greatly  favor  the  devel- 
opment of  that  peculiar  morbid  excitability  which  renders  them  ready 
subjects  for  hysterical  paroxysms  of  excitement.  The  same  predisposi- 
tion to  hysterical  temperament  is  promoted  by  all  those  circumstances, 
in  what  is  termed  fashionable  societj',  which  lead  the  young  into  plays 
and  amusements  of  such  a  nature  as  are  calculated  to, produce  strong 
emotions  of  any  kind.  The  attendance  upon  theaters,  balls,  or  occasions 
where  they  are  kept  till  late  at  night  in  the  midst  of  excitement,  and 
usually  high  temperature  of  the  air,  may  be  enumerated  as  predisposing 
causes.  Another  unquestionable  predisposing  influence  is  that  which  may 
be  denominated  heredity.  As  an  instance,  there  are  families  in  which 
a  well-marked  hysterical  development  has  been  noticed  from  one  genera- 
tion to  another,  through  several  generations.  Exciting  causes  of  hysteria 
consist  in  many  circumstances  which  are  calculated  to  produce  sudden 
and  strong  emotions,  or  passions  of  the  mind.  Often  a  most  trifling  disap- 
pointment in  persons  predisposed  will  throw  them  into  the  active  exhibi- 
tion of  hysterical  phenomena.  Almost  equally  reaily,  also,  will  be  the 
similar  responses  to  emotions  of  a  pleasant  character,  provided  they  are 
intense.  The  sudden  reception  of  news  of  an  exciting  character,  whether 
pleasant  or  unpleasant,  and  fright,  will  often  produce  the  same  results. 
Whenever,  through  hereditary  influences  or  otherwise,  a  distinct  hyster- 
ical temperament  has  been  established,  there  is  no  doubt  but  that  the 
occurrence  of  uterine  congestion  or  disturbance  tends  to  increase  the 
predisposition,  and  to  develop  or  induce  active  paroxysms  of  hysterical 
phenomena.  lu  females  of  this  class  the  menstrual  period  is  almost  al- 
ways one  in  which  more  or  less  of  the  active  hysterical  symptoms  are 
manifested.  And  in  some  of  them  almost  every  menstrual  period  will  be 
ushered  in  by  full  hysterical  co:ivulsions.  When  the  S'-ime  temperament 
exists  in  the  male,  sexual  excitement  is  liable  to  produce  the  same  results 
as  the  menstrual  period  in  the  female.  Such  persons,  indulging  in  sexual 
intercourse,  or  in  self-abuse,  will  not  infrequently  develop  directly  the 
phenomena  of  active  hysteria. 

8ijmptoin-. — To, enumerate  all  the  symptoms  observed  in  the  various 


SYMPTOMS.  757 

shades  and  forms  of  hysteria,  would  require  more  time  and  occupy  more 
space  than  would  be  profitable  or  necessary.  The  essential  feature  which 
may  be  said  to  characterize  all  the  phenomena  belonging  to  the  hyster- 
ical condition,  is  that  of  extremes,  or  the  production  of  phenomena  en- 
tirely out  of  proportion  to  the  nature  and  intensity  of  the  exciting  cause. 
And,  in  addition,  an  entire  want  of  steadiness  or  balance  in  the  manifes- 
tations of  phenomena.  Bv  this  I  mean  the  rapid  changing  from  one  ex- 
treme to  aiiother.  The  idea  is  best  illustrated  by  the  very  common  oc- 
currence of  passing  from  the  most  serious  sobbing  and  crying  in  a  few 
minutes  to  the  most  violent  and  uncontrollable  laughter  and  hilarity. 
Such  mental  variations  of  passing  from  one  extreme  to  another  character 
ize  all  the  phenomena,  physical  as  well  as  mental.  The  motor  apparatus 
may  be  disturbed  in  so  erratic  and  variable  a  degree,  that  the  patients  at 
one  hour  claim  to  be  powerless  or  incapable  of  motion,  as  though  utterly 
jiaralyzed,  and  in  ten  or  twenty  minutes  perhaps,  are  exhibiting  the  vio- 
lence of  physical  eifort  and  full  strength,  or  a  convulsion  that  would  re- 
quire one  or  two  attendants  to  keep  them  in  bed,  or  from  doing  them- 
selves harm.  Sensations  are  equally  variable  and  pass  to  extremes. 
More  generally  hyperaesthesia,  or  claiming  that  the  slightest  touch  is 
painful,  often  exhibiting  excessive  indications  of  pain,  or  suifering,  from 
any  touch  or  motion,  and  at  other  times  obstinately  claiming  that  there 
is  no  sensibility  in  the  parts  whatever. 

The  disturbance  of  the  involuntary  functions  are  also  characterized  by 
the  same  extremes,  as  illustrated  in  the  secretions.  In  one  instance  the 
urinary  secretion  may  appear  to  be  entirely  suppressed,  until  a  few  hours 
or  even  a  day  has  passed  by  with  no  secretion,  or  if  any,  but  a  few- 
drops,  and  yet  without  any  of  the  serious  consequences  of  suppression. 
Much  more  frequently,  however,  the  opposite  condition  exists,  and  while 
under  the  influence  of  active  hysterical  phenomena  the  secretion  isgreatlv 
increased,  so  that  a  large  chamber  vessel  may  be  filled  in  a  single  night. 
In  such  cases  the  urine  is  limpid  and  almost  like  clear  water,  and  of  low 
specific  gravity.  The  movements  of  the  heart,  and  respiration,  are  less  dis- 
turbed in  hysteria  than  almost  any  of  the  other  functions.  There  is  often, 
however,  very  great  oppression  or  distress  in  the  chest,  sometimes  in  the  form 
of  acute  pain  in  the  left  breast,  at  a  point  over  the  phrenic  nerve,  where 
it  reaches  the  diaphragm.  This  might  lead  the  inexperienced  to  think 
that  the  patient  had  a  pleuritic,  or  pericardial  inflammatory  attack.  But 
a  little  scrutiny  would  show  that  it  was  wholly  unaccompanied  bv  fever, 
or  any  real  disturbance  of  the  circulation  and  respiration  corresponding 
with  inflammatory  disease.  But  more  frequently  the  sensation  of  op- 
pression is  in  the  form  of  a  ball,  or  weight  in  the  epigastric  region,  fre- 
quently rising  up  through  the  chest,  creating  the  sensation  of  oppression, 
until  it  reaches  the  trachea,  where  it  will  appear  like  a  ball,  which  they  can 
neither  get  up  nor  force  down  by  swallowing,  but  causes  a  sense  of  chok- 
ing and  suffocation.  This  choking  sensation  is  unquestionably  induced 
by  the  transmission  of  a  morbid  impression  through  the  recurrent  branches 
of  the  pneumogastric  nerve.  Diagnostically,  it  has  been  styled  the  globus 
hystericus.  Manj-  hysterical  patients  sit  up  the  greater  part  of  the  night, 
from  dread  of  choking  or  suffocating  from  this  sensation  in  the  neck  or 
some  point  between  the  epigastrium  and  trachea.  In  what  is  called  a 
hysterical  fit,  or  full  hysterical  convulsion,  the  whole  voluntary  muscular 
system  is  thrown  into  violent  clonic  spasms,  much  resembling  the  lull 
paroxysms  of  epilepsy.  There  are,  however,  these  marked  and  reliable 
differences  between  the  hysterical  paroxysms  and  the  convulsions  of  the 
eijileptic.     In  the  latter,  the  temperature  rises  distinctly  above   the  nat- 


758  HYSTERIA. 

ural  standard,  and  consciousness  is  totally  obliterated.  Bat,  in  the  hys- 
terical convulsion,  there  is  no  rise  of  temperature,  and  it  is  also  invaria- 
bly the  case  that  if  the  patient  is  put  to  the  proper  test  it  is  found  that 
consciousness  is  not  entirely  obliterated  during  any  part  of  the  time. 
Hence,  it  is  more  rare  in  the  hysterical  convulsion  than  in  epilepsy,  that  the 
same  kind  of  accumulation  of  [)iilei^-m  in  the  fauces,  or  what  is  popularly 
styled  "  frothing  at  the  mouth  "  and  biting  of  the  tongue  occur.  Neither 
is  there  the  same  uniform  tendency  on  the  part  of  the  patient,  when  pass- 
ing out  of  the  pjiroxysm  of  a  convulsion  to  have  a  period  of  apparent  sleep 
as  ft  sequel  of  the  spasm.  But  the  hysterical  patient  not  only  arouses 
much  more  readily  and  quickly,  but  also  passes  again  quite  as  readily  and 
quickly  into  another,  with  but  a  short  interval  in  many  cases,  until  a  dozen  or 
more  have  been  encountered;  and  yet  when  they  finally  cease,  there  is 
not  anything  like  the  degree  of  exhaustion,  and  indication  of  serious  im- 
pairment of  cerebral  function  and  sensibility  that  would  bo  produced  by 
even  two  paroxysms  of  epilepsv,  occurring  at  short  intervals  of  time. 

Those  subject  to  hysterical  paroxysms,  if  even  of  frequent  occurrence, 
present  none  of  that  tendency  to  impairment  of  the  mental  faculties,  or 
permanent  changes  in  the  functions  of  the  brain  and  cerebro-spinal  centers, 
which  are  characteristic  of  well-marked  and  frequently  recurring  par- 
oxysms of  epilepsy.  I  may  say  then,  in  regard  to  symptoms  of  hysteria, 
that  they  consist  in  disturbances  of  the  sensations  and  emotions,  or  mental 
j^henomena,  of  almost  every  shape  and  variety  of  intensity  and  frequency 
of  manifestation,  from  the  simple  choking  in  the  neck,  to  the  most  violent 
clonic  spasm.  And  mentally,  changes  from  the  most  extreme  depression 
and  despondency  to  the  highest  degree  of  excitement  and  hilarity,  follow 
each  other  in  quick  succession.  Yet  in  all  these  variations  and  changes, 
they  have  left  no  impression  of  structural  change  or  permanent  impair- 
ment of  function;  consequently,  a  true  hysterical  patient  may  be  afflicted 
for  years  with  hardly  any  indications  of  permanent  impairment,  either  of 
mental  or  physical  functions. 

Diagnosis. — The  statements  I  have  just  made  in  regard  to  the  general 
characteristics  of  the  symptoms  and  phenomena  of  hysteria,  point  to  the 
most  reliable  means  of  diagnosis.  There  are  m my  phases  of  the  disease 
in  which  a  physician  on  fiist  coming  in  contact  with  the  patient  might 
be  unable  at  once  to  properly  interpret.  For  instance,  in  reaching  a 
patient  in  the  midst  of  a  violent  hysterical  convulsion,  it  might  be  im- 
possible during  the  time  of  the  convulsion  to  determine  by  the  phenomena 
alone,  without  an  accurate  history  of  the  patient,  whether  it  was  hysterical 
or  epileptic.  Yet,  as  soon  as  a  history  of  the  patient  has  been  obtained, 
or  time  enough  has  elapsed  to  watch  the  patient  tlirough  the  paroxysms  of 
the  convulsion,  and  a  few  subsequent  hours,  it  will  rarely  happen  that  the 
practitioner  will  not  be  able  to  detect  clearly  and  distinctly  those  exag- 
nerations,  or  want  of  balance  alluded  to  in  the  phenomena  that  pass  rapidly 
from  one  extrenie  to  another  in  the  mental  and  physical  changes,  and 
thereby  readily  distinguish  this  from  all  other  affections.  And  it  is  on 
this  careful  study  of  the  antecedents,  as  well  as  the  present  phenomena, 
that  the  physician  must  base  his  diagnosis,  and  not  upon  any  one  or  two 
of  their  special  symptoms. 

Pathology. — From  what  I  have  already  stated  in  regard  to  the  causes  and 
symptoms,  you  will  infer  that  there  are  no  anatomical  changes  in  the  nerv- 
ous centers,  or  in  any  other  portion  of  the  system,  that  have  "been  identified 
as  characteristic  of  this  form  of  disease.  Indeed,  it  has  seldom,  if  ever, 
terminated  fatally  without  complication  with  other  pathological  conditions 
that  are  really  the  cause  of  death.     And  therefore    it  can  hardly  be   said 


TREATMENT.  759 

that  there  have  been  opportunities,  except  very  rarely,  for  studying  the 
minute  anatomy  of  the  nervous  centers,  or  any  other  portions  of  the  system, 
of  those  who  have  died,  subject  to  well-marked  hysteria.  While,  however, 
there  are  no  distinctive  structural  changes  recognizable  in  any  portion  of 
the  nervous  centers  as  peculiar  to  this  form  of  disease,  it  is  undoubtedly 
true  that  the  elementary  properties  of  the  nerve  structures  generally  are 
materially  altered  from  that  of  health,  and  more  particularly,  that  prop- 
erty which  I  have  styled  elementary  susceptibility.  This  exaltation  of 
the  elementary  property  gives  to  the  nerve  tissue  of  the  hysterical  subject 
its  exaggerated  response  to  impressions  of  almost  every  character.  In 
some  instances,  undoubtedly,  this  morbidly  susceptible  condition  of  nerve 
tissue  is  restricted  to  a  certain  portion  of  the  nervous  system.  The  hys- 
terical symptoms  are  consequently  limited  in  their  manifestations.  For 
example,  we  see  sometimes  the  symptoms  limited  to  a  single  limb,  or  a 
particular  portion  of  the  body.  In  such  cases  it  may  take  the  form  of 
hysterical  paralysis,  or  some  unaccountable,  apparent  affection  of  the 
joints,  or  of  a  single  joint,  or  in  the  abdomen  assuming  the  ajDpearance  of 
a  tumor,  constituting  what  is  designated  as  phantom  tamor^  and  which 
has  sometimes  so  persistently  simulated  the  existence  of  a  tumor  as  to 
cause  experienced  surgeons  to  make  preparation  for  operations,  and  only 
to  be  relieved  from  the  deception  when  the  patient  was  on  the  operating 
table  and  placed  under  the  influence  of  an  angesthetic,  so  as  to  overcome 
all  consciousness,  when  with  the  obliteration  of  the  consciousness  of  the 
patient  the  tumor  also  disappeared.  In  other  instances  the  morbid  sus- 
ceptibility may  be  limited  to  certain  portions  of  the  hemispheres  apparently 
affecting  more  particularly  the  manifestations  of  certain  emotions  or  func- 
tions of  the  mind.  But  in  the  greater  number  of  cases  with  which  you  are 
liable  to  come  in  contact,  the  morbid  susceptibility  or  impressibility  of 
the  nervous  system  will  be  universal.  I  see  no  other  way  to  account  for 
the  want  of  balance,  the  ready  and  exaggerated  response  to  impressions 
of  almost  every  kind  that  can  be  given,  than  by  this  supposed  exaltation 
of  the  primary  susceptibility  of  the  structures  themselves.  As  I  have  stated 
in  the  beginning,  the  word  hysteria  indicates  a  relationship,  necessarily,  to 
the  uterus  and  ovaries,  and  therefore  is  misleading.  And,  as  the  most 
prominent  and  uniform  characteristic  of  the  phenomena  belonging  to  the 
disease  is  that  of  want  of  balance  in  the  performance  of  nervous  function, 
and  the  extremes  of  response  to  ordinary  impressions,  it  would  perhaps  be 
better  if  the  suggestion  of  Dr.  Hartshorne  was  adopted,  that  instead  of 
hysteria,  the  morbid  conditions  included  under  that  head  now,  were 
transferred  to  neurataxia,  indicating  loss  of  balance  in  the  functional  ac- 
tion of  the  nervous  centers. 

_  Prognosis. — So  far  as  relates  to  the  question  of  danger  to  the  patient's 
life,  the  prognosis  in  hysteria  is  uniformly  favorable.  It  rarely,  if  ever, 
proves  fatal.  Regarding,  however,  the  prospect  of  a  permanent  cure,  the 
prognosis  is  less  favorable.  While  many  cases  in  the  early  stages  of 
their  progress,  or  even  during  the  first  few  years  after  their  development,  can 
be  entirely  cured  under  favorable  circumstances,  there  are  others  under 
less  favorable  conditions,  in  which  palliation,  and  not  cure,  is  the  more  fre- 
quent result  of  all  the  efforts  that  can  be  made,  in  the  management  of  the 
patient. 

Treatment. — The  treatment  of  hysteria  includes  two  objects:  the  one 
relates  to  immediate  relief  of  the  present  distressing  symptoms,  and  the 
other  to  the  permanent  removal  of  the  causes  and  pathological  conditions 
which  give  rise  to,  and  constitute  essentially,  the  disease.  As  almost  all 
of  the  symptoms  of  sufficient  degree  of  intensity  to  require  special  pallia- 


760  HYSTERIA. 

tion  consists  either  of  spasmodic  action  in  some  portion  of  the  muscular 
system,  or  the  development  of  morbid  sensations  of  an  exaggerated  char- 
acter, the  remedies  for  temporary  relief  are  chiefly  those  denominated 
anti-spasmodics  and  sedatives  to  nervous  excitability.  For  relieving  most 
of  the  minor  symptoms  which  may  distress  the  patient  and  prevent  rest 
at  night,  such  as  o^Dpression  in  the  chest,  sensations  of  choking  in  the  neck, 
sleeplessness,  and  various  grades  of  mental  excitability  and  hallucination, 
a  combination  of  the  bromide  of  ammonium  with  some  preparation  of 
valerian,scutalaria,orhyosciamus,  orof  the  three  combined  in  proper  propor- 
tion will  usually  suffice  for  administration  at  the  proper  time,  and  in  suit- 
able doses.  A  prescription,  consisting  of  fluid  extract  of  valerian,  sixty 
cubic  centimeters  (fl.  3  ij),  fluid  extract  of  scutilaria  forty-five  cubic  cen- 
timeters (fl.  3  ij),  fluid  extract  of  hyosciaraus  fifteen  cubic  centimeters 
(fl.  3  iv)?  and  bromide  of  ammonium  twenty  grammes  (3  v)  may  be  given 
to  a  patient,  between  the  ages  of  fifteen  and  twenty-five  years,  in  doses  of 
four  cubic  centimeters,  (fl.  3  j),  diluted  with  a  little  additional  sugar  and 
water,  early  in  the  morning,  at  tea  time  and  bed  time. 

In  the  cases  to  which  I  last  alluded,  it  will  seldom  fail  to  relieve  the 
morbid  sensations,  produce  a  degree  of  quiet  during  the  day,  and  secure 
for  them  a  fair  degree  of  sleep  during  the  night.  Many  times  1  have  found 
that  two  doses,  one  at  tea  time  and  the  other  at  bed  time,  were  quite  suf- 
ficient for  accomplishing  these  purposes.  Where  the  disease  manifests 
itself  in  the  form  of  neuralgic  pains,  whether  in  the  left  breast  or  in 
almost  any  other  part  of  the  system,  valerianate  of  ammonium  is  one  of 
the  most  efficient  remedies  that  can  be  used,  so  far  as  my  observation  ex- 
tends. This  remedy,  given  in  doses  of  from  six  to  twelve  centigrammes 
(gr.  i  to  ij)  three  times  a  day  will  usually  aff'ord  the  desired  relief.  Where 
full  convulsions  occur  the  immediate  administration  of  an  enema,  contain- 
ing six  decigrammes  (gr.  x)  of  assafoetida,  and  the  same  quantity  of  hydrate 
of  chloral  suspended  in  sixty  cubic  centimeters  (fl.  |  ii)  of  warm  water  or 
mucilage,  and  introduced  into  the  rectum,  will  usually  produce  a  prompt 
and  decided  degree  of  relief.  As  soon  as  the  spasm  has  passed  suffi- 
ciently to  allow  the  patient  to  take  remedies  by  the  mouth,  a  gelatine- 
coated  pill  of  three  grains  of  assafoetida  may  be  given,  and  repeated 
every  two  hours  till  the  disposition  to  further  convulsive  movements  cease. 
In  such  cases,  where  full  convulsions  occur,  it.is  often  justifiable  also  to 
apply  sinapisms  over  the  epigastrium  and  warmth  to  the  extremities;  and 
when  the  sinapisms  have  been  applied  until  the  skin  is  red,  changing  it 
to  the  central  portion  of  the  spine  between  the  scapulae,  will  also  produce 
some  influence  in  relieving  the  patient.  I  have  mentioned  the  foregoing 
remedies  simply  as  specimens,  and  to  indicate  to  you  the  class  of  reme- 
dial agents  that  may  be  made  useful  for  temporary  purposes  in  relieving 
the  various  forms  and  shades  of  hysterical  excitement  and  active  phenom- 
ena. In  the  more  protracted  and  severe  cases,  especially  involving  con- 
vulsions, chloroft)rm  and  ether  may  be  called  into  requisition  temporarily. 
But  so  far  as  the  cases  can  be  managed  without  inducing  direct  angesthe- 
sia  on  the  one  hand,  and  more  particularly  without  the  use  of  opiates  on 
the  other,  it  will  be  desirable  to  do  so.  There  are  no  classes  of  patients 
that  so  readily  become  habituated  to  the  use  of  either  anaesthetics  or 
opiates  as  the  hysterical.  And  none  are  more  difficult  to  relieve  from  the 
habit,  especiali3'  of  the  use  of  opium,  where  they  have  once  acquired  it. 
And  not  only  this,  but  opiates  are  objectionable  in  this  class  of  patients, 
for  the  reason  thnt  while  they  may  prove  efficient  in  temporarily  quieting 
the  liysterical  excitement,  inducing  rest  and  relieving  spasms,  they  inva- 
riably produce  more  or  less   derangement  of  the   digestive   functions  and 


TREATMENT.  761 

secretions,  and  pave  the  way  for  a  return  of  the  active  symptoms  of  the 
disease  more  readily  than  though  they  had  not  Ijeen  used.  Conscquentiy 
it  is  desirable  always  to  avoid  their  use  in  this  class  of  subjects  as  far  as 
practicable,  and  my  own  experience  has  satisfied  me  that  the  cases  in 
which  they  are  strictly  necessary  are  exceedingly  rare.  The  same  re- 
marks apply  to  the  use  of  the  alcoholic  class  of  anajsthetics,  either  fer- 
mented or  distilled. 

No  class  of  subjects  more  readily  become  habituated  to  them,  or  claim 
that  they  relieve  their  varied  and  excessive  exaggeration  of  nervous  evils, 
than  the  hysterical.  And  yet,  their  effects  are  always  temporary,  rjever 
curative,  and  directly  calculated  to  perpetuate  the  constitutional  difficulty 
under  whicli  the  patient  labors.  In  regard  to  the  other  object  of  treat- 
ment, namely,  the  removal  of  the  diathesis  or  constitutional  tendency,  or, 
in  other  w^ords  the  removal  of  the  disease,  there  are  no  specific  remedies  to 
be  recommended.  Each  case  must  be  studied  by  itself;  the  causes,  pre- 
disposing and  exciting,  which  influence  the  individual  patient,  must  be 
accurately  ascertained,  and  as  far  as  possible  they  must  be  removed  or 
avoided  by  removing  the  patient  from  their  influence.  Wherever  special 
functional  disturbances  exist,  such  as  indigestion,  constipation  of  the 
bowels,  suppression  of  the  secretions  of  any  kind,  derangement  of  the 
uterine  function,  or  menstruation,  all  of  these  must  be  noted  and  remedies 
employed  appropriate  for  their  removal.  When,  as  far  as  practicable,  the 
predisposing  and  exciting  causes  have  been  removed,  and  collateral  dis- 
turbances that  may  act  injuriously  upon  the  patient  in  perpetuating  the 
nervous  derangements,  are  corrected,  the  remainder  of  the  treatment 
will  consist  in  procuring  for  the  patient  an  abundance  of  pure  air,  moder- 
ate and  regular  systematic  outdoor  exercise,  and  above  all  the  influence  of 
♦  s^eadv,  pleasant  mental  occupation.  Something  to  do  every  day,  and 
somethi  ,g  which  will  actually  engage  the  thought  and  attention,  as  well 
as  abso:  b  the  time  of  the  patient,  is  of  paramount  importance.  There  is 
no  obstacle  in  the  way  of  the  cure  of  these  patients  greater  than  that  of 
idleness  or  want  of  occupation.  And  no  part  of  the  management  is  more 
difficult  in  many  cases  than  supplying  such  occupation  as  is  needed.  But 
plain,  unstimulating  diet,  good  air,  warm  clothing  during  the  cold 
seasons  of  the  year,  careful  attention  to  the  digestive  function,  and  regu- 
lar pleasant  occupation  of  the  mind,  will  cause  almost  any  hysterical  sulj- 
ject  to  obtain  permanent  relief  from  her  difficulties.  A  considerable 
number  of  these  patients  present  a  moderate  degree  of  anaemia  or  slight 
impoverishment  of  the  blood,  and  will  be  benefited  by  the  protracted  use 
of  moderate  doses  of  iron,  combined  with  the  snilder  class  of  anodynes. 
A  combination  of  citrate  of  iron  and  hyosciamus,  thirteen  centigrammes 
(gr.  ii)  of  the  former  and  six  (gr.  i)  of  the  latter,  put  up  in  the  form  of  a 
gelatine-coated  pill  or  capsule  to  render  it  pleasant  for  the  patient  to 
take,  may  be  given  at  each  meal  time.  This  remedy  will  often  do  much 
to  improve  the  general  tone  of  health,  and  consequently  lessen  any  undue 
susceptibility  of  the  nervous  system.  If  the  patient  lives  in  a  malarious 
district,  and  has  been  more  or  less  subject  to  the  impairing  influence 
of  that  agent,  six  centigrammes  (gr.  i)  of  quinine  or  cinchonidia  may  be 
propi  rly  added  to  the  pill  of  iron  and  hyosciamus.  But  it  is  useless  to 
specify  particular  tonics,  for  if  you  see  clearly  the  objects  to  be  accom- 
plished, namely,  that  of  holding  a  steady,  moderate,  quieting  influence 
over  pure  excitability  on  the  one  hand,  and  promoting  a  more  act^v^ 
development  of  blood  corpuscles  and  efficiency  of  nutrition  upon  the 
other,  you  can  easily  select  from  the  materia  medica  an  ample  supply  of 
those  agents  which  will  be  calculated  to  fulfill  these  indications.     What- 


762  INSOMNIA. 

ever  ag-ent  is  used,  however,  should  be  given  in  moderate  doses  with  the 
expectation  of  continuing  it  through  a  considerable  period  of  time.  The 
administration  of  medicine  of  any  kind  should  never  cause  the  physician 
or  patient  to  lose  sight  of  the  value  and  necessity  of  occupation,  outdoor 
air  and  the  avoidance  of  extreme  excitement  in  all  the  relations  of  life. 

Ilustero-epiliipsy . — A  class  of  cases  that  recently  attracted  much  atten- 
tion, "chiefly  through  the  investigations  of  Charcot  and  others  in  Paris, 
may  be  styled  hystero-epilepsy,  or  a  combination  of  the  phenomena  of 
hysteria  and  epilepsy  in  the  same  person.  Thus  far,  all  the  cases  that 
have  been  presented  of  this  particular  class  are  females,  usually  in  the 
early  period  of  adult  life.  Some  of  them  have  exhibited  very  remarkable 
phenomena  in  varying  from  the  occurrence  at  irregular  intervals  of  slight 
muscular  rigidity,  sometimes  accompanied  by  increased  sensibility  or 
hyperaesthesia,  and  at  others  by  anasthesia,  or  loss  of  sensibility,  to  the  most 
violent  convulsions.  The  phenomena  are  sometimes  limited  to  Darticular 
parts  as  one  limb  or  one  half  of  the  body,  and  at  others,  involving  the 
whole  muscular  system.  In  anj^  stage  of  the  progress  in  these  cases  even 
coincident  with  the  convulsive  paroxysm,  there  are  presented  the  most 
remarkable  emotional  manifestations  and  the  assumption  of  the  most  gro- 
tesque and  ludicrous  attitudes.  Some  of  these  cases  have  been  studied  and 
exhibited  in  the  clinics  of  Charcot,  and  have  attracted  a  great  deal  of 
attention.  The  point  of  most  interest,  however,  connected  with  them  is 
the  apparent  demonsti-ation  of  the  relationship  between  the  ovaries  and  the 
manifestation  of  the  general  symptoms.  Several  of  the  cases  that  have 
been  exhibited  in  the  clinics,  and  some  that  have  been  studied  elsewhere, 
were  found  capable  of  manifesting  muscular  rigidity,  and  passing  through 
all  the  stages  that  I  have  just  alluded  to  by  simply  making  light  pressure 
over  one  or  both  ovaries.  * 

iVnd  yet,  firm  and  strong  pressure  over  those  parts  would  pretty  gen- 
erally arrest  the  further  progress  of  the  paroxysms.  So  much  so  indeed, 
that  pressure  upon  the  ovaries  has  been  proposed  as  a  temporary  mode  of 
relief,  and  the  extirpation  of  these  parts  suggested  as  a  permanent  means 
of  cure.  A  study  of  these  cases  has  brought  out  phenomena  so  striking, 
and  in  some  instances  bearing  such  close  resemblance  to  the  nervous  af- 
fections that  have  occasionally  appeared  like  epidemics  in  connection  with 
high  religious  excitement  in  the  past  three  centuries,  both  in  Europe  and 
in  this  country,  that  they  have  been  considered  as  affording  an  explana- 
tion of  the  phenomena  that  were  manifested  on  those  occasions.  Aside 
from  the  local  treatment  relating  to  the  ovaries,  these  cases  require  to  be 
managed  upon  the  same  principle  that  we  have  already  mentioned  in  re- 
gard to  hysteria  in  general. 


LECTURE    LXXYII. 

Insomnia  and  Neuralgia— Their  Varieties,  Causes,  Clinical  History,  Pathology,  Diagnosis,  Prog- 
nosis, and  Treatment. 

GENTLEMEN:  By  insomnia  is  meant  inability  to  sleep.  If  not  a 
distinct  disease  it  is  a  morbid  condition  of  not  very  infrequent  oc- 
currence and  may  originate  from  a  variety  of  causes.  From  the  most 
recent  and  careful  investigations  it  would  seem  that  the  condition  of  sleep 


TREATMENT.  763 

is  one  in  which  there  is  less  fullness  of  the  arterial  circulation  in  the 
brain,  a  state  of  less  activity  of  the  circulation  in  the  arterioles, 
while  that  of  wakefuln!  ss  and  insomnia  pathologically  is  the  opposite. 
In  the  latter  condition,  from  some  cause  the  arterioles  remain  excited  and 
maintain  a  morbidly  increased  activity  of  circulation,  fullness  of  blood, 
or  a  state  of  erethism,  as  it  has  been  termed  by  some.  This  condition  is 
capable  of  being  produced  by  prolonged  and  intense  mental  application, 
perhaps,  still  more  rapidly  by  intensity  of  mental  emotions,  whether 
depressing  or  exalting,  also  by  apprehension,  anxiety,  particularly  in  ref- 
erence to  business  concerns,  or  too  great  a  variety  of  important  objects  to 
be  attended  to,  so  that  the  mind  is  over-burdened.  These  are  among  the 
most  common  causes  of  insomnia.  The  first,  or  protracted  mental  appli- 
cation, is  the  one  most  frequent  among  students  and  literary  men.  That 
dependent  upon  mental  apprehension  and  intensity  of  thought,  or  anxiety 
about  results  is  most  apt  to  be  the  one  affecting  business  men.  But  all 
classes  of  individuals,  male  and  female,  are  liable  to  encounter  such  men- 
tal conditions,  and  be  involved  in  such  circumstances  as  may  lead  to  this 
condition  of  undue  cerebral  excitement  or  erethism  in  the  brain.  There  are 
some  agents  in  common  use  that  are  capable  of  Droducing  the  same  con- 
dition. Of  these,  strong  tea  and  coffee  are  among  the  most  common,  and 
there  are  thousands,  especially  in  the  female  community,  and  even  among 
servants  in  our  houses,  who  by  the  habitual  use  of  strong  tea  create  a 
condition  of  insomnia  coupled  with  disturbance  of  the  functions  of  the 
pneumogasti'ic  and  cardiac  nerves,  that  prevents  sleep  night  after  night, 
sometimes  for  months,  until  the  general  health  is  much  impaired,  A 
somewhat  similar  condition,  though  differing  a  little  in  its  phenomena,  is 
sometimes  induced  by  the  excessive  use  of  tobacco.  Alcohol,  by  its 
excessive  and  protracted  use  produces  insomnia,  but  the  phenomena  are 
connected  with  other  symptoms  so  as  to  distinguish  it  from  the  ordinary 
cases  and  give  it  such  characteristics  as  have  been  described  as  delirium 
tremens^  or  inania  potu.  The  disease  to  which  I  now  allude  is  not  one  of 
delirium,  however,  nor  one  of  mental  derangement  in  any  sense,  but 
simple  inability  to  sleep.  Sometimes,  though  not  frequently,  extreme 
exhaustion  from  over-exertion  may  produce  this  condition,  but  if  so  it  is 
rare.  If  insomnia  depends  upon  the  condition  to  which  I  have  just 
alluded,  and  may  arite  from  the  causes  enumerated  and  others  acting  in 
a  similar  direction,  it  is  not  difficult  to  select  the  remedies  that  may  be 
most  efficient  for  relieving  the  difficulty. 

Treatment. — The  first  and  most  important  item  in  the  treatment  is  the 
removal  of  the  cause,  or  suspension  of  its  further  action  whatever  it  may 
be.  If  the  use  of  tea,  coffee  or  tobacco  in  excessive  quantities  has  been 
the  exciting  cause,  it  must  be  discontinued.  If  intense  mental  exercise, 
protracted  mental  application,  or  an  excess  of  business  cares  excites  ap- 
prehension, little  can  be  expected  in  the  way  of  success  in  relieving  tlie 
patient  without  mitigating  or  removing  the  action  of  these  causes.  And 
the  patient  must  be  informed  that  a  change  which  will  relieve  him  of  all 
excess  in  any  and  all  of  these  directions  is  an  absolute  necessity  for 
obtaining  the  relief  that  he  desires. 

The  same  rule  will  apply  to  the  removal  of  any  and  every  variety  of 
cause  that  might  be  of  influence  in  developing  the  disease.  There  "is  a 
great  temptation  to  neglect  this  in  many  of  these  case-,  especially  as  they 
occur  among  men  largely  engaged  in  business  or  intently  occupied  in 
literary  pursuits  who,  by  administering  palliatives,  endeavor  to  palliate 
the  morbid  condition,  while  allowing  the  cause  to  continue.  The  claim  is 
that  the  patient  must  accomplish  this  or  that  task  or  object,  and  that  relief 


764  INSOMNIA. 

must  be  procured  by  agencies  that  will  6verwhelm  the  eflFects  of  the  ex- 
citing- cause.  All  such  cases  present  a  strono;  motive  for  using  anodynes 
and  anaesthetics  of  the  stronger  class,  which  by  their  use  always  en- 
danger developing  a  condition  of  the  nervous  system  far  more  injurious 
than  the  one  they  are  endeavoring  to  palliate.  It  happens  in  many  of 
these  cases  that  either  by  the  recommendation  of  the  jjhysician  or  from  the 
previous  knowledge  of  the  patient  himself,  but  more  frecjuently  from  the 
advice  of  some  of  his  neighbors,  he  commences  to  procure  sleep  by  taking 
a  certain  amount  of  alcoholic  drink  every  night.  In  mild  cases  it  will  be 
a  glass  or  mug  of  beer,  ale  or  porter.  In  cases  of  greater  severity,  whisky 
sling  or  punch  will  be  called  into  requisition,  and  under  these  they  will 
claim  to  sleep.  There  are  large  numbers  of  those  who  commence  to  pal- 
liate the  effects  of  injurious  mental  exercise  and  surrounding  circum- 
stances by  using  these  agents,  at  first,  simply  for  the  puipose  of  procuring 
sleep.  But  they  soon  create  that  condition  of  the  system  by  which  they  are 
induced  to  use  them  more  and  more  frequently,  until  before  they  are 
aware  of  it  they  have  become  completely  enslaved  by  the  alcoholic  anaes- 
thetic. After  acquiring  this  condition  it  is  more  difficult  to  cure  by  far 
than  the  original  disease.  If  instead  of  alcoholic  a!:?estliesia,  they  have 
assayed  to  palliate  their  symptoms  and  enforce  sleep  by  any  of  the  opiate 
preparations,  they  have  generally  ended  in  the  development  of  the 
opium  habit  which,  though  not  so  destructive  in  other  respects,  is  more 
difficult  to  eradicate  than  the  alcoholic  enslavement.  The  physician  can  not 
be  too  g-uarded  against  allowing  this  class  of  patients  to  enter  upon  the 
use  of  either  the  alcoholic  or  opiate  preparations.  It  is  the  imperative  duty 
of  the  physician  in  all  these  oases,  instead  of  yielding  to  the  use  of  such 
agents  for  the  purpose  of  allowing  the  patients  to  continue  the  operation 
of  the  causes  which  have  impaired  their  ability  to  sleep,  to  require  the 
immediate  removal  of  the  latter.  He  may  afford  such  aid  as  can  be 
done  without  resorting  to  injurious  medication,  or  such  as  will  endanger 
the  development  of  morbid  appetites  and  injurious  habits.  In  my  own 
experience  I  have  encountered  no  insuperable  obstacles  in  carrying  out 
the  measures  which  I  have  just  now  recommended.  Patients  will  seldom 
be  found  so  obstinate  or  blind  to  their  own  interests  that  they  will  not 
make  the  necessary  changes  in  their  business  and  habits,  if  the  physician 
clearly  explains  the  tendency  and  causes  of  their  trouble  and  familiarly 
points  out  to  them  the  necessity  for  modifying  and  removing  them. 

Nineteen  twentieths  of  all  cases  of  insomnia,  if  the  causes  are  avoided,will 
readily  yield  to  the  use  of  a  moderate  amount  of  any  one  of  the  bromides, 
either  alone  or  in  conjunction  with  digitalis.  From  six  to  thirteen  deci- 
grammes (gr.  X  to  xx)  of  the  bromide  of  potassium  or  ammonium,  with  the 
same  number  of  minims  of  the  tincture  of  digitalis,  for  an  adult,  adminis- 
tered from  half  to  three  quarters  of  an  hour  before  the  patient  desires  to 
go  to  sleep,  will  produce  the  desired  effect,  and  obtain  comfortable  sleep  at 
night.  In  cases  of  more  obstinacy,  the  dose  I  have  just  spoken  of  adminis- 
tered about  seven  o'clock  in  the  evening,  and  repeated  at  nine  or  half-past 
nine,  thus  making  two  doses  in  the  evening,  will  rarely  fail  to  pro- 
cure the  desired  sleep.  Chloral  is  often  resorted  to,  but  after  a  fair 
trial,  I  have  abandoned  its  use  in  this  class  of  patients  from  the  fact 
that  very  many  of  them,  while  they  sleep  during  the  night,  and 
especially  during  the  latter  part  of  the  night,  or  even  until  late  in 
the  morning,  continue  to  feel  during  most  of  the  following  day,  a  dull, 
stupefying  effect  upon  their  mental  faculties  that  is  not  pleasant.  And 
sometimes  they  exhibit  a  degree  of  dullness  amounting  to  an  incapacity 
to  attend  to  any  business  even  of  the  lightest   character.     This  tendency 


TREATMENT.  765 

to  perpetuate  the  dull,  stupefied  condition  of  the  cerebral  function  durinnr 
the  following  day,  renders  the  use  of  chloral  less  desirable  than  the  bro- 
mides, and  so  far  as  I  have  been  able  to  observe  it  is  not  in  any  degree 
more  efficient.  In  some  few  instances  I  have  known  at  first,  until  a  joar- 
tial  recover}'-  had  taken  p'ace,  a  combination  of  the  bromide  and  chloral 
to  do  better  than  chloral  alone.  As  you  will  perceive  also,  I  usually  give 
a  dose  of  digitalis  in  connection  with  the  bromides.  Direct  clinical  ob- 
servation, first  in  the  treatment  of  delirium  tremens,  has  led  me  to  reo-ard 
digitalis  as  possessing  much  efficacy  in  diminishing  that  peculiar  erethism, 
or  morbid  excitability  of  the  brain  which  prevents  sleep,  more  particularly  in 
that  class  of  cases  where  the  general  condition  is  one  of  impairment,  not  of 
auaemia  proper,  but  where  the  pulse  is  rather  quick  and  irregular,  with  un- 
due nervous  excitability  in  addition  to  wakefulness.  In  all  this  class  of 
cases,  the  influence  of  digitalis  in  giving  more  steadiness,  slowness  and 
uniformity  to  the  heart's  action,  renders  it  an  advantageous  agent,  and  aids 
very  much  the  more  purely  sedative  effect  of  the  bromides  upon  nervous 
excitability,  and  contributes  largely  to  the  recovery  and  re-establishment, 
permanently,  of  a  more  normal  condition  of  the  circulation  than  could  be 
obtained  without  its  use.  It  is  probable  that  the  fluid  extracts  of  cactus 
grandiflora,  and  of  convallaria  would  produce  effects  very  similar  to  those 
that  are  obtained  from  digitalis.  In  some  instances,  also,  valerian  com- 
bined with  the  bromides  will  contribute  decidedly,  not  only  in  the  pro- 
duction of  sleep  duiing  the  night,  but  by  a  pleasant  tonic  influence 
upon  the  nervous  system  contribute  much  in  establishing  its  proper 
tone.  It  is  unnecessary  to  say  that  in  all  these  oases,  in  addition  to  rem- 
edying the  causes  that  have  operated  injuriously  upon  the  mind 
attent;on  should  also  be  given  to  the  physical  functions  of  the  patient. 
Constipation  should  be  obviated,  indigestion  should  be  mitigated,  ami  at- 
tention should  be  given  to  the  natural  condition  of  all  the  functions  of  the 
body,  as  well  as  the  removal  of  such  causes  as  might  be  alreadj'  more 
especially  disturbing  the  functions  of  the  brain.  A  few  words  more  in  re- 
gard to  another  subject — night  terrors.  I  allude  to  cases  which  are  mot 
with  more  particularly  in  children  and  youth,  in  which  thev  become  sub- 
ject, not  every  night,  but  often,  to  starting  suddenly  in  their  sleep,  as  if 
greatly  terrified.  More  generally,  it  occurs  during  the  first  sleep  after  re- 
tiring to  bed.  The  child  has  been  placed  in  bed,  falls  asleep  quietlv,  ap- 
parently in  good  health,  and  in  from  one  to  two  hours,  suddenlv "starts 
up,  looking  wild  and  anxious,  crying  out  for  its  mother  or  its  attendant 
as  if  in  extreme  terror;  the  shrieking  may  be  for  something  to  go  away, 
as  if  in  immediate  danger  of  some  terrible  infliction.  After  the  mother  or 
attendant  comes  to  its  rescue,  it  pays  no  heed  to  her,  but  continues  the 
same  phenomena,  exhibiting  the  most  intense  excitement  and  fear  both 
in  its  utterances  and  in  its  motions.  Notwithstanding  the  shrieks  and  cries 
the  child  is  still  asleep  while  in  the  midst  of  these  terrors.  Cases  are 
occasionally  met  with  in  which  these  night  terrors  occur  so  frequently 
that  they  seriously  disturb  the  child's  sleep;  and  it  becomes  peevish 
habitually  and  more  or  less  nervous  or  excitable,  constituting  an  appreciable 
impairment  of  the  general  health,  besides  being  a  source  of  great  anxiety 
to  the  family  in  which  it  belongs.  The  treatment  required  in  such  cases 
consists,  first,  in  the  adoption  of  some  means  for  arousin£rthe  patient  from 
his  condition  of  terror,  and  secondly,  in  preventing  its  recurrence. 
The  first  is  generally  most  easily  effected  by  the  simple  process  of  im- 
mediately bathing  the  child's  face  with  a  cloth  wet  with  cold  water. 
The  application  of  a  cold,  wet  cloth  over  the  face  and  forehead  quickly 
arouses  it  from  the   condition   of  terror    to  one    of    wakefulness.     The 


766  NEURALGIA. 

moment  it  is  thus  aroused,  it  looks  about,  recognizes  its  friends  and  then 
generally  resumes  its  attitu  ie  for  rest,  and  in  a  few  minutes  is  again 
asleep.  Tiiere  are  some  instances  in  which  these  terrors  will  come  several 
times  during  the  same  night,  but  more  frequently  they  occur  but  once,  the 
patient  often  going  to  sleep  the  second  time,  and  sleeping  quietly  through 
the  remaining  part  of  the  night.  The  treatment  for  preventing  their  re- 
currence must  depend  upon  a  careful  examination  of  the  patient  with  a 
view  to  determining  the  cause  or  causes  from  which  this  condition  may 
come.  Sometimes  it  is  taking  food  too  late,  and  retiring  with  food  un- 
digested in  the  stomach.  Sometimes  it  may  be  attributable  to  excesses  in 
exercise  of  some  kind  during  the  day,  especially  in  the  latter  part  of  the 
day;  or  it  mav  arise  from  excessive  mental  exercise,  or  the  indulgence  of 
intense  emotions  and  passions.  A  careful  examination  into  the  temper 
and  habits  of  such  children  will  often  enable  the  physician  to  see  more 
clearly  the  causes  which  exercise  a  disturbing  influence  over  the  functions 
of  the  brain  during  sleep,  and  by  immediate  removal  of  these  causes  there 
will  he  little  else  required  to  procure  exemption  from  a  return  of  the 
attacks. 

But  where  the  causes  are  not  fully  apparent,  where  the  functions  of  the 
body  are  well  performed,  and  there  is  no  appreciable  error  in  the  men.tal 
influences  that  bear  upon  the  patient,  and  still  these  paroxysms  take  place, 
it  indicates  a  morbid  state  of  the  brain  in  which  sleep  develops  into  one 
of  only  partial  inactivity  accompanied  by  a  constant  tendency  to  frightful 
dreams,  which  give  character  to  the  sp3cial  phenomena  of  such  attacks. 
The  remedies  that  are  most  likely  to  succeed  in  preventing  such  attacks 
are  the  same  1  have  spoken  of  as  being  the  most  successful  in  cases  of 
insomnia;  that  is  the  bromides  and  digitalis,  or  the  bromides  with  vale- 
rian. Either  of  these  combinations  given  in  doses  calculated  to  produce  a 
decidedly  quieting  effect,  a  little  before  the  patient  goes  to  sleep,  will 
usually  secure  exemption  from  the  periods  of  excitement  and  dreaming 
till  the  tendency  is  finally  eradicated.  While  I  think  the  combinations 
I  have  just  mentioned  are  the  best,  they  are  by  no  means  the  only  ones 
that  may  be  used.  Chloral  hydrate,  hyoscyamus  and  camphor,  either 
separate  or  combined,  will  generally  produce  the  desired  resiilt,  more  es- 
pecially if  attention  is  given  at  the  same  time  to  keeping  the  various  func- 
tions of  the  body  in  order,  iind  to  the  proper  regulation  of  the  diet  and 
exercise  of  the  patient  during  the  day. 

Neuralgia. — Neuralgia,  by  which  is  meant  pain  in  a  nerve,  is  one  of  the 
most  common  affections  the  physician  is  called  upon  to  treat.  It  may  oc- 
cur in  any  of  the  nerves  of  sensation  derived  from  the  spinal  cord  or  brain, 
but  is  perhaps  most  frequent  and  troublesome,  and  consequently  most 
likely  to  call  for  the  attention  of  the  physician,  in  the  nerves  of  the  face, 
sometimes  taking  the  form  of  what  has  iDeen  styled  tic  douloureux.,  in  the 
soiatic  nerve,  called  sciatica,  in  the  phrenic  and  intercostal  nerves,  gener- 
ally called  pleuro-dynia,  and  in  the  nerves  of  the  stomach,  called  gas- 
trodynia  or  gastralgia.  These  are  names  derived  merely  from  the  nerves 
in  which  the  pain  makes  its  appearance,  and  not  from  any  differences 
in  the  nature  of  the  affection.  Neuralgia  as  distinguished  from  the 
pain  produced  by  inflammation,  either  in  the  nerves  or  in  the  nervous 
centers,  may  be  referred  to  three  pathological  conditions:  one,  in.  which 
the  morbid  sensitiveness  is  developed  in  the  nerve  itself  or  in  the  fibrous 
sheath  directly  surrounding  the  nerve  matter;  another  consists  in  a  morbid 
condition  developed  in  the  nervous  centers,  either  in  the  spinal  cord  or 
brain,  the  manifestation  being  shown  in  the  peripheral  extremity  of  one  or 
more   nerves;  and  the   third  pathological  condition  favorable  for  causing 


SYMPTOMS.  767 

neuralgic  pains,  is  an  impoverished  or  spanaernic  condition  of  the  blood,  or 
tlie  presence  in  that  fluid  of  some  toxgemic  ingredients  derived  from  with- 
out. The  first  of  these  pathological  conditions,  namely,  that  relating  to 
the  nerve,  or  its  sheath,  most  frequently  consists  of  an  inflammatory  con- 
dition of  the  sheath  arising  from  exposure  to  cold  and  wet,  closely  akin 
to  rheumatic  irritation,  causing  the  sheath  of  the  nerve  to  be  more  vas- 
cular, and  consequently  making  pressure  on  the  nerve  matter,  inducing 
pains  which  are  denominated  neuralgic.  The  same  eifecLs  may  be  produced 
by  the  pressure  of  tumors  in  the  course  of  a  nerve,  or  by  thickening  of  the 
periosteum  in  the  bony  orifices  through  which  nerves  pass  in  emerging 
from  the  spinal  canal  or  cavity  of  the  cranium. 

In  all  such  cases  the  neuralgia  is  characterized  by  being  uniformly 
manifest  in  the  same  nerve  and  its  branches,  instead  of  radiating  in  dif- 
ferent nerves.  Familiar  illustrations  of  this  variety  of  neuralgia  are 
found  in  the  thickening  of  the  periosteum  and  sheaths  of  the  nerves  of 
the  face  as  they  make  exit  from  the  different  orifices,  especially  in  the 
patients  that  are  laboring  under  constitutional  syphilitic  difficulty,  as  well 
as  those  which  may  be  accompanied  by  chronic  rheumatic  afl'ections  of 
the  same  tissue.  Another  very  common  example  is  sciatica,  by  which  is 
generally  meant  a  painful  affection  of  the  sciatic  nerve,  induced  in  most 
cases  by  rheumatic  inflammation,  affecting  the  sheath  of  the  nerve  and 
the  fibrous  tissue,  at  the  orifices  through  which  the  roots  of  the  nerve 
emerge  from  the  spinal  cord.  The  second  class  of  cases  of  neuralgia  are 
those  which  depend  upon  some  influence  in  the  nervous  centers,  and  the 
pain  is  seldom  restricted  to  a  single  nerve  or  its  branches,  but  is  found  to 
radiate  through  a  number  of  nerves,  having  origin  or  connection  with  the 
same  portions  of  the  nervous  center,  but  distributed,  perhaps,  in  differ- 
ent directions.  Wherever  the  neuralgic  pains  thus  vary  from  one  nerve  to 
another,  either  in  the  trunks  of  the  nerve  or  in  the  branches  derived  from 
different  nerves  in  quick  succession  or  simultaneously,  it  is  evident  that  there 
is  either  primary  or  reflex  irritation  established  in  the  nervous  centers  to 
which  those  nerves  belong.  The  third  class,  or  those  which  are  dependent 
on  the  condition  of  the  blood  or  the  action  of  some  toxaemic  agent  in  that 
fluid,  differ  from  both  the  preceding  in  the  pains  being  felt  sometimes  in 
one  part  and  sometimes  in  another,  until  almost  every  sentient  nerve  will 
be  found  to  be  in  turn  more  or  less  affected.  The  pains  are  usually  of  very 
short  duration  at  any  one  point,  but  are  frequently  repeated  and  generally 
very  acute  while  they  last.  Familiar  examples  of  this  variety  of  neuralgia 
are  found  in  patients  subject  to  gout  or  rheumatic  gout,  not  infrequently 
from  the  influence  of  malaria  in  impoverishing  the  blood. 

Diagnosis. — Diagnostic  features  of  neuralgia,  by  which  it  is  to  be  dis- 
tinguished from  the  pains  dependent  either  upon  the  febrile  conditions  or 
local  inflammations,  are  chiefly,  the  sudden  development  of  the  pain,  its 
equally  sudden  disappearance,  usuilly,  entirely  unaccompanied  by  any 
constitutional  disturbance,  either  of  increased  temperature  or  disturbed 
circulation  and  in  the  interval  between  the  paroxysms  of  pain,  almost 
entire  exemption  from  tenderness  or  increased  sensitiveness  of  the  part  af- 
fected, although  increased  sensitiveness  of  the  part  is  often  present  during 
the  attacks  of  pain.  There  are  different  degrees  of  severity  in  neuralgic 
pains.  Some  are  slight  and  momentary,  others  are  sharp  twinging  or 
pricking;  and  still  others  so  excruciating,  piercing,  and  severe,  as  to  cause 
the  most  agonizing  suffering  of  which  we  can  conceive.  Wiiile  they  vary 
thus  in  the  degree  of  severity,  their  most  characteristic  feature  is  suddenness 
of  development  and  equally  sudden  disappearance;  they  are  always  paroxys- 
mal, never  continuous  beyond  a  very  brief  period  of  time  without  interrup- 
tion. 


768  NEUEALGIA. 

Pathology. — In  speaking  of  the  causes  which  may  give  rise  to  neuralgia, 
I  intimated  at  the  same  time,  the  essential  pathological  conditions.  Per- 
haps, in  the  nerve  itself,  it  may  be  said  that  the  essential  pathological 
condition  is  an  exaltation  of  the  susceptibility  of  the  nerve  structure. 
There  are  no  changes  of  such  a  character  as  to  be  perceptible  or  recogniz- 
able in  the  arrangement  of  the  nerve  cells,  or  the  intricate  structure  of  the 
nerve  matter,  which  can  be  said  to  be  characteristic  of  neuralgia.  But  the 
disease  appears  to  be  purely  of  a  functional  nature,  not  necessarily  ac- 
companied by  structural  changes.  As  I  have  just  remarked,  it  consists  in 
the  development  of  a  morbid  degree  of  susceptibility,  sometimes  accom- 
panied by  pressure  from  congestion,  thickening  or  induration  of  some  por- 
tion of  the  nerve  sheath  or  connective  tissue  surrounding  the  nerve.  In 
such  cases  the  continued  pressure  on  the  nerve  tissue  sometimes,  if  of  long 
duration,  results  in  atrophy,  or  wasting  of  the  nerve  cells,  and  increase 
or  sclerosis  of  the  connective  tissue  in  which  the  nerves  are  contained,  con- 
stituting a  true  sclerosis  of  the  nerve  cord.  Those  cases  of  neuralgia 
which  are  not  traceable  to  local  conditions  relating  to  individual  nerves, 
but  are  maiiifestly  derived  from  some  morbid  condition  of  the  nervous 
centers,  often  afford  no  indications  of  structural  change  that  can  be  identi- 
fieJ  as  a  cause  of  the  neuralgic  difficulty.  The  same  is  true  to  an  equal 
extent  in  regard  to  those  neuralgias  thac  are  dependent  on  changes  in  the 
condition  of  the  blood. 

Treatment. — From  the  brief  review  I  have  given  of  the  nature, 
symptoms  and  causes  of  neuralgia,  you  will  have  inferred  that  no  method 
of  treatment  can  be  recommended  as  applicable  to  the  cure  or  removal  of 
all  cases  indiscriminately.  But  every  case  must  be  treated  in  accordance 
with  the  indications  it  may  afford  on  careful  examination  in  reference  to  the 
causes  and  pathological  conditions  which  give  rise  to  it.  It  may,  indeed, 
be  said  th  it  the  object  in  the  treatment  of  neuralgia  is  two-fold:  one  sim- 
ply to  mitigate  pain,  and  consequently  the  suffering  of  the  patient,  for 
temporary  relief;  the  other  curative,  or  having  for  its  object  the  removal 
of  the  causes  and  pathological  conditions  givinar  rise  to  the  pain.  The 
first  may  be  accomplished  by  almost  any  efficient  anodyne  or  anassthetic; 
but  the  effect  is  temporary,  and  only  relieves  the  patient  while  the  anodyne 
or  angfsthetic  effect  is  maintained,  unless  other  measures  are  adopted 
simultaneously  for  removing  the  cause.  It  is  not  desirable  that  patients 
become  accustomed  habitually  to  the  use  of  opiates  and  anaesthetics 
for  the  temporary  relief  of  their  sufferings,  so  long  as  it  is  possible  by  any 
form  of  treatment  to  remove  the  cause;  for,  once  habituated  to  the  influ-j 
ence  of  these  agents,  they  become  a  serious  injury  to  the  patient's  health 
and  happiness,  and  sometimes  create  a  morbid  condition  of  the  nervous 
system,  more  difficult  to  eradicate  than  the  original  disease.  My  own 
observation  has  shown  that  a  considerable  proportion  of  those  who  become 
habitual  opium  eaters,"  or  users  of  large  quantities  of  morphine,  have 
commenced,  and  gradually  developed  their  habit  for  the  purpose  of  reliev- 
ino-  some  form  of  neuralgia,  or  temporarily  mitigating  some  painful  aifec- 
tion  that  should  have  been  relieved  in  some  other  way.  Consequently, 
while  chloroform,  and  otiier  anaesthetics,  morphine,  and  especially  mor- 
phine and  atropine  combined  and  used  hypodermically,  may  be  resorted  to 
for  promptly  relieving  neuralgic  pains  of  unusual  degrees  of  intensity,  yet 
I  am  satisfied  that  it  is  better  to  dispense  with  such  remedies  as  early 
and  to  as  great  a  degree  as  can  be  done  and  allow  the  patient  to  get  any 
reasonable  degree  of  rest  during  the  tim3  that  the  more  curative  treat- 
ment is  carried  out.  The  curative  measures  must,  of  course,  depend  up- 
on tho  pathological  condition  giving  ris3  to  the  neuralgic  disease.    Where 


TREATMENT.  769 

the  fault  is  in  the  condition  of  the  blood,  either  by  the  retention  of  toxe- 
mic and  irritating  ingredients,  as  in  gout,  rlieuinatism,  malaria,  or  vari- 
ous other  agents  capable  of  acting  through  the  blood  upon  the  nervous 
system,  the  remedies  chosen  must  be  such  as  are  known  to  be  most  effi- 
cient in  removing  these  agents,  and  these,  I  have  already  pointed  out  to 
you  when  speaking  of  the  treatment  of  gout,  especially  neuralgic  gout, 
rheumatic  gout,  and  in  the  treatment  of  malarious  fevers,  and  their  vari- 
ous sequelae;  consequently  it  is  not  necessary  to  re-enumerate  the 
remedies  for  these  purposes  at  this  time.  Many  cases  of  neuralgia  that 
are  dependent  upon  malarious  influences  coupled  with  impoverishment  of 
the  blood  have  a  strict  periodicity,  almost  as  much  as  the  ordinary  parox- 
ysms of  intermittent  fever;  coming  at  stated  times  in  the  day,  and  some- 
times every  second  or  third  day,  but  without  the  accompaniment  of  fever 
or  chills.  All  such  cases  require  the  efficient  use  of  quinine  or  other  relia- 
ble antiperiodics.  At  the  same  time  due  attention  should  be  given  to  the 
use  of  such  tonics  or  nutrients  as  will  most  efficiently  promote  the  forma- 
tion of  red  corpuscles,  and  the  restoration  of  a  healthy  condition  of  the 
blood.  Those  cases  of  neuralgia  dependent  upon  a  morbid  condition  af- 
fecting the  nervous  centers,  either  in  the  spinal  cord  or  in  the  brain,  can 
be  removed  only  by  removing  the  central  pathological  conditions.  Some- 
times these  consist  in  the  development  of  tumors,  pressing  upon  some 
portion  of  the  brain;  hematoma,  induced  in  advanced  life,  in  connection 
with  pachy-meningitis;  and  not  infrequently  those  changes  caused  by 
constitutional  syphilis,  either  in  the  production  of  thickening  of  the  dura- 
mater,  causing  pressure  upon  the  brain  or  spinal  cord  of  the  same  nature 
with  thickening  of  the  periosteum  or  the  bones  of  the  extremities,  or  by 
the  degenerative  change  styled  syphiloma,  affecting  the  nerve  struct- 
ures. All  these  are  conditions  capable  of  giving  rise  to  the  most  annoy- 
ing and  protracted  neuralgic  affections,  such  as  hemicrania  or  migraine, 
facial  neuralgias,  sometimes  severe  neuralgic  pains  in  the  arms,  especially 
near  the  insertion  of  the  deltoid  muscles,  and  occasionally  radiating 
through  the  pneumogastric,  as  far  as  the  stomach,  causing  violent  parox- 
ysms of  gastrodynia.  One  case  came  under  my  own  observation  within 
the  last  two  or  three  years,  in  which  an  adult,  in  the  early  period  of  life, 
had  suffered  for  a  number  of  years  with  the  most  severe  neuralgic  pains 
usually  affecting  the  nerves  of  the  head,  the  posterior  muscles  of  one  side 
of  his  neck  extending  down  to  the  shoulders  as  far  as  the  insertion  of  the 
deltoid  at  times,  and  which  in  its  later  stages  became  associated  with 
more  or  less  paralysis  and  with  temporary  turns  of  unconsciousness,  usu- 
ally not  lasting  more  than  a  few  hours  at  a  time.  This  patient  ultimately 
died  under  well-marked  symptoms  of  cerebral  disease,  and  the  post  mor- 
tem revealed  a  tumor,  evidently  originating  from  the  dura-mater  im- 
bedded in  the  posterior  lobe  of  the  left  hemisphere  of  the  brain,  fully  two 
inches  in  diameter  and  in  structure  presenting  all  the  appearances  of  a 
sarcoma.  Of  course  when  neuralgia,  either  alone  or  complicated,  depends 
upon  such  structural  changes  as  are  in  themselves  incurable,  no  amount 
of  treatment  will  do  more  than  palliate  the  suffering  of  the  patient,  until 
a  fatal  result  is  reached.  If  you  study  closely  the  general  diathesis  of  the 
patient,  the  influences,  hereditary  or  otherwise,  v,'hich  may  have  existed, 
and  capable  of  leading  to  deteriorative  changes  in  some  portions  of  the 
nervous  system,  you  will  generally  be  able  to  comprehend  clearly  the 
nature  of  the  case  you  have  to  treat;  and  in  those  that  are  capable  of  re- 
moval, to  adopt  such  treatment  as  will  be  successful  in  accomplishing  that 
result.  Of  course,  in  those  subject  to  constitutional  syphilis,  or  to  tuber- 
cular disease,  the  course  of  treatment  must  be  guided  by  the  nature  of  the 
49 


770  TETANUS. 

pntholon^ical  ch  ing9'?  belonging  to  each  case.  These  have  already  neen 
discussed  when  speaking  of  the  various  constitutional  diseases.  The 
form  of  neuralgia  which  is  most  common  and  most  amenable  to  judicious 
treatment  is  that  which  depends  upon  some  pathological  condition  relating 
directly  to  the  nerve  in  which  the  pain  is  located.  Yet  such  of  these  as 
depend  on  a  permanent  thickening  of  the  dura-mater  or  of  periosteum  in 
the  (orifices  of  bone  through  which  the  nerve  trunks  pass,  or  on  indura- 
tions that  have  become  permanent  in  the  sheath  of  the  nerve,  are  incura- 
ble unless  some  operative  procedure  can  be  brought  to  bear,  such  as  re- 
moval of  a  section  of  the  nerve  on  the  central  side  of  the  point  of  pressure 
or  disturbance,  which  is  sometimes  not  practicable.  In  those  dependent  on 
syphilitic,  rheumatic  or  gouty  influences,  the  treatment  usually  available 
for  the  removal  of  the  constitutional  affections,  if  aiiopted  and  pursued 
steadily  through  a  considerable  period  of  time  will  afford  the  patient  relief. 
In  several  cases,  both  of  hemicrania  and  facial  neuralgia,  which  had  ex- 
isted for  a  long  period  of  time  and  had  been  regarded  as  incurable,  I  found 
the  patients  to  recover  permanentlv  by  causing  them  to  use  steadily 
through  several  weeks  of  time  a  combination  of  the  iodide  of  sodium  and 
bichloride  of  mercury  with  conium  in  moderate  doses,  but  persistently 
three  times  a  day,  in  the  same  manner  as  for  treating  syphilitic  nodes  on 
any  of  the  exterior  portions  of  the  extremities  or  cranium.  By  pursuing 
such  a  course,  on  the  supposition  that  the  difficulty  was  a  thickening  of 
the  sheath  of  the  nerves,  or  at  the  point  of  their  exit  from  the  cranium  or 
spine,  such  supposed  thickening  has  disappeared,  or,  at  least,  the  neural- 
gias have  been  cured,  and  the  patients  in  all  respects  improved  in  their 
health  and  physical  condition.  In  a  word,  then,  the  curative  treatment  of 
neuralgia  consists  in  ferreting  out  as  accurately  as  possible  the  patholog- 
ical condition  on  which  it  depends,  and  adjusting  the  use  of  remedies  in  each 
individual  case  to  the  removal  of  such  condition,  whether  in  the  blood,  in 
the  nervous  centers  or  in  some  portion  of  the  individual  nerve  in  which 
the  pain  is  located. 


LECTURE    LXXVIII. 


Tetanus— Its  Causes,  Clinical  History,  Pathology,  Diagnosis,  Prognosis  and  Treatment. 

GENTLEMEN:  The  next  subject  to  which  I  will  direct  your  attention 
is  one  much  less  common,  but  far  more  destructive  in  its  effects,  when 
it  does  occur,  than  that  which  has  just  occupied  your  attention.  Tetanus 
is  a  disease  affecting  the  nervous  system,  which  has  been  known  and 
described  since  a  remote  period  in  the  history  of  medicine.  It  consists 
essentially  in  such  a  pathological  condition  of  some  portion  of  the  nerv- 
ous centers,  generally  in  the  spinal  cord,  as  will  induce  continuous,  rigid 
muscular  contraction  accompanied  by  exacerbations  of  greater  intensity, 
during  which  there  is  not  infrequently  clonic  spasms.  But  the  character- 
istic feature  of  the  disease  is  continued  rigid  muscular  contraction,  with 
more  or  less  intensity  of  pain.  In  the  great  majority  of  cases  the  first 
indications  of  the  disease  are  felt  in  the  muscles  that  move  the  lower  jaw, 
causing  that  degree  of  rigidity  of  the  temporal  and  masseter  muscles,  and 
sometimes  other  muscles  of  the  neck,  that  renders  it  difficult  and  painful 


SYMPTOMS.  771 

to  open  the  mouth;  and  when  the  disease  is  fairly  devolopod,  renderiiijr 
it,  in  most  cases,  impossible  for  the  patient  to  open  the  mouth  or  separate 
the  teeth  far  enough  to  allow  the  taking  of  eve-i  liquids  without  much  dif- 
ficulty. In  most  cases,  soon  after  the  rig-idity  of  the  muscles  of  the  jaws 
has  made  its  appearance,  a  similar  degree  of  rigidity  begins  in  the  mus- 
cles of  the  back  of  the  neck  and  along  each  side  of  the  spines  of  the  ver- 
tebrae. From  the  first,  it  is  difficult  for  the  patient  to  bend  his  neck  or 
turn  his  head,  and  soon  the  contractions  of  the  dorsal  muscles  draw  the 
l)ead  backward  and  bend  the  whole  body,  making  it  convex  anteriorly  and 
curved  or  concave  along  the  spine.  This  rigid  contraction  curvino-  the 
spine  backward,  causes  great  pain  to  the  patient,  particularly  throuo-h 
the  direction  of  the  diaphragm,  the  chest  and  the  epigastrium,  but  more 
especially  directly  through  the  central  portion  of  the  body  in  the  line  of 
the  diaphragm.  The  tetanic  contraction  of  the  muscles  is  continuous, 
allowing  no  positive  relaxation  at  any  period  of  time  during  the  progress 
of  the  disease.  But  while  there  is  constant  rigidity  or  contraction  there 
are  also  frequent  paroxysms  of  still  greater  contraction  of  a  temporary 
character,  constituting  paroxysms  of  spasmodic  action  in  which,  some- 
times, all  the  voluntary  muscles  are  called  into  action  and  may  be  more 
or  less  rigid.  The  patient  is  placed  in  extreme  suifering,  it  being  difficult 
for  him  to  obtain  breath,  and  causing  the  tension  and  tightness  through 
the  central  portion  of  the  body  to  be  extremely  distressing. 

In  the  mean  time  while  this  peculiar  muscular  rigidity,  manifested 
mostly  in  the  muscles  of  the  jaws  and  along  the  spine,  continues,  with  the 
intervention  every  few  minutes  of  more  decided  cramps  and  distress,  the 
disturbances  of  temperature  and  circulation  are  only  moderate.  Tne  tem- 
perature rises  but  little  above  the  natural  standard  in  the  great  majority 
of  cases;  the  pulse  usually  becomes  moderately  increased  in  frequency, 
rather  soft  and  weak,  the  extremities  cool,  lips  looking  a  little  dry,  the 
countenance  anxious  in  its  expression,  deglutition  more  or  less  difficult, 
respiration  rendered  inefficient  and  unsteady  on  account  of  the  frequent 
spasmodic  contractions  of  the  diaphragm  and  thoracic  muscles,  but  the 
discharge  of  urine  and  fteces  often  continues  nearly  natural.  The  symp- 
toms I  have  described  are  such  as  characterize  the  great  majority  of  cases 
during  the  first  three  or  four  days  after  the  development  of  the  disease. 
If  no  relief  is  obtained  during  that  time,  the  patient's  strength  beo-ins  to 
fail  somewhat  rapidly,  the  pulse  becomes  small  and  frequent,  the  mind 
sometimes  wandering,  the  extremities  become  cold,  bluish,  the  spasmodic 
paroxysms  increase  in  frequency  and  severity,  sometimes  bending  the 
body  backward  almost  into  a  half  circle  and  creating  the  most  intense 
distress  at  the  epigastrium,  almost  entire  inability  to  perform  the  act  of 
deglutition,  involuntary  discharges,  particularly  at  times  durino-  the  vio- 
lent spasmodic  paroxysms,  and  in  two  or  three  days  more  complete  exhaus- 
tion and  death  supervene.  Cases  of  a  little  more  moderate  character 
may  continue  from  nine  to  fourteen  days  and  yet  prove  fatal  from  exhaus- 
tion. Perhaps  a  majority  of  cases  of  tetanus  of  every  variety  terminate 
fatally  between  seven  and  nine  days.  Occasionally  a  case  is  met  with 
especially  of  traumatic  origin  which  will  run  a  more  protracted  course, 
the  tetanic  rigidity  being  limited  mostly  to  the  muscles  of  the  face  and 
jaws,  back  of  the  neck  and  upper  part  of  the  trunk.  Being  less  violent 
in  its  nature  or  in  its  course,  the  ■,  atient  does  not  become  exhausted  to  a 
fatal  degree  until  the  end  of  three,  four  and  even  six  weeks.  Cases  of 
tnat  duration  are,  however,  very  rare. 

A  '(itomical  Changes. — In  the  large  majority  of  cases  in  which  post- 
n  ortem  examinations  have  been   made,  no  lesions  of  structure  visible  to 


772  TETANUS. 

the  unassisted  eye  have  been  detected  in  the  spinal  cord  or  brain,  whicli 
could  be  considered  as  coiistituting  an  essential  part  of  the  tetanic  dis- 
ease. A  few  of  those  who  have  had  opportunity  to  make  post-mortem 
examinations  and  have  carried  these  examinations  to  a  microscopic  mi- 
nuteness, have  found  traces  of  sclerosis  in  some  portions  of  the  spinal  cord 
and  medulla  oblongata.  This  has  led  them  to  regard  the  disease  as 
essentially  iiiflammatory  in  its  nature,  and  akin  to  other  affections  involv- 
ing sclerosis  or  hypertrophy  of  the  connective  tissue  of  the  cord,  with 
wasting  and  impairment  of  the  nerve  cells.  And  it  is  probable  that  in 
many  of  the  cases  of  traumatic  tetanus  in  which  the  disease  runs  a  pro- 
tracted course,  minute  examination  would  show  some  degree  of  the 
structural  changes  which  are  included  in  the  word  sclerosis,  in  the  spinal 
cord. 

These  changes,  however,  are  undoubtedly  the  result  of  the  continuance 
of  the  disease  through  several  days.  The  aljsence  of  any  other  charac- 
teristic structural  changes  in  the  cerebro-spinal  nervous  centers  leads  to 
the  supposition  that  tetanus,  like  some  of  the  neuralgic  conditions,  is 
dependent  essentially  upon  the  development  of  an  exaggerated  or  morbid 
degree  of  the  elementary  susceptibility  of  the  nerve  tissue;  in  other 
words,  the  alteration  of  the  properties  inherent  in  the  nerve  matter, 
rather  than  any  appreciable  alteration  in  the  arrangement  of  atoms  con- 
stituting the  structure.  In  reference  to  the  etiology  of  tetanus,  the 
cases  met  with  in  practice  are  divisible  into  three  classes. 

Causes. — The  first  are  such  as  have  been  styled  idiopathic  tetanus  and 
have  usually  been  attributed  to  the  effects  of  cold  and  damp  air.  But  if 
it  be  true  that  they  are  caused  by  exposure  to  cold  and  damp  air,  it  is 
proper  to  presume  that  the  checking  of  eliminations  causes  retention  in 
the  blood  of  such  elements  as  prove  directly  irritative,  or  capable  of 
exalting  the  properties  of  the  nerve  matter  of  the  cord,  and  consequently 
inducing  tetanic  contraction  of  the  muscles  to  which  the  spinal  nerves  are 
distributed.  Anosher  class  of  cases  much  larger  than  that  just  alluded 
to  are  called  traumatic,  because  they  are  traceable,  more  or  less  directly, 
to  injuries  or  to  the  effects  of  surgical  operations.  Wounds  of  a  pene- 
trating and  lacerating  character  are  much  more  liable  to  give  rise  to  teta- 
nus than  the  incised  or  cleanly  cut  wounds.  Many  cases  have  originated 
from  very  trifling,  penetrating  wounds.  The  insertion  of  a  needle  or  pin 
into  the  palm  of  the  hand  or  bottom  of  the  foot  and  sometimes  in  other 
portions  of  the  surface  have  been  sufficient  to  act  as  exciting  causes  of 
the  disease.  But  much  more  frequently  the  disease  is  caused  by  such 
injuries  as  the  penetration  of  a  nail  into  the  bottom  of  the  foot  by  stop- 
ping upon  it  or  upon  any  sharp  substance,  whether  metal  or  wood. 
But  any  lacerating  or  penetrating  wound  or  the  performance  of  any  surgi- 
cal operation  by  which  nerves  or  their  sheaths  are  injured,  may,  in  the 
progress  of  the  case,  transmit  such  an  influence  to  the  spinal  centers  as  to 
develop  tetanic  rigidity  of  the  muscles  and  all  the  phenomena  and  results 
ascribed  to  tetanus.  How  wounds  or  injuries  produce  the  morbid  action 
which  we  see  in  these  cases  is  not  easy  to  explain.  Whether  it  is  wound- 
ing of  nerves  at  the  point  of  injury  causing  inflammation  in  the  nerve 
matter  and  the  transmission  of  the  irritative  influence  to  the  spinal  center, 
or  whether  in  all  such  cases  there  is  generated  in  the  wound  some  poison- 
ous or  septic  material  that  is  transmitted  along  the  nerve  matter  to  the 
central  portion,  or  through  the  blood  like  other  septic  poisons,  is  difficult 
to  determine.  The  modus  operandi  by  which  traumatic  tetanus  is  pro- 
duced, has  never  been  satisfactorily  explained.  To  say  it  is  a  reflex  irri- 
tation in  the  spinal  cord  from  some  point  of  the  periphery  of  the  sentient 


PROGNOSIS.  /  /  o 

nerves  is  simply  stating  the  fact  rather  than  giving  an  explanation.  The 
third  variety  of  tetanus,  that  which  occurs  in  young  children  or  infants, 
is  called  trismus  nascentlum.  It  is  usually  manifested  during  the  first 
two  weeks  after  birth,  sometimes  in  two  or  three  days.  In  some  coun- 
tries tetanus  in  young  children  is  of  frequent  occurrence.  Such  is  the 
case  in  Iceland  and  the  Hebrides  islands.  It  is  most  apt  to  occur  in  the 
infants  that  are  born  in  the  over-crowded  tenement  houses  or  in  the  midst 
of  bad  sanitary  conditions.  Although  met  with  occasionally,  it  certainly  is 
not  of  frequent  occurrence  in  our  own  country,  and  especially  in  this  city. 
For  in  a  busy,  general  practice  of  many  years  here,  with  a  due  propor- 
tion of  attendance  upon  both  mothers  and  their  infants,  I  have  met  with 
no  cases,  except  two  or  three,  to  which  I  have  been  called  in  consultation 
occurring  in  the  practice  of  others.  Some  writers  have  attributed  the  oc- 
currence of  tetanus  in  infants  to  the  condition  of  the  umbilicus  while  healr 
ing,  after  the  separation  of  the  cord,  in  the  same  manner  as  they  refer  the 
disease  occurring  in  the  adult  during  the  progress  of  wounds  or  injuries 
of  various  kinds.  But  the  disease  has  shown  itself  in  some  infants  after 
the  wound  left  from  severing  the  cord  had  entirely  healed,  and  conse- 
quently couid  have  had  no  possible  influence  in  producing  it.  One 
writer  has  attributed  the  occurrence  of  tetanus  in  infants  to  the  continu- 
ance of  the  pressure  of  the  occipital  bone  upon  the  posterior  part  of  the 
brain.  During  severe  and  protracted  labor  with  average  pressure  upon 
the  child's  head,  there  is  alwaj's  a  pressing  in  of  the  occipital  bone,  while 
the  parietal  juts  beyond  or  overlaps  it.  And  if  no  care  is  taken  to  keep 
tiie  child  upon  its  side  and  it  is  allowed  to  rest  the  back  of  the  head  upon 
the  arm  of  the  nurse  or  on  the  pillow,  when  lying,  this  depression  some- 
times does  not  become  restored  during  the  next  day  or  two  after  birth, 
but  renriins  and  produces  an  injurious  effect  upon  the  functions  of  the 
brain.  I  have  known  several  instances  of  this  kind  where  the  effect  was 
such  as  to  produce  a  constant  peevish  restlessness;  a  ravenous  desire  for 
nursing  as  if  it  felt  an  unusual  appetite,  and  yet  the  growrh  of  the  child 
by  nutrition,  generally  appears  to  be  entirely  suspended.  Some  instances 
of  this  kind  I  have  known  to  continue  for  three  months  after  birth.  The 
discharges  from  the  bowels  were  constantly  more  frequent  than  natural 
and  very  variable  m  color,  with  rapid  emaciation  and  very  little  tendency 
to  sleep  in  any  part  of  the  twenty-four  hours. 

x\nd  yet,  when  the  depressed  condition  of  the  occipital  bone  was  de- 
tected, the  child  placed  so  as  to  rest  the  head  upon  the  parietal  pro- 
tuberances, leaving  the  occipital  and  frontal  regions  entirely  free  from 
]iressure,  a  iaw  weeks  have  sufficed  to  cause  the  occipital  bone  to  resume 
its  position  on  a  level  with  the  bones  it  joins,  the  patient  soon  became  en- 
tirely free  from  the  previous  bad  symptoms,  and  regained  rapidly  its  ordi- 
nary flesh  and  strength.  I  have  seen  this  in  such  a  number  of  cases,  that 
I  have  deemed  it  desirable  to  mention  it  here,  if  for  no  other  purpose  to 
put  you  upon  your  guard  while  in  attendance  upon  mothers  and  their  new- 
born f)abies.  Observations  in  reference  to  the  condition  of  the  head  in 
very  young  cliildren  should  never  be  neglected.  The  symptoms  of  tetaims 
in  infants  are  the  s:-ime  in  all  respects  as  in  the  adult,  except  that  the  rigid- 
ity or  continuous  contraction  of  the  musclesis  not  as  severe,  while  the 
paroxysms  of  a  temporary  character  are  of  more  frequent  occurrence  than 
in  the  adult.  It  almost  always  runs  a  protracted  course  of  moderate 
severity,  but  ends  fatally  in  a  very  large  proportion  of  all  the  cases.  A 
few  cases  of  recovery  are  on  record,  but  the  tendency  of  the  disease  is 
very  generally  to  a  fatal  termination. 

J-'rognosis. — This  same  remark,  however,  may  be  made  in  regard  to  all 


V  /  4  TETANUS. 

the  varieties  of  tetanus — idiopathic,  traumatic  and  infantile — it  being  one 
of  the  most  severe,  painful,  and  fatal  affections  which  you  will  have  to 
treat. 

Treatment. — As  might  be  expected,  in  the  management  of  a  disease  so 
generally  tending  to  progress  unfavorably  until  reaching  a  fatal  result,  a 
great  varietv  of  remedies  have  been  tried  from  tinie  to  time,  but  without 
a  satisfactory  degree  of  success.  At  an  early  period,  opiates  were  used 
freely,  and  in  some  instances  in  very  large  doses.  And  at  the  present 
time  there  are  many  who  recommend  as  remedies  of  the  greatest  degree  of 
efficiency,  opium  and  the  alcoholic  class  of  angesthetics.  Some  give  from 
six  to  twelve  centigrammes  (gr.  i  to  ii)  of  opium  or  its  equivalent  of  mor- 
phine, every  hour  during  the  ^ay,  and  increase  it  at  night,  and  from  fifteen  to 
thirty  cubic  centimeters  (fl.|ss  to  |i)  of  brandy  between  each  of  the  doses  of 
the  opiate.  In  some  instances  during  the  same  period  of  time,  injections 
containing  hydrate  of  chloral  either  alone  or  combined  with  belladonna 
have  been  used  as  enemas,  and  more  or  less  chloroform  inhaled  for  tem- 
porary relief  from  the  more  violent  spasmodic  action,  thereby  subjecting 
the  patient  to  the  strong  influences  of  full  doses  of  opium,  chloral,  and 
chloroform  at  the  same  time.  At  an  early  period  after  I  entered  upon 
practice,  the  dependence  was  placed  largely  upon  opium,  and  patients 
were  given  such  quantities,  that  in  a  day  or  two  the  pain,  with  tetanic 
contractions,  ceased,  the  muscular  system  relaxed,  and  the  patients  passed 
into  a  profound  sleep.  In  such  cases  there  was  great  danger  that  the 
quantity  of  the  opium  which  had  accumulated  in  the  system  would  render 
the  sleep  one  of  profound  stupor  with  contracted  ])upils  and  speedy  death. 
I  must  caution  you  to  strictly  guard  against  giving  patients,  in  any  form 
of  disease,  opiates,  and  at  the  same  time  other  anodynes,  and  ansesthet- 
ics  in  different  modes,  rendering  it  almost  impossible  for  \  ou  to  estimate 
correctly  the  amount  of  influence  you  are  to  get  from  such  combination 
of  narcotics  and  anaesthetics  in  any  given  time.  If  the  doses  are  fre- 
quently repeated  it  is  impossible  for  the  system  to  eliminate  these  drugs 
as  fast  as  they  are  given.  For  instance,  when  opium  is  given  in  doses 
of  six  or  twelve  centigrammes  (gr.  i  or  ii)  every  hour,  if  at  the  end  of 
twenty-four  or  thirty-six  hours  the  tetanic  rigidity  begins  to  relax  and 
the  pains  cease,  it  is  evident  that  a  very  large  part  of  the  opium  taken 
is  still  in  the  system,  and  may  develop  not  only  sleep  but  a  dangerous 
degree  of  narcotism.  In  many  such  cases  the  patients  have  died  coma- 
tose— not  from  the  disease  but  from  the  eflPects  of  the  remedies  us"d. 

And  in  this  affection,  as  in  delirium  tremens,  there  was  a  period  maiiy 
years  since,  in  which  death  often  resulted  after  the  disease  had  subsided 
from  the  direct  effects  of  the  large  doses  of  narcotics  used  for  its  cure. 
If  it  be  true  that  tetanus  depends  primarily  upon  the  establishment  of  a 
peculiar  and  extreme  morbid  sensitiveness  in  certain  tracts  of  the  spinal 
cord,  connected  through  the  nerves  with  the  muscles  of  voluntary  motion, 
the  leading  indication  for  treatment  is  to  overcome  that  morbid  condition 
of  the  cord  without  seriously  interfering  with  the  continuance  of  other 
important  functions  of  the  economy.  From  the  knowledge  that  we  pos- 
sess of  the  modus  oxjerandi  of  drugs,  we  should  expect  to  accomplish 
more  in  removing  the  pathological  conditions  constituting  tetanus  by 
such  agents  as  physostigma  or  calabar  bean,  ergotin,  cannabis  indica, 
chloral  hydrate,  conium  and  hyosciamus,  than  from  any  other  remedies 
now  known.  All  these  agents  ap[)ear  to  be  capable  of  diminishing  more 
or  less  directly  the  morbid  excitability  of  the  cerebro-spinal  nerve 
centers. 

In  scanning  the  medical   literature   of  the  present  time   there   can    be 


TREATMENT.  /  /  O 

found  a  varied  amount  of  evidence  in  favor  of  the  curative  effects  of  the 
physostig-ina,  cannabis  indica  and  chloral.  Dr.  Watson,  of  Glasgow,  Dr. 
Eraser,  of  Edinburgh,  and  some  others,  have  reported  a  considerable  number 
of  recoveries  from  the  efficient  use  of  the  physostigma,  its  use  having  been 
commenced  early  and  pushed  to  as  large  a  degree  as  would  seem  to  be 
safe.  Of  the  eighteen  cases  reported  by  Dr.  Watson  as  treated  by  phy- 
sostigma, ten  recovered.  Dr.  W.  M.  Kane,  of  Philadelphia,  treated  a  case 
successfully,  in  which  the  ordinary  tincture  of  physostigma  was  given  in 
doses  of  from  four  to  twelve  cubic  centimeters  (fl.  3  i  to  3  iii)  every  few 
hours  for  several  days.  A  well-marked  case  that  came  under  my  own  ob- 
servation of  traumatic  tetanus  arising  from  the  penetration  of  a  nail  into 
the  bottom  of  the  foot,  although  not  recovering,  was  relieved  to  a  very 
marked  degree  for  several  days  by  the  use  of  the  physostigma,  cannabis 
indica  and  hydrate  of  chloral  in  combination.  The  effects  of  the  remedies 
were  such  as  to  lead  me  to  the  confident  conclusion  that  if  they  had  been 
commenced  in  the  beginning  of  the  disease,  it  would  have  been  controlled 
permanently.  But  the  first  four  days  in  the  progress  of  the  case  were 
passed  under  treatment  entirely  inefficient,  and  the  patient  had  conse- 
quently become  considerably  exhausted  before  being  put  upon  the 
remedies  that  I  have  just  mentioned.  Perhaps  the  whole  manage- 
ment of  ordinary  cases  of  tetanus  may  be  summed  up  in  the  direc- 
tion to  keep  the  room  of  the  patient  darkened,  as  perfectly  free 
from  noise  and  excitement  as  possible,  the  smallest  number  of  at- 
tendants that  will  be  adequate  to  administer  to  his  wants  efficiently, 
giving  milk,  beef  tea  or  other  liquid  nourishment  in  small  quantities 
while  the  patient  can  swallow  them,  and  after  a  while  add  the  use  of 
nutritive  enemas,  and  the  prompt,  efficient  and  persistent  use  of  such 
doses  as  will  be  safe,  of  one  or  more  of  the  remedies  I  have  just  men- 
tioned. If  they  are  used  separately,  my  confidence  would  be  first  in  the 
physostigma,  next  in  ergotin  and  cannabis  indica,  and  third  in  chloral. 
But  I  know  of  no  reason  why  we  should  not  a;ive  more  than  one  of  these 
remedies  at  the  same  time,  especially  a  combination  of  physostigma  and 
ergotin,  or  the  cannabis  indica  and  chloral.  The  extreme  exacerbations 
may  be  palliated  while  carrying  on  this  treatment  by  the  inhalation, 
temporarily,  of  sufficient  chloroform  to  mitigate  the  violence  of  the 
spasms.  Some  form  of  application  may  be  made  to  the  spine.  The  ap- 
plication of  bags  filled  with  ice  water  has  been  recommended  by  some, 
keeping  them  in  contact  with  the  whole  length  of  the  spinal  column. 
There  are,  however,  those  who  with  equal  confidence  advise  the  applica- 
tion of  bags  filled  with  water,  as  hot  as  can  be  borne.  While  still  others 
apply  early  thorough  counter  irritation,  blisters  and  sinapisms.  I  should 
expect  more  benefit  by  cupping  and  the  application  of  bags  tilled  with  water 
as  warm  as  can  be  conifortably  Ijorne,  kept  steadily  in  contact  with  the  whole 
length  of  the  spine  during  the  first  two  days,  and  if  the  disease  was  per- 
sistent, the  application  of  blisters  pretty  extensively. 

And  where  the  cuticle  had  been  raised,  after  the  blister  was  removed, 
two  or  three  centigrammes  (gr.  ^  to  ^)  of  morphia  might  be  sprinkled  upon 
the  raw  surface  two  or, three  times  in  the  tvrenty-four  hours,  and  it  would 
be  likely  to  be  taken  up  in  sufficient  quantity  to  produce  a  moderate  de- 
gree of  diminution  in  the  sensibility  of  the  sentient  nerves  of  the  part, 
and  thereby  help  some  in  alleviating  the  sufferings  of  the  patient.  There 
are  some  cases  of  tetanus  that  are  idiopathic  in  which  there  is  evidently 
more  or  less  of  the  malarious  influence.  Patients  have  been  subjected  to 
that  influence,  which  is  prevalent  in  the  atmosphere  where  they  live,  and 
the  symptoms  of  the  tetanic  disease  are  aggravated  at  certain  times  each 


776  HYDROPHOBIA. 

twenty-four  hours  sufficient  to  indicate  clearly  that  this  agent  has  pro- 
duc:^d  some  effect  upon  th6  patient.  Where  this  is  the  case,  while  the 
same  remedies  may  be  given  with  all  due  degree  ol'  activity,  moderately 
lull  doses  of  quinine  should  be  added  two  or  three  times  in  the  twenty-four 
hours.  For  if  it  can  not  be  well  taken  by  the  mouth,  it  can  be  used  hypoder- 
mically,  or  introduced  by  enemas  through  the  rectum.  In  the  treatment 
of  tetanub  in  young  infants,  trismus  nascentium,  chloral  has  gained  more 
reputation  than  any  other  one  remedy.  It  should  be  taken  in  fair  doses 
and  increased  gradually  till  either  the  disease  yields  or  the  patient  dies. 
Some  of  this  class  of  cases  have  been  treated  successfully  with  quinine. 
In  all  cases,  whether  those  in  which  the.  dieease  has  its  appearance  in 
youno-  infants,  or  in  traumatic  cases,  the  extent  of  the  wound  should  be 
carefully  examined,  and  every  source  of  irritation  as  far  as  practica])le 
removed  from  it.  If  there  is  any  evidence  of  the  generation  of  septic 
influences,  the  thorough  use  locally  of  antiseptics  should  not  be  omitted. 
In  a  few  instances  where  the  disease  has  originated  from  injuries  to 
sentient  nerves  in  one  of  the  extremities,  amputation  has  been  resorted 
to  with  a  very  few  reported  recoveries. 


LECTURE  LXXIX. 


Hydrophobia— Its  Causes,  Clinical  History,  Pathi^ogy,  Diagnosis,  Prognosis  and  Treatment. 

GENTLEMEN:  Hydrophobia  is  a  disease  not  of  frequent  occurre.nce 
but  one  of  the  most  fatal  with  which  the  physician  has  to  deal.  It  is 
supposed  to  originate  from  a  specific  poison,  usually  derived  from  wounds 
inflicted  by  some  of  the  lower  animals  laboring  under  the  disease.  How- 
ever, there  is  not  wanting  evidence  strongly  indicating  the  possibility  of 
the  disease  originating  without  any  such  communication  or  inoculation. 
The  lower  animals  chiefly  subject  to  the  disease  are  the  dog,  cat  and  other 
varieties  of  the  same  general  class  of  the  animal  kingdom.  As  the  dog, 
cat  and  other  domestic  animals  have  access  to  houses,  iyiid  are  more  sub- 
ject to  attacks  of  this  disease  than  any  other  species,  they  are  the  chief 
sources  from  which  individuals  become  inoculated.  The  popular  impres- 
sion is  that  the  disease  is  more  apt  to  originate  in  dogs  during  the  warm 
season  of  the  year  ;  hence  the  hottest  part  of  summer  has  received  the 
appellation  of  "  dog  days.''''  And  in  some  countries  and  municipalities 
even  up  to  the  present  time,  laws  are  enacted  and  enforced  requiring  dogs 
CO  be  either  shut  up  or  muzzled  durins"  the  heat  of  summer,  founded  en- 
tirely upon  the  supposition  that  their  liability  to  become  affected  with  hy- 
drophobia is  connected  with  the  prevalence  of  high  heat.  This,  however, 
is  erroneous,  as  has  been  shown  conclusively  by  statistical  investigation. 
A  paper  read  to  the  American  Medical  Association  a  few  years  since  pre- 
sented facts  and  statistics,  clearly  proving  that  rabies  or  hydrophobia  was 
quite  as  prevalent  among  the  domestic  animals,  particularly  the  dog, 
during  the  winter  as  the  summer;  consequently  there  is  just  as  much  ne- 
cessity of  muzzling  these  animals  or  preventing  their  running  at  large  at 
one  season  of  the  year  as  at  another. 

When  an  individual   has  been  bitten  by  an  animal   laboring  under  the 
disease,  and   in  such  a  manner  as  to  allow  the  introduction  of  any  of  the 


CAUSES.  777 

saliva  into  the  wound,  there  is  great  danger  that  inoculation  will  ensue, 
and  an  attack  of  the  disease  at  some  subsequent  period  will  follow.  I  say 
when  the  wound  is  inflicted  in  such  a  way  that  more  or  less  of  the  saliva 
of  the  rabid  animal  enters  the  wound,  because  there  is  sufficient  evidence 
to  justify  the  assertion  that  the  poison  is  conveyed  chiefly  in  the  sal'va. 
Inoculation  with  the  blood  of  a  rabid  animal  would  probably  produce 
similar  results.  But  in  the  infliction  of  wounds  by  biting  it  is  not  merely 
the  wound  that  causes  the  mischief,  but  it  is  caused  by  inoculation  with 
the  poison,  which  appears  to  impregnate  the  saliva  of  the  animal.  Conse- 
quently, when  a  bite  is  made  through  one  or  more  thicknesses  of  clothing, 
there  is  a  strong  probability  that  the  saliva  will  be  wiped  from  the  teeth 
of  the  animal  by  the  cl'ithing,  and  although  p3netrating  deep  enough  to 
inflict  a  wound  in  the  flesh,  it  will  often  happen  that  no  saliva  finds  its  way 
into  the  wound.  In  such  instances  tha  chances  are  strongly  in  favor  ot 
the  individual  escaping  any  subsequent  harm.  And  as  such  are  the  cir- 
cumstances under  which  a  large  proportion  of  the  bites  take  place,  it  can 
readilv  be  seen  why  it  happens  that  a  large  proportion  of  those  who  are 
actually  bitten  by  rabid  animals  do  not  suffer  attacks  of  the  disease.  So 
far  as  statistics  have  been  gathered  it  would  appear  that  on  an  average  not 
more  than  one  in  six  or  seven  of  those  bitten  ever  become  aff"ected  with 
the  disease,  which  is  probably  owing  to  the  circumstances  connected  with 
the  manner  of  the  bite,  as  I  have  just  explained.  The  escape  of  so  large 
a  proportion  opens  a  wide  field  for  deception  in  regard  to  the  use  of  pre- 
ventive measures.  It  is  natural  to  assume  that  the  remedies  which  are 
applied  to  the  wound  and  the  mode  of  treatment  adopted  are  the  causes  of 
preventing  the  subsequent  occurrence  of  the  disease,  when  in  fact  there 
may  have  been  no  inoculation  with  the  poison.  Where  inoculation  does 
take  place  the  wound  generally  heals  without  any  apparent  difficulty,  and 
the  individual  bitten  remains  apparently  well,  unless  the  mind  is  disturbed 
by  anxiety  and  apprehension  on  the  supposition  that  there  is  danger,  for  a 
period  averaging  from  one  to  three  months.  In  some  instances,  however, 
the  incubation  may  be  not  more  than  two  weeks,  in  others  it  may  extend 
to  six  or  twelve  months,  or  if  we  are  to  credit  the  cases  that  are  reported, 
it  mav  remain  dormant  for  two  or  three  years,  and  then  develop  all  the 
phenomena  and  results  of  genuine  hydrophobia.  I  must  confess,  however, 
that  it  is  a  little  difficult  to  conceive  how  a  poison  that  has  remained 
dormant  so  long  a  period  should  again  assume  an  activity  sufficient  to  pro- 
duce so  violent  a  disease. 

It  is  more  probable  that  in  such  cases,  if  all  the  facts  could  be  known, 
either  the  disease  originated  spontaneously,  independent  entirely  of  the 
long-previous  bite,  or  that  a  subsequent  inoculation  had  taken  place  and 
escaped  record.  That  the  disease  may  and  does  originate  in  some  rare 
instances  without  definite  inoculation,  I  think  we  are  justified  in  believ- 
ing, although  such  occurrence  may  be  very  rare.  A  case  came  under  ray 
own  observation  in  the  wards  of  Mercy  Hospital  a  few  years  since,  in 
which  no  evidence  could  be  found  either  within  the  recollection  of  the 
patient  or  any  of  his  frienr's  and  acquaintances,  that  he  had  been  bitten 
by  a  dog  or  any  other  domestic  animal.  No  trace  of  injury  could  be 
found  upon  his  person,  and  during  the  initial  symptoms  no  particular 
locality  afforded  tenderness,  which  would  suggest  the  possibility  of  a 
previous  bite  having  been  inflicted.  Yet  the  case  presented  every  symp- 
tom of  typical  hydrophobia,  and  proceeded  as  usual  to  a  fatal  termination. 
This  was  in  the  person  of  a  man  in  the  early  period  of  adult  life,  whose 
business  was  that  of  a  railroad  engineer,  but  who  a  few  weeks  previous  to 
his  attack  had  been  but  little  occupied  in  his  business,  and  had  pu.-sued  a 


778  HYDROPHOBIA. 

rather  intemperate  course  of  life,  inJulgingin  frequenting  dancing  parties 
and  places  of  amusement  till  lat^e  hours  of  the  night,  and  of  course  subject 
to  excessive  excitement  during  the  three  or  four  weeks  previous  to  his 
attack. 

Symj)toms. — The  symptoms  of  hydrophobia  in  most  subjects  usually 
commence  with  the  appearance  of  unusual  mental  anxiety  and  depression, 
coupled  with  a  peculiar  nervous  excitability.  The  countenance  is  ex- 
pressive both  of  anxiety  and  despondency.  There  is  but  little  disposition 
to  converse,  little  or  no  tendency  to  sleep,  the  mind  is  easily  agitated  and 
quickly  provoked  to  ill  temper.  These  phenomena  usually  are  followed 
in  from  twelve  to  twenty-four,  or  at  the  longest  fo.ty-eight  hours,  by  the 
addition  of  a  feeling  of  constriction  in  the  oesophagus  and  larynx,  soon 
increasing  to  that  of  decided  spasmodic  action. 

The  choking  causes  the  patient  to  make  attempts  to  swallow  with  ina- 
bility to  do  so,  and  the  gasping  for  breath  may  be  coupled  with  intense 
momentary  mental  excitement.  The  pulse  now  begins  to  be  more  fre- 
quent than  natural  and  a  little  elevation  of  temperature.  These  phenom- 
ena soon  assume  the  form  of  distinct  paroxysms  of  spasmodic  disturbance, 
particularly  in  the  muscles  concerned  in  respiration  and  deglutition.  And 
these  spasmodic  movements  are  excited  by  almost  every  trifling  occurrence 
that  may  take  place.  An  attempt  to  drink  any  kind  of  fluid  will  provoke 
them  to  such  an  extent  as  to  threaten  strangulation  or  arrest  of  breathing. 
Medicines  may  be  directly  refused,  and  the  patient  may  push  away  food 
and  drink  as  though  repugnant,  when  the  real  difficuity  is  the  distress 
that  is  occasioned  by  the  spasmodic  action  provoked  by  the  attempt  to 
take  it.  Any  attempt  to  converse,  any  sudden  noise,  movements  of  the 
body  or  footsteps  in  the  room,  will  wery  generally  provoke  more  or  less  of 
this  spasmodic  action  of  the  muscles  of  the  chest,  neck  and  throat.  And 
even  where  every  source  of  annoyance  is  avoided,  the  room  kept  darkened 
and  as  still  as  it  is  possible,  the  paroxysms  of  spasmodic  action,  though  not 
so  frequent,  will  occur  usually  every  five,  ten  or  fifteen  minutes,  and  pro- 
duce great  excitement  in  the  patient's  mind  from  a  sensa  of  suffocation  and 
apprehension  of  choking,  leading  sometimes  to  sudden  and  violent  exer- 
tion. After  the  first  two  da3^s  have  passed,  in  most  cases,  the  paroxysms 
are  accompanied  by  some  delirium.  The  gasping  for  breath  and  struggles 
of  the  patient  will  sometimes  in  the  midst  of  a  paroxysm  cause  such  irreg- 
ular breathing  as  to  produce  frothy  saliva  from  the  mouth  and  occasionally 
sudden  closing  of  the  jaws,  which  may  catch  folds  of  the  inside  of  the 
cheek  or  edges  of  the  tongue  and  inflict  wounds  upon  them,  as  in  other  in- 
stances of  violent  spasmodic  action.  In  the  popular  mind  these  struggles 
and  this  sudden  closure  of  the  jaws  and  delirious  condition  of  the  patient, 
are  construed  into  efforts  at  biting.  Sometimes  the  irregular  respiratory 
movements  occasioned  by  the  spasm  cause  a  stertorous  noise  in  the 
breathing,  sometimes  quite  loud,  which  are  also  construed  into  resem- 
blances to  the  barking  of  a  dog.  Bit  the  popular  notion  of  patients  la- 
boring under  hydrophobia  biting  and  barking,  are  mostly  erroneous.  They 
suffer  the  most  intense  distress  during  the  exacerbations,  and  are  some- 
times so  delirious  as  to  make  extraordinary  exertion  to  get  out  of  bed,  and 
when  attendants  restrain  them,  manifest  a  violence  of  temper  as  a  part  of 
their  delirium,  and  not  as  a  special  manifestation  of  the  disease.  The 
strength  of  the  patient  fails  rapidly  in  the  progress  of  the  disease  ;  and 
the  difficulty  of  taking  medicines  without  increasing  the  violent  parox- 
ysms to  which  the  patient  is  subjected  often  limit  the  means  of  adminis- 
tration to  hypodermic  injections,  and  inhalation  of  anaeithetic  vapors  al- 
most entirely.     The  patients  become    prostrated  so  rapidly   that  they   usu- 


ANATOMICAL    CHANGES.  11\) 

ally  sink  into  a  state  of  fatal  exhaustion  in  from  thr^e  to  eig-ht  Jays;  tde 
averag-e  duration  of  the  disease  being  about  five  days.  The  disease  is  dis- 
tinguished from  other  spasmodic  and  cerebral  affections  mainly  by  the 
mental  phenomena,  accompanied  by  the  peculiar  paroxysms  of  spasmodic 
action  limited  in  a  large  degree  to  the  muscles  concerned  in  the  act  of 
respiration  and  deglutition,  together  with  inability  to  take  anything,  in 
the  way  of  food  or  drink,  without  provoking  paroxysms  of  much  greater 
activity,  and  the  consequent  apparent  repugnance,  not  to  water  alone,  i)ut 
to  everything.  Although  the  patients  manifest  intense  desire  for  drink 
during  the  active  progress  of  the  disease,  they  are  deterred,  not  by  dread  of 
water,  but  by  the  dread  of  the  extreme  distress  and  threatened  suifocatioa 
that  follows  the  attempt  to  take  it. 

Anatomical  Changes. — In  nearly  all  the  cases  which  have  been  re- 
corded embracing  post  mortem  examinations,  evidences  of  decided  con- 
gestion or  hyperiemia  of  the  vesseis  bordering  upon  actual  inflammation, 
have  been  found  in  the  upper  part  of  the  spinal  cord,  medulla  oblongata, 
convolutions  at  the  base  of  the  brain,  and  in  some  cases  extending  more  or 
less  into  the  central  ganglia  of  the  cerebrum.  The  case  to  which  I  al- 
luded as  occurring  in  the  Mercy  Hospital  was  examined  after  death  and 
the  medulla  oblongata,  crura  cerel)ri,  cerebellum  and  pyramidal  bodies 
were  most  intensely  injected  with  blood  of  a  bright  arterial  hue.  The  in- 
jection of  vessels,  or  congestion,  extended  along  the  lower  part  of  the  pos- 
terior lobes  of  the  cerebrum,  and  also  between  the  lower  surfaces  of  the 
posterior  lobes  and  the  cerebellum.  There  was  also  increased  fullness  of 
the  vessels  as  far  anterior  upon  the  base  of  the  brain  as  the  origin  of  the 
optic  and  pneumo-gastric  nerves.  The  upper  part  of  tha  cerebral  hemi- 
spheres presented  but  little  alteration  from  the  natural  condition;  the  in- 
terior of  the  brain  also  retained  the  normal  degree  of  density  and  structural 
appearance,  but  when  cut  through  below  the  corpus  caliosum  nearer  to 
the  base  of  the  brain,  most  of  the  vessels  oozed  blood  in  a  way  to  indicate 
some  degree  of  increased  fullness.  A  very  correct  model  of  the  medulla, 
upper  part  of  the  spinal  cord,  and  whole  base  of  this  brain,  is  still  open 
for  your  examination  in  the  ujuseum  of  the  college.  So  far  as  post  mortem 
appearances  go,  the}'  would  induce  us  to  regard  the  medulla  oblongata  as 
the  chief  center  of  pathological  change.  And  if  we  remember  that  the 
muscles  of  respiration  and  deglutition  are  more  profoundly  disturbed  dur- 
ing the  progress  of  the  disease  than  any  others  we  shall  see  that  the  symp- 
toms and  post  mortem  appearances  are  in  harmony  with  each  other.  Un- 
doubtedly, the  specific  poison  which  gives  rise  to  the  disease,  when  it 
originates  from  inoculation,  spends  the  larger  part  of  its  disturbing  influ- 
ence directly  upon  this  great  cerebro-spinal  center  of  the  nervous  struct- 
ures. And  it  is  the  profound  interference  with  the  functions  of  respira- 
tion and  deglutition,  that  so  rapidly  causes  prostration  and  so  certainlv 
leads  to  a  fatal  result. 

Prognosis. — While  there  are  on  record  several  cases  claiming  to  be  gen- 
uine cases  of  hydrophobia  derived  from  inoculation,  or  the  bites  of  rabid 
animals,  reported  as  cured,  it  must  be  acknowledged  that  the  prognosis  in 
this  disease  is  extremely  unfavorable.  If  the  cases  reuorted  as  recoverino- 
were  genuine  hydrophobia,  still  their  number  compared  with  the  whole 
number  of  cases  is  so  small  that  it  would  represent  the  disease  as  one  of 
the  most  uniformly  fatal  that  the  physician  is  called  upon  to  treat. 

Treatment. — From  the  remark  I  have  just  made  you  will  infer  that  there 
are  yet  known  no  specific  remedies  for  the  cure  of  hydrophobia;  and,  in 
fact,  there  are  none  in  which  we  can  place  very  strong  confidence,  as  to 
their  ability  even  to  modify  materially  its  progress,  except  merely  to  mit- 


780  HYDROPHOBIA. 

igate  the  patient's  suffering.     The  cases  which  have  been  reported    cured 
have  been    subjected   to  various    methods  of   treatment.     One    or  two  are 
chiimed  to  have  been  cured  by   thorough,  hot   water  baths;  one  or  two  by 
the  use  of  curare;  I  think  one  is  claimed  to  have    recovered   under  the  in- 
fluence of  large  doses  of  cannabis  indica;  one  by  chloral   hydrate;  and  an- 
other is  said  to  have  recovered  under  the  influence  of  apomorphia,  used  by 
hypodermic  injection.     I  will    not  go  so  far  as  some  writers   have  gone  in 
asserting  that  ail  these   reported    cases  are    fallacious,  or   that   they    were 
founded   upon    mistaken    diagnosis,  and  that  the   disease  treated  was  not 
real  hydrophobia.     I  see  no  reason  why  cases  may  not  be  cured,  provided 
the  patient  can  be  kept  from  a  fatal  degree  of  exhaustion  until  the  modified 
or  limited   amount  of  congestion    is   relieved  and   the   poison   eliminated 
from  the  system.     And  if  it  be  true,   as  I.  have   previously  suggested,  that 
the  disease  may  originate  spontaneously,  with  the  same  form  of  congestion 
and  local  disturbance  of  the  cerebro-spinal   centers,  developing  symptoms 
precisely  the  same  in  all  respects,  except  the  absence  of  the  specific  poison, 
there  would  be  no  reason  wliy  this  idiopathic   development   of  the   disease 
might  not  yield  under  the  influence  of  remedies  calculated  to  restore  the 
contractility  of  the  smaller  vessels  and  lessen  the   peculiar  grade  of  irrita- 
bility involved    in  the    disease.     But    while  cases   have  been    reported  as 
cured  under  various  remedies,  J  think  each  and  all  of  these  remedies  have 
been  tried  in  other  cases  with  the  most  heroic   faithfulness  by  every  mode 
of  administration  practicable,  and  yet   have  failed  so  uniformly  as  to  leave 
us  very  little  confidence  in  their    efficacy.     It   would    seem   that    in  those 
cases    derived     from     inoculation    of   poison    from     rabid    animals   there 
were  three  leading  indications   to   be  kept  in    view  in  the   manageTuent  of 
each  case:     First,  to  administer  as   efficiently  as  possible   such  antiseptic 
remedies  as  might  be  supposed  to  exert  a  neutralizing  or  destructive  influ- 
ence upon   the  poison  itself.     Second,  such  as  are   calculated  to  overcome 
or  counteract  the  extreme   functional   disturbances  or   spasmodic    actions 
which  threaten  to  suffocate  or  strangulate  the  patient.     This  would  require 
the  most  efficient  antispasmodics  or  nervous   sedatives   that  we  possess. 
The  third  indication,  founded  upon  post  mortem    appearances,  would  lead 
us  to  use  whatever  remedies  may  be  found  practicable  for  lessening  cere- 
bral fullness,  or  hyperremia  of  the.  vessels  of  the  medulla  and  base  of  the 
brain.     If  it  be  supposed  that  the  poison    itself  is  essentially    composed  of 
organic  germs,  it  could  be  met  probably  with  no  more    efficient  germicide 
than  the  bichloride  of  mercury  in  as  active  doses  as  the  patient  would  bear 
without  pioducing  injurious  results.     This  substance  has  been  proven  by 
several  direct  experimenters,  especially  Dr.  Steinberg,  of  the  army,  and 
Dr.  H.  O.  Marcy,  of  Boston,  to  be,  by  far,  the  most  active  agent   in  df^- 
stroymg  the  vitality  of  all  known  forms  of  bacteria,  micrococci  and  bacillt 
that  we  possess.     Bat  aside  from  this,   it  would   also  act  as  an  alterative, 
using  the  phraseology  of  former  times,  in  lessening  tiie  inflammatory  action, 
and  theie.ore  would  be  somewhat  calculated  to  fulfill  the  third  indication 
we  have  mentioned  as  well  as    the   first.     The  second    indication,  to  allay 
spasmodic  action  by  lessening  the  extreme  morbid  excitability  or  irregular 
nerve  influence   radiated  from  the  medulla  upon  the  muscles  of  respiration 
a. id  deglutition,  a  temporary    resort    may  be  had    during  the   most  violent 
paroxysms    to    ansesthetics    by    inhalation.     Chloroform,    ether,  nitrate  of 
amy!,  using  due  caution  in  their   administration,  may  be    made   greatly  to 
mitigate  the  suffering' of  the  patient,  although  these  agents  appear  to  exert 
no  curative  effect.     In  the  same  direction  we  might  expect  much  fi'om  in- 
troducing in  any  practical   way   into  the  system    etfleient    doses,    either  of 
cannabis  ind.ca  physostigma,   ergotin,  or  chloral    hydrate.     To  attempt  to 


PEOPHYLAXIS.  781 

put  patients  into  hot  vapor  baths,  and  still  more  into  hot  water  baths,  in- 
volves a  degree  of  disturbance  that  usually  aggravates  the  suffering  and 
renders  more  frequent  the  violent  spasms,  and  thereby  tends  to  produce 
more  harm  than  benefit.  The  intelligent  selection  of  remedies  aimed  at 
the  accomplishment  of  the  three  indications  I  have  mentioned,  and  their 
judicious  and  persevering  use  according  to  the  indications  and  principles 
■which  have  been  explained,  will  afford  the  patient  the  best  chance  of  re- 
covery. The  patient's  room  should  be  darkened  and  kept  free  as  possible 
from  every  variety  of  annoyance  or  unnecessary  disturbance,  with  efforts 
to  sustain  the  patient  with  nourishment  either  by  injections  or  by  swallow- 
ing, if  the  latter  act  can  possibly  be  perfoi  med. 

JProjyhylaxis . — In  regard  to  a  disease  so  uniformly  fatal,  and  in  which 
the  cause  is  very  generally  known  as  consisting  of  a  poison  by  the  direct 
biting  or  infliction  of  a  wound,  the  subject  of  prophylaxis  becomes  one  of 
paramount  importance.  Almost  the  only  safety  the  patient  may  be  sup- 
posed to  have,  if  introduction  has  certainly  taken  place,  is  based  upon 
the  success  of  measures  that  may  be  adopted  to  prevent  the  poison  from 
developing  in  the  system.  The  means  of  prevention  may  be  divided  into 
two  classes:  one  having  for  its  object  the  actual  prevention  of  disease, 
by  the  destruction  of  the  poison  before  it  can  be  taken  up  by  the 
vessels  of  the  wound,  and  the  other  the  prevention  of  the  multiplication  of 
the  poison  in  the  system  after  it  may  have  been  absorbed.  The  first  object, 
that  of  preventing  the  poison  from  being  absorbed,  is  regarded  by  many 
as  the  only  reliable  method,  and  the  means  consist  of  immediate  excision 
of  the  part  bitten  in  toto.  Where  the  opportunity  for  doing  this  is 
afforded  almost  immediately  after  the  infliction  of  the  wound,  and  it  is  cer- 
tainly known  that  the  wound  is  that  of  a  rabid  animal,  and  has  been  in- 
flicted directly  upon  the  naked  part  and  not  through  the  clothing,,  it  would 
be  justifiable  to  excise  it,  cutting  out  the  flesh  so  completely  as  to  be 
pretty  sure  of  removing  all  the  poison.  After  such  excision,  cauterize 
the  surface  that  is  left  and  wash  it  thoroughly  with  some  antiseptic  wash. 
But  it  is  not  often,  or  at  least  it  is  only  in  a  minority  of  the  cases,  that 
the  surgeon  is  so  near  at  hand,  or  the  parties  so  self-possessed  in  their  in- 
telligence, that  immediate  excision  is  available.  Where  this  is  not  availa- 
ble most  writers  encourage  the  direct  application  of  caustics.  For  this 
purpose  strong  nitric  acid,  nitrate  of  silver  and  various  other  caustics, 
such  as  un dilute  carbolic  acid,  have  been  recommended  and  extensively 
used.  Where  the  wound  has  penetrated  too  deeply  to  allow  complete 
excision  with  the  knife,  caustics  must  be  made  to  penetrate  as  deeply  as 
the  wound  itself.  Another  means  of  destroying  the  poison  before  it  is 
taken  up  is  by  the  application  of  efficient  antiseptic  solutions.  Pretty 
strong  solutions  of  carbolic  acid,  the  sulphite  or  hyposulphite  of  sodium  or 
a  solution  of  the  permanganate  of  potassium,  and  still  more  a  solution  of 
the  bichloride  of  mercury  may  be  made,  not  only  directly  to  the  surface 
of  the  wound,  but  by  saturating  fibers  of  lint  and  crowding  them  as  near 
to  the  bottom  of  the  wound  as  possible. 

After  the  wound  has  been  thoroughly  wet,  lint  may  be  saturated  with  a 
solution  of  either  of  the  substances  that  I  have  named,  and  allowed  to  re- 
main over  the  wound  constantly,  the  wetting  being  renewed  several  times 
a  day,  thereby  rendering  it  probable  that  the  solution  used  would  be  ab- 
sorbed through  the  same  vessels  freely  that  were  most  likely  to  have  taken 
up  the  poison,  if  any  had  really  entered  the  vascular  system.  But  the 
efficacy,  you  will  readily  see,  of  any  of  these  means,  whether  excision, 
cauterization  or  saturating  the  wound  with  antiseptics,  depends  entirely 
upon  the  question  whether  they  have  been  made  to  reach  the  poison  or  to 


782  HYDIIOPHOBIA. 

intercept  it  before  It  has  entered  the  circulation  of  the  blood.  After 
having  entered  the  circulation,  it  can  not  be  claimed  that  any  of  these 
agents  are  reliable.  According  to  my  observations,  not  more  than  one  in 
ten  of  all  the  bites  that  are  inflicted  by  dogs  or  animals  that  are  supposed 
to  be  rabid  are  brought  under  the  eye  of  any  person  prepared  to  apply 
any  of  these  remedies  efficiently  in  less  than  from  one  to  ten  hours  from 
the  time  of  the  infliction  of  the  bite.  And  you  all  know  that  the  shortest 
of  the  periods  named,  ^.  e.,  one  hour,  is  sufficient  for  any  active  poison  to 
be  taken  more  or  less  into  the  vessels,  when  in  contact  with  the  surface  of 
an  open  wound.  Consequently,  in  much  the  larger  per  centage  of  cases 
it  must  be  acknowledged  that  the  poison  has  probably  passed  beyon(i  the 
reach  of  local  treatment.  This  must  not  deter  us  from  adopting  local 
treatment  as  a  possible  means  of  destroying  the  poison  before  it  has  en- 
tered the  circulation.  So  far  as  remedies  are  concerned,  I  should  hold  it 
to  be  a  duty  to  apply  some  form  of  local  treatment  in  every  case  presented, 
if  no  longer  time  than  ten,  twelve  or  twenty-four  hours  had  elapsed  from  the 
time  of  the  infliction  of  the  wound.  As  to  the  relative  value  of  the  different 
modes  of  local  treatment,  I  am  not  prepared  to  make  a  positive  statement. 
The  great  preponderance  of  advice  is  to  excise  or  cauterize  or  both. 
But  for  the  last  twenty  years  I  have  done  neither,  but  have  contented 
myself  with  the  thorough  saturation  of  the  wound,  as  soon  as  the  bites 
have  been  brought  to  my  notice,  with  solutions  of  known  strength,  either 
of  the  bichloride  of  mercury  or  of  a  combination  of  carbolic  acid  and  the 
hyposulphite  of  sodium.  When  the  latter  remedies  are  to  be  used,  I 
make  a  solution  containing  at  least  twenty  per  cent,  of  the  carbolic  acid 
and  thirty  per  cent,  of  the  hyposulphite  of  sodium;  and  first  introduce 
this  solution  as  deeply  into  the  wound  as  possible,  and  subsequently  keep 
lint  constantly  wet  with  the  solution  laid  directly  over  the  part,  re- 
newing it  often  enough  to  keep  it  moist  constantly  for  two  or  three 
days.  At  the  same  time,  from  the  very  first  knowledge  of  the  case,  I  have 
uniformly  ordered  a  solution  of  the  hyposulphite  of  sodium,  with  tincture 
of  belladonna  to  be  administered  internally.  I  give  the  hyposulphite 
of  sodium  in  doses  of  six  decigrammes  (gr.  x)  with  the  same  number  of 
minims  of  the  tincture  of  belladonna  the  first  forty-eight  hours  at  intervals 
of  once  in  two  or  three  hours,  and  subsequently  continue  them  regularly 
three  times  a  day  for  at  least  four  weeks  or  during  the  greater  part  of  the 
first  month  after  the  infliction  of  the  bite.  I  say,  this  has  been  my 
uniform  treatment  of  all  wounds  that  have  come  under  my  observation, 
suspected  of  having  been  inflicted  by  rabid  animals.  I  have  taken  some 
pains  to  learn  the  results  in  as  many  of  the  cases  as  possible,  and  there 
has  not  yet  occurred  a  single  instance  in  which  hydrophobia  has  ensued  in 
any  of  the  parties  that  have  been  brought  under  my  observation  and  thus 
treated,  although  one  or  more  cases  of  hydrophobia  occur  in  this  city  and 
result  fatally  almost  every  year. 

It  does  not  follow,  however,  from  these  facts,  that  any  one  of  the  cases 
would  have  had  hydrophobia  if  they  had  not  been  treated  at  all;  for  a  ve'ry 
large  proportion  of  all  the  cases  of  wounds  or  bites  that  men,  women  and 
children  receive  from  dogs  and  cats,  whether  belonging  to  their  house- 
holds or  in  the  streets,  that  they  suspect  may  be  rabid,  are  cases  in  which 
the  animal  had  nothing  of  the  disease  suspected.  It  is  to  be  presumed 
that  occasionally  one  is  rabid.  But  one  difficulty  in  the  way  of  carrying 
out  an  investigation  concerning  the  condition  of  the  suspected  animal,  so 
as  to  determine  whether  the  bites  that  you  are  called  upon  to  treat  are 
inflicted  by  rabid  animals  or  not,  results  from  the  almost  universal  prac- 
tice of  immediately  killing  the   animal.      A  dog  is  encountered  in    the 


SUX-  STKOKE.  783 

s'reet  looking  tired,  hagfrard,  acting  cross,  snaps  at  parties  who  encounter 
liim,  soon  attracts  attention  and  in  consequence  of  being  followed  up  or 
meddled  with,  becomes  still  more  cross,  endeavors  to  bite  his  way,  and 
infl'cts  wounds  upon  one  or  more  parties.  The  animal  is  immediately 
dispatched  and  put  out  of  the  way.  No  person  competent  to  judge  has 
seen  him,  and  being  dead,  there  is  no  mode  of  determining  positively 
whether  he  was  laboring  under  any  disease  of  the  nature  of  hydrophobia 
or  not.  This,  however,  is  the  history  of  nine  out  of  ten  of  all  the  cases 
that  create  alarm  in  the  community.  If  we  make  allowance  for  these,  and 
then  also  make  some  allowance  for  the  failure  in  many  of  the  cases  of 
really  rabid  animals  to  convey  the  poison  through  the  clothes  which  the 
teeth  penetrate  before  they  enter  the  flesh,  we  shall  see  that  of  all  those 
bitten  only  a  small  number  are  really  inoculated.  And  therefore  it  is 
quire  probable  that  any  person  occupying  a  wide  field  of  observation, 
would  have  a  number  of  these  wounds,  which  are  suspected  to  have  been 
inflicted  by  rabid  an'mals  presented  to  him  and  subjected  to  treatment  of 
some  kind,  in  which  there  would  have  been  no  bad  results  developed 
if  there  had  been  no  trsatment  at  all.  And  yet  no  one,  as  a  physician, 
would  be  justified  in  assuming  that  every  case  coming  to  him  was 
harmless,  and  therefore  refuse  to  take  proper  precautious.  On  the 
contrary,  the  possibility  of  the  introduction  of  so  deadly  a  poison  should 
cause  us  as  intelligently  as  possible  to  neutralize  it  from  without,  by 
agencies  most  certain  to  destroy  it  before  it  reaches  the  interior,  and  with 
equal  promptness  to  introduce  into  the  blood,  as  freely  as  will  be  borne 
without  injury  to  the  patient,  such  agents  as  are  supposed  to  be  most  ef- 
ficient for  destroying  all  eKisting  germs,  and  of  preventing  further  devel- 
opment from  any  that  may  have  been  introduced.  The  agent  that  is  used 
internally  should  be  continued  not  less  than  from  four  to  six  weeks.  Another 
l)enefit  resulting  from  this  treatment  is  the  influence  it  exerts  on  the 
Tiiind  of  the  patient.  The  simple  fact  that  something  is  being  done  to 
destroy  the  action  of  the  supposed  poison  has  a  powerful  influence  in 
quieting  the  fears  of  the  patient  and  his  friends,  and  in  giving  them  con- 
fidence, hope  and  cheerfulness,  which  is  exceedingly  desirable,  from  the 
well  known  fact  that  the  opposite  condition  of  mind,  namely,  fright,  ap- 
prehension, dread,  foreboding  of  terrible  consequence'^,  have  a  powerful 
influence  in  encouraging  the  development  of  the  very  disease  that  is 
dreaded. 


LECTUEE  LXXX. 

Sun-Stroke— Its  Varieties,  Causes,  Clinical   History,  Anatomical  Changes,  Prognosis,  Diagnosis 
and  Treatment. 

GENTLEMEN:  Under  the  terms,  sun-stroke,  heat-stroke,  co?//!  de  soleil^ 
have  been  grouped  a  class  of  cases  of  suddenly  developed  disease 
dependent  more  or  less  for  their  immediate  causation  upon  high  tempera- 
ture. It  is  not  essential  that  the  high  temperature  be  produced  by  the 
sun,  or  that  the  sun's  rays  be  admitted  directly  upon  the  subject  taken 
sick.  A  study  of  the  various  cases  described  as  belonging  to  this  class 
will  resolve  them  into  three  groups,  having  some  diff'eVences  which  are 


784  SUN  STROKE. 

important  to  recognize,  especially  with  a  view  of  properly  adjusting  treat- 
ment. Of  those  which  have  been  produced  by  the  more  direct,  intense 
action  of  the  heat  of  the  sun,  there  are  a  few  cases  which  appear  to  be 
simply  acute  attacks  of  meningitis.  They  correspond  in  all  respects  with 
the  most  severe  grade  of  inflammation  of  the  meninges  of  the  brain,  as  ] 
have  already  fully  described  to  you  when  speaking  of  the  local  inflamma- 
tions, and  consequently  these  cases  need  not  be  further  considered  here, 
The  more  numerous  class  of  cases  included  under  the  general  designation 
of  heat-stroke,  occur  generally  under  the  direct  action  of  the  sun,  or  in  a 
very  high  temperature  of  the  air,  and  are  characterized  by  all  the  symp- 
toms of  sudden  and  severe  congestion  of  the  vessels  of  the  brain,  and  the 
membranes  covering  it. 

Symptoms. — In  these  cases  the  patient,  while  exposed  to  high  tempera- 
ture, begins  to  feel  a  sense  of  confusion  and  pressure  in  the  head,  distinct 
buzzing  or  rushing  in  the  ears,  dimness  of  sight,  more  or  less  intense  pain 
in  the  head,  and  in  a  few  moments  staggers  and  then  falls  to  the  ground 
or  to  the  floor  in  a  state  of  entire  unconsciousness.  Sometimes  as  the^^ 
fall  a  shudder  like  a  slight  electric  shock  passes  through  the  muscular 
system,  after  which  the  muscles  more  generally  are  relaxed  and  the  limbs 
quiet,  but  the  face  becomes  deeply  suffused  with  redness,  soon  assuming 
more  of  a  purplish  or  cyanosed  hue;  the  breathing  becomes  hurried,  irreg- 
ular and  sometimes  stertorous;  the  pupils  of  the  eve  are  slightly  dilated, 
though  sometimes  varying  or  vacillating  from  contraction  to  dilatation; 
the  vessels  of  the  conjunctiva  are  unnaturally  full;  the  pulse  usually  fre- 
quent and  somewhat  variable,  sometimes  bounding  and  full,  at  other  times 
small  or  contracted,  but  pretty  uniformly  frequent,  and  the  heart's  action 
partaking  of  a  similar  variable  character,  sometimes  throbbing  or  pulsat- 
ing violently,  and  then  pgain  more  feeble  and  irregular  as  to  the 
rate  of  frequency.  In  the  most  severe  class  of  cases  the  pulse  grows  more 
rapid  and  more  easily  compressed,  the  lips  and  face  more  deeply  purple, 
the  breathing  more  and  more  obstructed  or  stertorous,  and  in  from  fifteen 
minutes  to  two  or  three  hours  death  takes  place  without  any  return  of 
consciousness,  though  sometimes  preceded  by  a  general  convulsion,  but 
in  a  larger  number  by  entire  muscular  relaxation.  Cases  of  less  severity 
may  linger,  from  three  to  twelve  or  eighteen  hours,  and  then  terminate 
fatally  apparently  by  suspension  of  the  cerebral  function,  or-by  cessation 
of  the  heart's  action  after  a  few  paroxysms  of  violent  beating.  In  cases 
of  a  little  less  severity  the  symptoms  may  be  of  the  same  character,  suffi- 
ciently severe  to  bring  on  complete  unconsciousness,  a  flushed,  turgid  con- 
dition of  the  vessels  of  the  face,  head  and  neck,  continuing  for  five  or  six 
hours,  when  signs  of  improvement  begin.  These  are  first  noticeable  in 
the  surface  becoming  less  purple,  the  pulse  slower,  more  steady,  and  the 
breathing  less  stertorous,  with  a  deeper,  fuller  inflation  of  the  lungs.  This 
improvement  continues  gradually  until  in  eighteen  or  twenty- four  hours 
the  patient  has  recovered  his  consciousness;  the  pulse  and  respiration  re- 
turned more  nearly  to  their  natural  standard,  and  although  extremely  ex- 
hausted and  feeble,  convalesence  has  ensued.  One  symptom  mentioned 
as  characterizing  these  cases,  and  a  very  important  one,  is  the  rapid  devel- 
opment of  a  high  temperature.  In  the  severer  class  of  cases  progress- 
ing toward  a  fatal  result,  the  temperature  rises  so  rapidly  that  in  the 
axilla  the  thermometer  will  often  range  from  43°  to  43°  0.  (108°  to 
110°  F.)  Less  severe  cases  will  show  a  range  of  temperature  from 
40°  to  42°  C.  (104°  to  108°  F.)  during  all  the  first  twenty  to  thirty-six 
hours,  if  the  patient  lives  that  length  of  time.  But  as  the  symptoms  of 
recovery  and  improvem-^nt  show  themselves,  the  temperature  falls  pretty 
rapidly  till  it  returns  to  the  natural  standard. 


HEAT    EXHAUSTION.  785 

Anatomical  Changes. — The  anatomical  changes  which  are  found,  as 
might  be  expected  I'rom  the  rapidity  with  which  death  approaches,  and 
the  brief  time  that  the  patient  is  sick,  are  not  of  a  structural  character;  yet 
many  changes  in  the  condition  of  the  circulation  are  noticeable  in  all  these 
cases,  and  also  in  the  quality  or  condition  of  the  blood.  The  sinuses  and 
veins  within  the  cranium  are  usually  strongly  congested  or  turgid  with 
blood;  the  right  side  of  the  heart  is  in  the  same  condition  with  a  consider- 
able amount  of  congestion  and  engorgement  in  the  lungs;  while  the  left 
side  of  the  heart  is  usually  empty  and  contracted;  the  blood  itself  is  very 
much  diminished  in  the  coagulability  of  its  fibrine,  indeed,  not  infrequent- 
ly in  an  entirely  iluid  condition,  of  a  dark  hue,  and  many  of  the  corpuscles 
crenated  or  puckered  at  the  edges. 

Meat  JEJx/iaustion. — The  remaining  group  of  cases  which  have  been 
classed  under  the  general  head  of  sun-stroke,  and  which  really  are  the 
most  numerous  class  of  cases  met  with  in  practice,  occur  not  so  much  from 
direct  exposure  to  the  rays  of  the  sun  as  from  the  exhaustion  of  continu- 
ous high  temperature.  The  symptoms  differ  very  decidedly  from  those 
last  described.  The  class  of  persons  that  are  most  apt  to  be  attacked  with 
this  variety  of  disease,  which  by  way  of  distinction  is  called  heat  exhaustion^ 
are  those  undergoing  either  excessive  physical  exercise  in  an  unusually 
warm  atmosphere,  whether  it  be  by  day  or  night,  in-doors  or  out,  or  those 
who  have  l)een  addicted  to  the  habitual  use  of  alcoholic  beverages.  That 
the  use  of  alcoholic  drinks  greatly  predisposes  to  this  form  of  disease 
has  been  proven  by  the  observation  of  many  medical  men  attached 
to  armies,  witnessing  the  results  in  soldiers  upon  a  march  under  a  high 
temperature.  The  uniform  testimony  of  these  observers  is  that  the  at- 
tacks are  limited,  not  absolutely,  but  in  a  very  great  degree,  to  those  who 
are  addicted  to  the  use  of  alcoholic  drinks  in  some  form.  Dr.  Bartholov,^, 
in  his  practice,  speaks  of  his  own  observation  when  connected  with  a  divis- 
ion of  the  army  on  a  long  march  under  high  temperature,  where  for 
several  days  many  succumbed  to  the  influence  of  high  heat,  but  they  were 
limited  almost  entirely  to  those  addicted  to  strong  drink.  A  large  pro- 
portion of  all  the  cases  that  occur  in  our  cities  during  the  occasional  waves 
of  very  high  atmospheric  heat  in  summer  belong  to  this  class.  In  1868  a 
period  of  this  high  heat  caused  several  hundred  deaths  froiii  what  was 
denominated  sun-stroke  or  heat  exhaustion  in  New  York;  several  seasons  in 
Saint  Louis  the  number  of  deaths  has  been  very  large  from  the  same 
cause.  In  this  city  our  waves  of  high  temperature  are  always  modified  in 
a  material  degree  by  the  cooling  influence  of  the  lake  upon  our  border, 
and  consequently  these  cases  are  far  less  numerous  here  than  in  the  cities 
more  nearly  in  the  middle  belt  of  the  United  States.  Still  in  those  sum- 
mers when  there  occur  one  or  more  extraordinary  waves  of  high  heat  last- 
ing through  several  days  in  succession,  it  is  not  uncommon  to  meet  with 
attacks  of  heat  exhaustion  well  characterized,  and  occasionally  reaching 
a  fatal  result. 

/Si/mptoms. — The  symptoms  of  this  class  of  cases  differ  from  those  I 
have  described  as  from  direct  heat  upon  the  head,  not  so  much  in  the 
feelings  of  the  patient  as  in  objective  phenomena.  For  the  patient  com- 
plains sometimes  for  an  hour  or  more  of  some  sense  of  weakness  or  ex- 
haustion, dizziness  or  reeling  in  the  head,  noises  in  the  ears,  momentary 
dimness  of  vision,  but  especially  a  great  sense  of  exhaustion;  and  yet,  if 
a  laboring  man,  he  not  infrequently  persists  in  keeping  at  his  work,  and  in 
from  half  an  hour  to  two  or  three  hours  after  the  supervention  of  these  feel- 
ings he  begins  to  reel,  the  sight  grows  dim,  his  attempts  to  talk  fail  him  and 
in  a  moment  he  falls  prostrate  and  generally  becomes  entirely  unconscious; 
50 


786  "  HEAT    EXHAUSTION 

but  instead  of  an  appearance  of  congestion  or  fullness  his  face  is  pale, 
lips  pule  or  livid,  his  surface  cool,  pulse  quick,  somewhat  weak,  very 
variable  and  irregular;  heart's  action  generally  weak,  systolic  movements 
short,  quick  and  irregular;  respiration  imperfect,  giving  imperfect  inflation 
of  the  lungs,  and  some  stertor;  the  temperature  hardly  above  normal, 
pupils  of  the  eyes  usually  decidedly  dilated,  sometimes  relaxation  of  the 
sphincters  of  the  bladder  and  rectum,  allowing  apparently  involuntary 
discharges,  but  more  frequently  only  a  scanty  secretion  of  urine.  In  the 
more  severe  of  these  attacks  the  paleness  of  the  suri'ace,  coolness  of  the 
extremities  and  feebleness  of  pulse  increase  with  the  supervention  of  a 
copious,  cold,  clammy  sweat,  irregular,  sighing  respiration,  and  in  perhaps 
half  an  hour  to  an  hour  after  the  supervention  of  the  attack,  sudden  death 
from  cessation  of  the  heart's  action  or  syncope.  But  the  great  ma- 
jority of  this  class  of  cases  if  they  are  at  all  well  taken  care  of  will  remain 
in  a  feeble,  cool,  unconscious  condition  for  two  or  three  hours,  when  they 
begin  slowly  to  improve.  The  first  noticeable  improvement  is  in  the  color 
of  the  lip,  in  a  slower  and  steadier  condition  of  the  pulse  and  a  more  natu- 
ral systolic  action  of  the  heart.  Three  or  four  hourj  later  consciousness 
is  restored  and  the  patient,  although  feeble  and  feeling  greatly  exhausted, 
is  nevertheless  in  a  convalescing  condition;  and  under  proper  manage- 
ment in  regard  to  rest  and  nourishment,  in  a  few  days  he  will  recov(>r 
fully  and  resuuie  his  ordinary  duties.  In  the  cases  of  this  class  terminat- 
ing fatally,  the  post  mortem  appearances  differ  from  the  group  just  previ- 
ously described  in  there  being  much  less  evidence  of  congestion  and  full- 
ness of  blood  in  the  vessels  of  the  brain,  although  there  is  usually  consid- 
erable congestion  of  the  venous  part  of  the  circulation  in  the  lungs  and 
fullness  of  the  right  cavities  of  the  heart  with  dark,  imperfectly  coagula- 
ble  blood.  The  blood  is  more  profoundly  altered  in  its  properties  and  in 
•the  condition  of  its  corpuscles  than  in  the  cases  previously  mentioned. 
The  difference  in  the  pathology  of  this  and  the  preceding  group  would 
•seem  to  consist  chiefly  in  the  fact  that  in  the  first  group,  or  those  of  heat 
fever,  there  is,  with  the  deteriorative  action  of  high  temperature  upon  the 
■quality  of  the  blood,  a  primary  and  direct  dilatation  of  the  vessels  of  the 
brain  and  its  membranes,  and  in  the  lungs  perhaps,  from  vaso- motor  paral- 
ysis, causing  early  and  intense  local  congestion  in  these  organs  with 
diminished  oxygenation  and  coagulability  of  the  blood  and  consequent 
incapacity  to  maintain  its  natural  impression  upon  the  various  tissues  of 
the  body;  while  in  the  second  class  of  cases  or  those  of  heat  exhaust. on, 
the  phenomena  depend  almost  entirely  upon  the  extreme  alterations  in 
the  projierties  of  the  blood  and  in  the  impairment  of  the  property  which 
I  have  denominated  vital  affinity  throughout  the  whole  muscular  struct- 
vires  cf  the  body,  without  special  local  congestion  or  hypeireinia  in  the 
brain.  This  absence  of  the  local  hypergemia  or  engorgement  causes  tiie 
coldness  or  low  temperature  in  the  second  class  of  cases,  and  its  presence 
explains  the  rapid  accumulation  of  heat  in  the  first  class. 

Diagnosis. — But  little  difficulty  can  arise  in  forming  a  correct  diagnosis 
in  either  variety  of  the  cases  I  have  been  describing,  where  all  the  facts 
connected  with  the  condition  of  the  patient  at  the  time  of  supervention  of 
the  attack  can  be  known.  The  sudden  supervention  from  a  state  of  pre- 
viously comparative  good  health,  to  the  intense  engorgement  or  fullness 
of  blood  in  the  vessels  of  the  head  and  neck,  accompanied  by  the  symp- 
toms that  I  have  described  as  taking  place  under  a  high  temperature,  es- 
pecially under  exposure  more  or  less  to  the  rays  of  the  sun,  can  hardly 
leave  a  doubt  upon  the  mind  of  the  physician  as  to  the  nature  and  origin 
of  the  disease.     But  in  cases,  which  may  happen,  whore  the  patient  isfound 


DIAGNOSIS.  787 

perhaps  upon  the  highway  or  in  some  place  where  he  has  been  overtaken 
alone  with  no  one  to  give  any  history  of  his  previous  condition  or  circum- 
stances, the  question  will  immediately  arise  in  regard  to  the  first  class  of 
cases,  those  accompanied  by  congestion  or  heat  fever,  as  to  whether  the 
patient  is  laboring  under  an  attack  of  apoplexy,  or  the  excessive  stupor  of 
intoxication  from  alcoholic  beverages.  From  apoplexy,  sun-stroke  or  heat 
fever  may  be  generally  distinguished  by  the  character  of  the  pulse,  respir- 
ation and  temperature.  In  apoplexy,  the  pulse  is  more  uniformly  slow, 
full  and  labored,  with  sustained  cardiac  force  or  impulse.  The  breathing 
is  more  constantly  stertorous,  with  the  well-known  puff  of  the  lips  arid 
cheeks  in  the  act  of  respiration.  The  pupil  of  the  eye  at  the  beginning  or 
early  stage  is  more  generally  contracted.  If  it  be  in  the  advanced  stage  in 
apoplectic  patients  the  pupils  may  be  dilated,  but  they  seldom  correspond 
the  one  eye  with  the  other,  either  in  the  degree  of  dilatation  or  in  the  axis 
of  vision.  Apoplexy  rarely,  if  ever,  affords  anything  like  the  high  tem- 
perature that  is  found  in  the  class  of  cases  of  heat  fever.  From  profound 
intoxication,  heat  fever  or  sun-stroke  is  still  more  readily  distinguished  on 
comparing  the  symptoms  critically,  because  the  state  of  profound  intoxi- 
cation, either  from  alcohol  or  opium,  is  accompanied  by  a  reduced 
instead  of  increased  temperature.  Opium  contracts  the  pupils  strong- 
ly, while  alcohol  not  only  reduces  the  temperature  instead  of  increas- 
ing fever  heat,  but  it  produces  also  an  odor  in  the  breath  which  can 
generally  be  detected,  and  the  breathing  is  altogether  steadier  and  slower; 
indeed,  slower  than  in  health,  and  much  steadier  and  more  uniform  than 
that  existing  in  an  unconscious  state  from  heat  fever.  If  we  compare 
these  same  diseases,  i.  e.,  profound  stupor  from  alcohol  or  narcotics  and 
apoplexy,  v/ith  the  cases  of  heat  exhaustion,  we  may  find  more  difficulty  in 
some  respects.  But  from  apoplexy,  heat  exhaustion  is  distinguished,  by 
the  fact  that  the  patient  is  pale,  usually  sweating  profusely,  and  cold, 
with  a  very  feeble  pulse,  symptoms  which  are  in  direct  contrast  with 
what  are  usually  found  in  connection  with  apoplexy.  But  the  phenomena 
of  profound  drunkenness  or  extreme  alcoholic  intoxication,  and  those  of 
heat  exhaustion,  present  many  points  of  positive  resemblance.  In  both, 
the  temperature  is  low.  In  both,  there  may  be  moderate  dilatation  of 
the  pupils,  with  a  pulse  soft,  irregular  and  easily  compressed.  But  in 
heat  exhaustion,  the  pulse  is  usually  much  more  rapid  as  well  as  feebler 
than  it  is  in  alcoholic  intoxication. 

Usually  the  respiration  in  heat  exhaustion  is  also  more  unsteady,  pant- 
ing perhaps,  and  then  interrupted,  like  one  tired,  than  it  is  in  a  state  of 
intoxication.  The  alcoholic  odor  in  the  breath  generally  characterizes 
intoxication  and  would  be  a  suitable  mark  of  distinction  were  it  not  for 
the  fact  that  heat  exhaustion  very  frequently  attacks  those  who  are 
already  more  or  less  under  the  influence  of  intoxicating  drinks.  Conse- 
quently you  might  nave  a  case  of  heat  exhaustion  with  an  alcoholic 
breath.  But,  however  difficult  it  may  be  to  distinguish  them  primarily  in 
the  height  of  their  development,  their  progress  leaves  a  sufficient  margin 
of  difference  to  enable  tiie  diagnosis  to  be  made  in  a  few  hours.  Alco- 
holic stupor  passes  off  gradually,  all  the  symptoms  approaching  more  and 
more  toward  the  natural  condition,  till  the  individual  appears  to  be  only 
in  a  natural  sleep,  while  heat  exhaustion,  if  it  be  only  a  case  of  average 
severity,  also  in  a  few  hours  begins  to  diminish.  The  patient,  however, 
arouses  himself  much  earlier  and  exhibits  much  greater  weakness,  and 
yet  much  less  of  the  unsteadiness  of  gait  and  peculiar  mental  traits  tliat 
characterize  an  individual  coming  out  from  a  condition  of  extreme  intoxi- 
cation. 


788  HEAT    EXHAUSTION. 

Prognosis. — When  sun-stroke  or  active  heal  fever  is  the  result  of  in- 
tense action  of  the  sun's  rays  directly  upon  the  head,  there  is  great  tend- 
ency to  a  fatal  termination.  In  the  group  of  cases,  however,  that  we 
have  denominated  heat  fever,  while  there  is  much  danger  to  life  in  a 
large  proportion  of  the  attacks,  and  a  high  ratio  of  deaths  has  resulted 
wherever  these  cases  have  become  numerous,  still  they  are  not  necessa- 
rily fatal.  But  the  milder  cases  tend  spontaneously  to  recovery,  and 
many  of  the  more  severe  cases,  if  taken  in  charge  and  treated  judiciously 
from  the  beginning  of  the  attack,  recover.  It  must  be  admitted,  how- 
ever, that  this  class  of  attacks  involve  much  danger,  and  yield  a  pretty 
high  ratio  of  mortality.  Of  those  classes  denominated  heat  exhaustion,  a 
much  more  favorable  prognosis  may  be  given.  Under  any  judicious 
management  only  a  small  ratio  of  mortality  results  in  this  class  of  cases. 
If  the  attack,  however,  is  severe,  complete  insensibility  supervenes  rap- 
idly, and  the  pulse  presents,  from  the  first,  great  feebleness  with  irregu- 
larity of  respiration  and  very  much  depression  of  mind.  When  the  heart 
acts  tumultuously  for  a  few  seconds,  and  then  slow  and  feeble,  it  may  be 
said  that  there  is  very  great  danger  of  a  fatal  result  from  syncope,  or  entire 
cessation  of  the  heart's  action.  But  of  all  the  cases  of  less  sudden  and 
severe  development  there  is  reasonable  prospect  of  recovery,  unless  the 
patient  has  been  previously  very  much  impaired  in  his  vitality  and  recu- 
perative energies,  by  habits  of  intemperance  or  other  exhausting  influ- 
ences. 

Treatment. — As  you  will  have  inferred  from  the  description  both  of  the 
symptoms  and  anatomical  changes,  no  one  treatment  can  be  mentioned 
that  is  suited  to  all  the  cases  grouped  under  the  heads  of  sunstroke.,  heat 
fever  and  heat  exhaustion.  The  different  cases  require  to  be  very  care- 
fully discriminated,  that  their  treatment  may  be  judiciously  adjusted  tc 
fulfil]  the  indications  of  each  case.  Those  denominated  iieat  fever,  in 
which  there  are  rapidly  developed  symptoms  of  great  fullness  of  the  vessels 
of  the  head  and  face,  and  more  or  less  accumulation  of  blood  in  the  lungs, 
with  a  rapid  rise  of  temperature,  the  indications  are  clearly  for  the  appli- 
cation, promptly,  of  such  measures  as  are  calculated  both  to  lessen  the  lull- 
ness  of  blood  in  the  parts  congested  and  to  arrest  the  elevation  of  tem- 
perature. Consequently  the  prompt  application  of  cold  to  the  head  and 
indeed  to  the  whole  surface,  directing  the  nurse  to  wash  the  head  and 
trunk  of  the  patient  over  quickly  but  freely  with  cold  water,  sponging 
him  subsequently  with  the  same  until  the  temperature  begins  to  fall,  con- 
stitutes one  of  the  measures  that  can  be  made  most  available  and  efficient 
in  the  onset  of  the  disease.  In  India,  where  these  attacks  are  of  frequent 
occurrence  during  some  parts  of  a  more  than  usually  severe  sumniei-,  the 
practice  of  applying  douches  of  cold  water  to  the  patients  and  wrapping 
them  subsequently  in  cold  blankets  with  ice  caps  to  the  head  is  considered 
the  most  efficient  practice,  and  of  late  years  it  has  been  much  resorted  to 
in  some  of  the  cities  of  our  country  where  these  cases  are  of  frequent 
occurrence.  In  addition  to  these  measures,  dry  cups  between  the  suoul- 
ders  and  upon  the  back  of  the  neck  and  the  application  of  leeches  to  the 
temples  may  also  be  of  some  value.  As  soon  as  the  patient  can  be  made 
to  swallow,  remedies  may  be  given  to  procure  moderately  free  evacuations 
from  the  bowels  and  to  encourage  healthy  and  active  secretion  by  the 
kidneys.  But  before  the  patient  is  conscious  enough  to  readily  take 
medicines  internally,  the  bowels  may  be  moved  to  some  extent  by  ene- 
mas of  warm  water  containing  common  salt  or  sulphate  of  magnesia  in 
solution,  and  the  circulation  may  be  more  or  less  influenced  favorably  by 
the  use  of  digitalis.     This  remedy  may  be  used  hypodermically  or  it  may 


TREATMENT.  789 

1)0.  used  in  the  form  of  enemas  into  the  rectum.  After  the  temperature 
has  been  reduced  by  the  aiiti-pyretics  externally  and  the  use  of  digitalis, 
and  sometimes  cupping  or  leeching,  if  the  symptoms  improve,  there  can 
bo  but  little  done  except  to  maintain  the  effects  of  the  digitalis  and  the 
cold  ajjplications  in  a  less  energetic  manner  till  the  temperature  falls  to 
the  natural  standard  and  consciousness  is  restored.  After  its  arrest,  for 
several  days  a  mild,  plain  diet  and  the  avoidance  of  mental  and  physical 
exercisft  will  be  sufficient  in  most  cases  to  complete  the  recovery  of  the 
patient.  In  many  instances,  as  I  hav^e  remarked  when  speaking  of  the 
symptoms  in  the  advanced  stage  of  this  class  of  cases,  convalescence 
occurs.  Where  general  convulsions  make  their  appearance  the  most 
efficient  means  for  relieving  them  are  probably  hypodermic  injections  of 
morphia,  being  cautious  to  use  such  doses  as  will  not  over-narcotize;  or 
the  inhalation  of  chloroform. 

Practitioners  should  be  very  cautious,  however,  how  they  use  both  these 
agents  simultaneously,  as  has  sometimes  happened.  I  have  known  one 
or  two  instances  where  patients,  not  from  heat  stroke  but  from  convul- 
sions from  other  causes,  had  taken  full  doses  of  chloral  internally,  at  the 
same  time  had  hypodermic  injections  of  morphia,  perhaps  twice  in  suc- 
cession at  short  intervals,  and  as  the  convulsive  movements  did  not 
cease  readily,  inhalations  we.'-e  added.  The  convulsions  soon  ceased,  but 
with  the  cessation,  profound  stupor,  rapidly  failing  pulse,  and  finally  ces- 
sation of  life  followed.  It  may  happen  that  in  usina*  pretty  full  medicinal 
doses  of  two  or  three  different  narcotics  and  ana3sthetics,  the  combined 
effect  which  comes  to  be  develope  1  is  much  greater  than  has  been  esti- 
mated: And  while  they  may  overcome  the  morbid  action  for  which  they 
were  given,  the  amount  present  in  the  system  is  sufficient  to  immediately 
produce  a  fatal  result  as  the  direct  effect  of  the  remedies  themselves. 
Consequently,  while  it  is  admissible,  either  to  parry  convulsions  in  these 
cases  by  chloroform  inhalation,  or  inhalation  of  other  anaesthetics  on  the 
one  hand,  or  by  the  judicious  use  of  hypodermic  injections  of  morphia,  or 
morphia  and  atropia  together,  and  to  endeavor  to  accomplish  something 
by  enemas,  using  pretty  full  doses  of  chloral,  you  should  be  cautious 
not  to  use  all  these  agents  so  rapidly  one  after  the  other  that  the  effects 
accumulate  in  the  system  sufficient  to  develop  a  greater  influence  than 
had  been  intended.  In  the  treatment  of  the  second  class  of  cases,  or 
those  v.'hich  we  have  denominated  heat  exhaustion^  where  the  surface  is 
pale  and  cool,  skin  relaxed,  circulation  irregular  and  feeble,  there  are,  of 
course,  no  indications  for  the  use  of  the  cold  douche,  or  the  external  ap- 
plication  of  cold  in  any  form.  Neither  is  there  any  indication  for  deple- 
tion in  any  direction.  The  patient  should  be  put  entirely  at  rest  in  as 
cool  fresh  air  as  possible;  warm  applications  applied  to  the  head,  perhaps 
warm  bottles  and  flasks  of  warm  water  along  the  spine,  and  such  reme- 
dies given  internally  as  are  calculated  to  improve  the  tone  or  contractility 
of  the  muscular  structures,  especially  of  the  heart,  and  thereby  counteract 
the  tendency  to  mipairment  in  the  quality  of  the  blood.  In  the  uncon- 
sciousness of  the  patients  and  difficulty  of  their  swallowing,  remedial 
measures  are  limited  largely  to  such  remedies  as  may  be  used  in  hypo- 
dermic injections  and  enemas.  Perhaps  as  good  a  combination  as  could 
be  used  for  an  enema  consists  often  cubic  centimeters  (fl.  3iiss)of  the  fluid 
extract  of  valerian,  two  cubic  centimeters  of  the  tincture  of  digitalis  and 
one  cubic  centimeter  of  the  tincture  of  opium  in  sixty  cubic  centimeters 
of  water  about  milk  warm.  An  enema  thus  composed  passed  into  the 
rectum  gently  and  the  parts  supported  as  the  syringe  is  withdrawn 
for    a    few   minutes,  will    frequently    be    retained,  the    greater  part  of  it 


790  DELIETUM    TREMENS. 

absorbed,  and  the  effects  of  valerian  and  digitalis  on  the  circulaticii 
are  as  favorable  as  can  be  induced  by  any  other  remedies.  Such  an  enema 
may  be  repeated  at  intervals  of  three  or  four  hours,  during  the  first 
twenty-four  hours  in  the  progress  of  the  case.  Usually  during  that  time 
the  patient  will  have  so  far  progressed  in  his  recovery  as  to  require  littie 
else  than  simple  nourishment  and  rest  to  complete  his  recovery.  If  the 
enema  can  not  be  retained  in  the  rectum  sufficient  to  be  absorbed,  the 
digitalis  may  be  introduced  hypodermically.  In  the  same  manner  you 
can  also  introduce  moderate  doses  of  the  sulphate  of  quinia,  or  sulphate  ol' 
cinchonidia  for  additional  tonic  effect.  Most  vpriters  recommend  the  lib- 
eral use  of  alcoholic  remedies  in  these  cases,  advising  brandy  or  vs^hisky 
to  be  given  by  enemas,  and  when  the  patient  can  swallow  to  be  taken  in- 
ternally. My  own  experience  has  led  me  to  the  conclusion  that  if  the 
patient  had  rest  in  good  air,  aided  by  the  enemas  that  I  have  indicated, 
whenever  he  is  capable  of  swallowing  brandy  or  whisky,  he  is  equally  ca- 
pable of  taking  enough  milk,  beef  tea  or  any  other  suitable  nourishment, 
and  for  stimulants,  tea  and  coffee,  or  their  active  principles,  theine  and 
caffeine,  which  are  much  more  efficient  and  valuable  than  any  kind  of  al- 
c(jhoiic  remedies,  and  will  yield  a  larger  ratio  of  ultimate  recoveries.  It 
]s  a  little  curious  to  contemplate  a  process  (>f  reasoning  by  which  it  is  in- 
ferred that  the  very  agents  that  are  most  efficient  of  all  others  to  predis- 
pose to  and  favor  attacks  of  heat  exhaustion  should  be  so  generally  re- 
sorted to,  and  recommended  as  remedies  in  the  treatment  of  the  disease. 
But  it  only  illustrates  that  apparently  fixed  and  almost  irresistible  habit 
of  resorting  to  alcoholic  agents  for  every  conceivable  condition  that  pre- 
sents an  element  of  supposed  weakness.  Of  course  if  the  patient  recovers 
after  using  any  of  that  class  of  remedies,  it  is  taken  for  granted  that  they 
aided  in  his  recovery,  notwithstanding  the  experience  of  those  who  with- 
hold them,  gives  a  greater  ratio  of  recoveries  than  were  obtained  under 
their  use. 


LECTURE   LXXXI. 

Derriura  Tren^ens  fMania-Potu)— Its  Causes,  Clinical  History,  Anatomical  Changes,  Diagnosis 
Prognosis  and  Treatment. 

GENTLEMEN:  "We  next  invite  your  attention  to  a  class  of  cases  of 
disease  which  have  usually  been  included  under  the  names  of  delirium 
tremens,  or  mania-potu.  As  the  name  would  indicate,  at  least  the  second 
name  mentioned,  the  disease  to  which  I  allude  arises  chieflv  from  the  ha- 
bitual and  excessive  use  of  alcoholic  beverages.  A  very  similar  condition  of 
the  system,  however,  may  l)e  induced  by  the  use  of  opiates  and  other  narcot- 
ics and  excitants.  But  ]:)ractically  thoy  are  of  very  rare  occurrence,  except  as 
the  result  of  the  use  of  alcoholic  drinks.  The  greater  part  of  the  cases  by  far 
are  met  with  in  those  persons  who  are  addicted  to  the  use  of  the  stronger 
drinks  or  distilled  spirits,  such  as  whisky,  brandy,  gin  and  rum,,  although 
the  disease  may  be  produced  by  the  use  of  fermented  drinks  alone;  yet 
such  is  seldom  the  case,  for  the  simple  reason  that  the  quantity  of  alco- 
hol in  the  fermented  drinks  is  so  small  as  to  require  a  very  Jai-ge  amount 
of  the  liquids  to  produce  the  peculiar  eflfect  upon  the  brain  and  nervous 
system  which  constitutes  delirium  tremens.     The  disease  is  most  general- 


SYMPTOMS.  791 

ly  the  result  of  the  continued  and  excessive  use  of  the  stronger  alcoliolic 
beveraores  through  a  period  of  from  one  to  four  weeks,  and  at  the  same 
time  the  use  of  but  a  very  limited  amount  of  ordinary  nourishment.  You 
arc  all  aware  that  as  an  ordinary  rule,  the  individual  who  commences 
what  is  known  as  a  period  of  dissipation  or  of  almost  continuous  intoxica- 
tion, soon  loses  his  appetite  or  relish  for  food,  while  his  period  of  excessive 
drinking  continues.  Whether  it  be  one,  two,  three  or  four  weeks,  he  seldom 
takas  a  sufficient  amount  of  ordinary  wholesome  food  once  a  day.  The  re- 
sult is  that  his  blood  becomss  impoverished  of  nutritive  elements,  derived 
from  the  daily  supply  of  food,  and  becomes  surcharged  with  the  products 
of  disintegration  and  waste  that  are  retained  in  it  from  the  effect  of  the  al- 
cohol in  diminishing  the  elimination  of  waste  ingredients  through  the 
lungs,  or  taking  up  of  oxygen  in  the  opposite  direction  into  the  blood. 
This  impoverishn)ent  of  nutritive  materials,  coincident  with  a  steady  in- 
crease of  the  effete  constituents,  interferes  directly  with  the  play  of  vital 
affinity  and  molecular  changes  in  the  processes  of  nutrition  and  disintegra- 
tion. Sooner  or  later  this  places  all  the  functions,  and  especially  the  func- 
tions of  the  cerebro-spinal  nervous  system,  in  a  condition  in  which  it  can  no 
longer  perform  its  natural  office.  The  pulse  becomes  generally  soft,  quick 
and  irregular,  skin  cool,  face  pale,  muscular  system  tremulous  and  un- 
steady, mind  excited  and  apprehensive,  little  or  no  disposition  to  sleep; 
and  after  the  commencement  of  these  symptoms  in  from  twenty-four  to 
forty-eight  hours  the  tremulousness  is  much  increased,  the  pulse  has  be- 
come still  more  disturbed,  lips  bluish,  face  rather  haggard  and  anxious, 
and  the  mind  decidedly  beginning  to  lose  its  power  of  self-control,  and 
to  be  filled  with  images  and  hallucinations;  noises  are  heard  that  are  im- 
aginary, startling  visions  generally  of  unsightly  and  unpleasant  objects 
appear  on  every  side,  and  these  so  rapidly  increase  that  the  patient  be- 
comes entirely  delirious,  or  at  least  incoherent,  and  has  no  disposition 
to  sleep.  Frightful  ol)jects  now  appear  to  the  patient  in  any  and  every 
corner  of  the  room  and  on  the  bed,  sometimes  in  the  bed,  keeping  him 
in  frantic  efforts  to  get  away  or  drive  the  snakes  and  demons  away, 
until  after  three  or  four  days  and  nights  he  arrives  at  a  stage  of  extreme 
exhaustion;  yet  still  sleepless,  trembling,  agitated  in  almost  every  muscle, 
v  ith  extremely  quick  action  of  the  heart,  thready  and  excited  pulse,  cold, 
extremities,  sometimes  frequent  discharges  from  the  bowels,  and  occa- 
sionally vomiting  with  scantiness  of  urine,  and  unless  relief  is  obtained, 
in  this  class  of  cases,  death  from  exhaustion  supervenes,  more  generally  at 
the  end  of  the  first  or  second  week.  While  some  cases  thus  terminate 
fatally,  the  great  majority  of  them,  if  placed  under  any  judicious  manage- 
ment, will  proceed  to  the  development  of  all  the  phenomena  I  have  indi- 
cated m  a  characteristic  degree,  and  after  five  or  six  days  the  excitement 
begins  to  abate,  the  patient  catches  now  and  then  a  little  quiet  slumber, 
takes  mere  nourishment,  and  from  day  to  day  the  pulse  becomes  more 
steady,  the  mind  less  annoyed  by  hallucinations,  sleep  more  natural,  and 
at  the  end  of  nine,  twelve  or  fourteen  days  convalesence  is  fully  estab- 
lished. The  jDatient,  though  weak  and  pale,  soon  recovers  his  usual  ap- 
petite and  feeling  of  health  while  at  rest,  but  is  not  well  able  to  return 
to  work,  requiring  either  much  mental  or  physical  exercise  until  more 
time  has  been  had  to  restore  the  normal  condition  of  nutrition.  There 
are  all  degrees  in  the  severity  of  the  attacks  of  what  are  called  delirium 
tremens^  from  that  stage  where  the  patient  is  simply  sleepless,  apprehen- 
sive, startled  at  every  noise  or  footstep  and  occasionally  troubled  with 
hallucinations  of  vision  or  sight,  up  to  that  extreme  degree  of  develop- 
ment which  furnishes  perhaps  the  most  violent  and  severe  form  of  tempo- 


792  DELIRIUM    TREMENS. 

rary  mental  derangement  known,  a  form  in  which  the  patient  malc^s 
the  utcnost  exertion  to  escape,  taking  two  or  three  persons  to  keep  him  in 
bed  and  prevent  him  from  doing  himself  or  others  harm.  Some  of  these 
cases  in  the  active  stage  present  the  most  frightful  picture  of  terror,  es- 
pecially at  night,  that  can  be  imagined.  Sometimes  the  protracted  par- 
oxysm terminates  in  fatal  exhaustion  before  the  end  of  a  week.  But 
more  frequently  the  excitement  gradually  subsides  until  the  case  ends  in 
recovery.  There  are  two  classes  of  cases  of  delirum  tremens.  One  class 
consists  of  patients  who  are  attacked  after  they  have  suspended  the  use 
of  alcoholic  drinks,  and  the  popular  idea  is  that  their  delirium  comes  from 
stopping  their  drink  too  suddenly.  The  other  class  is  composed  of  pa- 
tients in  whom  the  delirium  is  manifested  while  they  are  still  taking  their 
full  supply  of  alcoholic  drinks.  In  the  first  class  the  symptoms  of  deliri- 
um of  a  characteristic  type  may  come  on  in  from  twenty-four  to  fortv- 
eight  hours  after  the  alcoholic  drink  is  stopped.  But  more  gi-nerally  the 
disease  develops  in  from  one  to  two  weeks  or  the  patient  escapes  an  at- 
tack altogether.  As  I  have  just  remarked,  the  popular  idea  is,  that  the 
delirium  is  caused  by  stopping  the  drink  too  suddenly.  I  am  by  no 
means  satisfied,  however,  that  this  is  true.  On  the  contrary,  m  ail 
cases  of  this  kind  that  have  come  under  my  observation  the  system  hnd 
become  so  disordered  or  the  stomach  so  irritable  as  to  prevent  them  from 
taking  more  of  either  food  or  drink;  and  consequently  they  had  no  power 
to  replace  the  exhausted  nutritive  elements  of  the  blood  and  tissues  in 
time  to  prevent  the  development  of  the  characteristic  functional  disturb- 
ance of  the  brain.  The  de.irium  came  not  because  they  stopped  drinking 
altogether,  but  because  they  failed  to  stop  before  the  organs  of  digestion 
and  assimilation  had  become  too  much  disordered  to  immediately  re- 
sume their  natural  functions.  Under  my  own  observation,  both  in  pri- 
vate practice  and  in  along  period  of  attendance  upon  a  public  hospital  in 
which  manv  of  these  cases  are  admitted  every  ye&r,  I  am  sure  that  in  as  high 
a  ratio  as  three  out  of  four  of  all  the  cases  1  have  seen,  the  delirium  has 
supervened  during  the  time  the  drinking  was  being  actively  continued. 
The  patients  have  passed  frequently  into  a  state  of  delirium  in  its  full  de- 
velopment, while  thev  were  receiving  a  full  supply  of  drink,  and  were 
taking  it  several  times  in  a  day.  There  is,  however,  little  or  no  difference 
in  the  .symptoms  or  course  of  the  disease,  whether  it  has  supervened  after 
drinking  has  been  abandoned,  or  while  it  is  being  continued;  I  think  the 
general  experience  of  all  has  been  that  the  delirium  supervening  during 
tlie  progress  of  drinking  is  more  likely  to  be  persistent  and  dangerous  than 
where  it  supervenes  in  a  few  days  after  the  intoxicant  has  been  susppndod. 
As  the  degree  of  severity  differs  widely  in  different  cases  of  both  classes, 
so  the  duration  also  differs  much.  In  some  instances  of  the  milder  type 
it  will  continue  only  three  or  four  days  and  nights,  when  in  others  it  may 
continue  as  many  weeks.  More  generally  the  course  of  the  disease  is  to 
run  through  its  stages  and  terminate  in  from  one  to  two  weeks.  Under 
judicious  treatment  very  few  cases  continue  beyond  five  or  seven  days. 

Anatomical  Changes. — There  are  no  phenomena  revealed  by  post 
mortem  examinations  of  those  who  die  during  the  progress  of  delirium 
tremens  that  may  be  said  to  be  characteristic,  or  the  direct  result  of  mor- 
bid action  connected  with  the  delirium.  Almost  all  such  cases  show  in- 
creased redness  or  vascularity  of  the  mucous  membrane  of  the  stomach, 
sometimes  of  the  duodenum  also,  with  some  degree  of  fullness  of  the 
vessels  of  the  right  side  of  the  heart,  moderate  congestion  in  the  capil- 
laries of  the  lungs  and  some  degree  of  hyperjemia  or  increased  fullness  of 
the  vessels  of  the  brain  and  its  membranes.     In  some  instances,  h.owevcr, 


PROGNOSIS.  793 

there  is  hardly  more  fullness  of  blood  in  the  vessels  of  the  brain  and 
membranes  than  natural;  but  on  examining  the  structure  of  the  brain 
minutely,  there  has  been  found  some  evidence  of  changes  in  the  nerve 
cells,  indicating  fatty  degeneration  or  the  appearance  of  fat  granules  and 
some  degree  of  sclerosis  or  hypertrophy  of  the  connective  tissue,  thereby 
giving  to  the  substance,  when  cut  across  and  minutely  examined,  either 
increased  hardness,  which  is  the  more  common,  or  more  rarely  the 
opposite,  called  softening.  These  changes,  particularly  those  in  the 
mucous  membrane  of  the  stomach,  and  that  indicating  structural 
degeneration  in  the  nerve  tissues  of  the  brain  or  in  the  muscular  struct- 
ure of  the  heart,  where  sometimes  the  same  appearances  of  fatty 
degeneration  exist  as  in  the  brain,  are  the  result  not  of  the  delirium,  nor 
do  they  occur  during  the  progress  of  the  delirium;  but  they  are  the 
effects  of  the  alcohol  upon  the  structures  of  the  body  during  all  the  drink- 
ing habits  of  the  individual,  which  have  generally  extended  throus^h  many 
months  or  even  years.  The  morbid  condition  of  the  brain  and  cerebro- 
spinal axis  belonging  especially  to  the  disease  denominated  delirium 
tremens,  is  not  one  of  visible  structural  change  but  of  impaired  nutrition, 
or  impoverishment,  coupled  with  a  peculiar  morbid  susceptibility  of  the 
nerve  structures,  by  which  the  functions  of  the  brain  are  perverted,  and 
the  peculiar  hallucinations  and  incoherences  which  constitute  the  essen- 
tial phenomena  of  delirium  tremens  are  induced. 

Diagnosis. — But  little  need  be  said  in  regard  to  diagnosis,  as  it  seldom 
happens  that  the  history  of  these  cases  is  not  easily  ascertained,  and  the 
peculiar  character  of  the  mental  hallucinations,  coupled  with  muscular 
tremors,  following  directly  upon  a  course  of  alcoholic  dissipation  or  of  the 
excessive  use  of  other  intoxicants,  leave  very  little  room  lor  doubt  as  to 
the  true  nature  of  any  given  case. 

Prognosis. — The  prognosis  in  delirium  tremens,  whenever  it  can  be 
brought  under  judicious  management  in  the  early  part  of  its  progress,  is 
favorable;  yet  some  cases,  especially  when  complicated  with  more  or  less 
active  gastritis  or  duodenitis  will  terminate  fatally  under  any  treatment. 
They  constitute,  however,  only  a  small  percentage  of  the  whole  number, 
and  aside  from  these  and  a  still  smaller  number  that  have  been  met  with, 
complicated  with  direct  inflammation  of  the  membranes  of  the  brain, 
there  is  almost  a  uniform  tendency  to  recovery.  Probably  forty-nine  out 
of  every  fifty  cases  of  ordinary  delirium  tremens  not  complicated  with 
gastritis  or  meningitis  would  recover  with  no  medication  under  simply 
careful  nursing,  rest  and  nourishment.  Yet,  such  is  the  distressing  nature 
of  the  delirium,  the  fear  that  it  impresses  upon  the  patient  himself  and 
upon  his  friends  around  him,  that  it  becomes  desirable,  and  indeed  neces- 
sary in  the  great  majority  of  cases,  for  the  patient  to  be  placed  in  the 
hands  of  a  judicious  physician,  who  may  pursue  some  apparently  definite 
and  well-considered  treatment.  When  they  are  not  complicated  as  I 
have  just  said,  the  indications  to  be  fulfilled  in  their  treatment  are  very 
fully  embraced  in  two  words — rest  and  nourishment.  So  soon  as  the 
patient  can  be  induced  to  commence  even  very  brief  periods  of  natural 
sleep  and  the  processes  of  digestion  and  assimilation  of  food  sufficient 
to  begin  the  work  of  repairing  tissues,  just  so  soon  he  commences  to  en- 
ter upon  his  convalescence,  and  continuance  of  rest  and  nutrition  will 
soon  restore  him  to  health.  If  possible,  the  management  of  a  case  of  de- 
lirium tremens  should  embrace  the  service  of  a  judicious  and  kind,  yet 
courageous  and  patient  nurse.  This  is  of  very  great  importance,  as 
nothing  is  worse  for  a  patient  under  the  excitement  of  delirium  tremens 
than  having  a  dozen  frightened  individuals  about  him,  endeavoring  to 


794  DELIRIUM    TREMENS. 

hold  him  by  main  force,  and  constantly  arguing  with  him  in  an  excitnd 
manner,  to  convince  him  that  his  hallucinations  are  only  imaginary. 
All  such  management  only  makes  him  more  excited,  and  aggravatess 
the  disorder  in  a  very  marked  degree.  One  or  two  self-possessed,  cool, 
deliberate  and  kind  persons,  who  will  take  turns  with  each  other  and  be 
with  the  patient  continuously,  and  instead  of  arguing  about  the  delu- 
sions of  the  patient  simply  proffer  their  services  to  aid  and  protect  him 
from  his  supposed  enemies,  thereby  quieting  and  encouraging  him  with  as 
few  words  as  possible,  and  when  any  positive  restraint  becomes  nec- 
essary insist  upon  such  only  as  is  actually  required  to  prevent  him 
from  self  injurv,  and  let  even  that  mucli  be  done  as  far  as  possible  under 
the  pretext  of  protecting  the  patient  from  the  snakes  and  hobgoblins  that 
haunt  him,  and  he  will  sooner  sink  down  in  weariness  to  rest,  than  by  al- 
most any  other  influence  that  you  can  bring  to  bear.  From  medicines,  in 
nearly  all  the  cases  only  two  influences  are  needed;  the  one  quieting  or  seda- 
tive to  the  excited  condition  of  the  nervous  system,  and  the  other  calculated 
to  increase  the  steadiness  and  force  of  the  heart's  action.  I  know  of  no 
agents  that  fulfill  these  two  requirements  in  a  more  reliable  manner  than 
suitable  doses  of  the  bromides  and  digitalis.  The  first  act  as  pure  seda- 
tives to  nervous  excitability,  and  the  latter  increases  the  force  and  lessens 
the  frequency  of  the  cardiac  action,  and  also  aids  the  quieting  of  the 
bromides.  For  many  years  pas;  I  have  treated  nearly  all  the  cases  of 
delirium  tremens  that  have  come  under  my  care  with  these  two  remedies 
aided  only  occasionally  by  the  addition  of  chloral  hydrate  at  night.  Gen- 
erally the  chloral  has  been  needed  oidy  during  the  first  two  or  three 
nights.  A  very  common  prescription  is  bromide  of  potassium  twenty-five 
grammes  (3  vi),  tincture  of  digitalis  twenty  cubic  centimeters  (fl.  3  v), 
simple  elixir,  sixty  cubic  centimeters  (fl.  |  ii),  and  water  sixty,  (fl.  |  ii)  of 
which  r  give  four  cubic  centimeters,  or  a  good-sized  teaspoonful  in  a  little 
additional  water  every  two,  three  or  four  hours,  according  to  the  degree 
of  excitement  and  mental  agitation  exhibited  by  the  patient.  In  the  early 
stage,  when  the  patient  does  not  become  sufficiently  quiet  by  these  reme- 
dies to  get  some  sleep,  I  add  from  ten  to  thirteen  decigrammes  (gr.  xv  to 
xx)  of  chloral  about  eight  o'clock  in  the  evening,  and  if  the  patient  is  not 
asleep  bv  ten  o'clock  repeat  the  dose.  I  seldom  give  more  than  these  two 
doses  during  the  early  part  of  each  night  for  the  first  three  nights,  but 
continue  the  bromide  and  digitalis  at  the  usual  intervals,  except  not  wak- 
ing the  patient  out  of  sleep  to  take  medicine  alter  sleep  is  once  induced. 
By  pursuing  such  a  course  I  have  very  seldom  found  a  failure  in  steadily 
diminishing  the  phenomena  of  the  disease,  and  after  the  first  three  or 
four  days  the  chloral  could  be  discontinued  entirely,  and  the  bromide  and 
digitalis  continued  at  intervals  not  oftener  than  once  in  four  or  six  hours. 
In  some  of  the  cases  at  the  beginning  of  the  treatment,  the  tongue  is 
found  coated,  the  urine  scanty,  and  there  is  a  slight  elevation  of  the  tem- 
perature, indicating  slight  feverishness  and  general  derangement  of  tiie 
secretions.  With  such,  in  addition  to  the  treatment  just  described,  I  have 
given  two  or  three  alterative  doses  of  calomel,  lollowing  it  by  a  laxative, 
sufficient  to  move  the  bowels.  These  remedies  usually  remove  the  fever- 
ishness, correct  the  derangements  of  secretion,  and  more  readily  bring  the 
stomach  to  a  condition  for  tolerating  and  digesting  such  food  as  may  be 
necessary.  Sometimes  in  the  wildness  of  delirium  of  the  patients  it  is 
difficult  to  administer  medicine  with  any  regularity.  They  occasionally 
become  suspicious  of  those  around  them,  thinking  they  are  trying  to 
poison  them  with  every  dose  that  is  g'ven.  Consequently,  the  attendants 
are  apt  to  become  discouraged  in  their  eftorts  to  administer  either  medi- 


TKEATMENT.  795 

n\ne  or  food.  In  svich  cnses  great  benefit  may  be  obtained  bv  hvpo- 
dermic  injections  'of  morphine  either  alone  or  tempered  with  atropine, 
sufficient  to  give  the  patient  quiet,  and  often  before  the  delirium  is  renewed 
you  may  succeed  in  the  administration  of  other  remedies  and  some 
nourishment.  In  some  instances  support  can  not  be  accomplished  bv  in- 
jections, because  it  is  found  as  difficult  to  use  injections  during  the  de- 
lirious condition  as  it  is  to  give  medicine  by  the  mouth.  I  do  not  use 
opiates  in  the  treatment  of  delirium  tremens,  except  in  those  casrs  when^ 
as  I  h;ive  just  remarked,  I  find  it  impracticable  to  get  them  to  take  med- 
icine sufficiently  regular  by  the  mouth  or  rectum  to  get  the  effects  needed. 
In  such  instances  the  temporary  use  of  morphine  becomes  almost  ab- 
solutely necessary.  But  great  care  should  be  exercised  in  using  hypo- 
dermic injections  of  morphine  lest  the  quantity  thus  used  should  produce 
too  profound  narcotism,  more  especially  if  given  soon  after  full  doses  of 
chloral  hydrate  have  been  taken,  so  that  when  once  quiet  the  patient  gets 
the  fall  toxic  effect  of  both  remedies  and  sinks  into  a  sleep  from  w^hich  he 
never  awakes.  I  have  known  several  cases  in  which  this  result  has  act- 
ually been  obtained  much  to  the  chagrin  of  the  attending  physician. 
Quiet,  careful  attention  to  ventilation,  watchfulness,  gentle  nursino-  and 
the  simple  remedies  I  have  just  indicated,  have  been  sufficient  in  my  own 
hands  for  the  last  twenty  years  to  conduct  every  case  of  delirium  tremens 
to  a  safe  recovery  which  has  come  under  my  control  either  in  the  hospital 
or  out.  There  are  many  other  remedies  that  may  be  used  with  advantao-e, 
but  I  know  of  no  qualities  that  they  possess  superior  to  those  I  have  in- 
dicated, and  none  more  readily  adjusted  accurately  to  produce  the  effects 
needed.  The  patient  must  be  just  as  intelligently  supplied  wi^h  proper 
nourishment  and  in  proper  quantities  as  with  any  of  his  remedial  ao-ents. 
If  either  is  to  be  preferred  the  nourishment  is  the  most  important.  It 
should  be  plain,  easily  digestible  and  readily  absorbed,  or  convertible  into 
elements  of  blood  with  but  little  active  gastric  digestion.  For  the  lars^er 
proportion  of  these  patients  have  but  little  normal  gastric  secretion  and 
frequently  considerable  irritability  of  the  gastric  mucous  membrane,  so 
that  nourishment  should  be  given  in  very  moderate  quantities  and  usually 
in  a  liquid  form  until  the  patients  begin  to  recover.  Beef  tea  and  other 
animal  broths  properly  seasoned  with  salt,  milk,  lime  water  and  milk,  oat 
meal  gruel  and  milk,  rice  and  arrow  root,  are  among  the  nutriments  best 
adapted  to  these  cases.  As  soon  as  they  manifest  a  disposition  to  have 
other  food  they  may  be  supplied  with  any  ordinary  plain  food  in  moderate 
quantities  as  fast  as  the  appetite  demands  it.  They  should  be  carefully 
guarded  against  too  early  returning  to  severe  mental  and  muscular  exercise; 
and  especially  should  they  be  cautioned  against  ever  returnino-  to  the  use 
of  alcoholic  beverages;  for  every  attack  of  delirium  tremens  evidently 
leaves  the  nervous  system  in  some  degree  predisposed  to  another  attack. 
Consequently,  the  patient  more  and  more  readily  induces  these  attacks  by 
repeatmghis  potations,  til'  sooner  or  later,  complications  spring  up  in  the 
form  of  gastritis  and  sometimes  meningitis;  or  there  supervenes  in  connec- 
tion with  the  drinking  habit,  fatty  degeneration  of  the  liver  and  perhaps 
sclerosis  of  the  kidneys,  and  in  the  midst  of  the  delirium  sudden  suppres- 
sion of  urine  inducing  urasmic  poisoning,  convulsions  and  death.  While 
on  this  subject  of  delirium  from  the  use  of  intoxicating  drinks,  we  might 
pass  directly  to  the  consideration  of  what  has  been  denominated  metho- 
mania  or  dypsomania;  but,  if  such  a  lorm  of  disease  exists,  it  is  a  species 
of  mental  derangement  that  Avill  be  more  appropriately  alluded  to  in  the 
brief  review  I  sliall  make  of  mental  derangements  in  the  next  one  or  two 
lectures. 


796  MENTAL    DEHANGEMENT. 


LECTUEE     LXXXII. 


Mental  Derangements— Their  Varieties,  Causes,  General  Characteristics  and  Pathological  Rela- 
tions. 

GENTLEMEN:  Under  the  head  of  mental  derangements,  I  shall  not 
attempt  to  direct  your  attention  to  a  lull  consideration  of  the  various 
forms  of  insanity  and  impairment  of  mind  which  might  be  included 
under  so  general  a  designation.  The  subject  of  insanity  in  its  relations 
to  the  individual,  to  the  community  and  to  the  State,  is  so  important  and 
in  some  respects  so  different  from  other  classes  of  disease  that  it  has 
been  very  generally  considered  in  separate  treatises,  and  in  modern  times 
often  entirely  omitted  from  works  on  general  practice.  I  have  not 
thought  it  best,  however,  to  pass  the  subject  without  a  very  brief  consid- 
eration, aiming  to  make  it  such  as  would  assist  you,  as  general  practition- 
ers, in  recognizing  the  early  stage  of  the  different  forms  of  insanity,  and 
in  comprehending  the  causes  most  likely  to  produce  these  disorders,  that 
you  might  be  prepared  to  render  such  patients  a  reasonable  degree  of 
assistance  at  that  early  period  when  medical  attention  and  care  has  the 
best  chance  of  success.  A  glance  at  medical  literature  will  show  that 
there  are  two  prominent  and  distinct  modes  of  viewing  the  subject  of 
insanity.  The  one  which  was  predominant  until  within  the  last  i'ew 
years,  considers  the  subject  from  a  psychological  or  philosophical  stand- 
point almost  exclusively,  paying  little  attention  to  its  connection  with 
any  disorder  of  the  brain  or  nervous  system.  The  other  regards  the  men- 
tal derangements  as  in  a  great  measure,  if  not  wholly,  the  result  of  prior 
and  coincident  derangements  of  the  physical  organs  through  which 
mind  is  manifest,  i.  e.,  the  brain  and  its  appendages.  It  is  probable 
that  neither  of  these  extreme  views  are  correct,  and  yet  there  is  a  valu- 
able amount  of  truth  in  both.  If  you  stud^"^  the  causes  which  are  known 
to  favor  the  development  of  mental  derangements,  you  will  readily 
observe  that  such  causes  are  divisible  into  two  classes;  one  class  is 
addressed  almost  exclusively  to  the  mind  itself  and  may  be  said  to  be 
purely  mental;  the  other  acts  with  equal  directness  upon  the  physical 
organization,  and  consequently  reaches  derangements  of  the  mind,  neces- 
sarily through  changes  in  the  physical  structure.  You  will  remember 
that  at  the  last  lecture  in  alluding  to  the  form  of  mental  derangement 
called  delirium  tremens,  which  is  caused  almost  exclusively  by  alcoholic 
drinks,  that  the  physical  agent,  alcohol,  makes  its  impression  upon  the 
structures  of  the  brain  and  nervous  system  as  well  as  upon  the  other 
organs  of  the  body,  and  induces  those  changes  in  the  nutritive  functions 
that  render  the  brain  incapable  of  manifesting  mental  action  in  a  coher- 
ent and  natural  manner,  there  can  be  no  doubt.  This  would  serve  as  an 
example  of  all  that  class  of  agents  which  act  through  the  physical  system 
in  producing  modifications  in  the  properties  or  structure  of  the  brain  m 
such  a  way  as  to  disorder  the  mind  in  its  manifestations.  On  the  other 
hand,  persons  who  may  be,  as  far  as  can  be  determined,  in  the  most  per- 
fect physical  health,  if  subjected  to  causes  that  operate  primarily  and 
entirely  upon  the  mental  faculties,  emotions  and  passions  may,  by  persist- 
ence, develop  derangements  quite  as  certain  and  as  serious  in  their  char- 
acter as  any  causes  that  act  more  directly  through  impressions  on  the 
physical  structures.     It  is  only  rarely  that  sudden   and  transient  impres- 


CAUSES    AND    VARIETIES.  797 

sions  upon  the  m:!ntal  faculties  and  emotions,  however  intense  they  may 
be,  have  produced  actual  mental  derangements,  but  it  is  those  causes 
which  act  more  or  less  intensely  and  persistently  through  considerable 
periods  of  time  which  are  most  likely  to  result  in  actual  disorder  to  the 
mental  faculties  or  in  some  form  of  insanity.  Among  the  causes  that 
act  upon  the  mental  faculties  may  be  enumerated  prominently,  persistent 
cares  and  other  depressing  mental  emotions  long  continued;  intense 
mental  application  directed  to  some  particular  theory  or  problem,  such  as 
questions  in  theology  or  concerning  the  future  existence,  or  such  ques- 
tions in  philosophy  or  metaphysics  as  have  the  power  to  concentrate  some 
particular  intellectual  faculties  so  intensely  as  to  interfere  with  regular 
sleep.  The  mind  thus  occupied  with  a  special  train  of  thought  through 
many  days  and  nights  in  succession  is  one  of  the  more  common  causes  of 
mental  derangements.  Those  misfortunes  consisting  in  loss  of  property, 
changes  in  domestic  circumstances  and  disappointment  of  aifections,  when 
of  sujh  character  as  to  cause  loss  of  sleep  and  persistent  dwelling  upon 
the  sime  thing,  are  extremely  liable  to  produce  mental  disorders,  and  are 
all  of  them  addressed  in  their  action  to  the  mind  itself.  On  the  other 
hand  not  only  the  use  of  alcoholic  drinks,  but  a  \^ariety  of  narcotics  and 
anreithetics  and  the  existence  of  certain  diseases,  are  capal  le  of  pro;iuoing 
such  an  influence  on  the  brain  as  to  disorder  the  mental  manifestations. 
If  the  whole  series  of  causes  which  favor  the  occurrence  of  mental  dis- 
orders are  examined  closely  and  analytically,  it  will  be  found  that  a  large 
proportion  of  those  which  ate  addressed  to  the  physical  system,  such  as 
the  narcotics,  anaesthetics  and  other  physical  agents  that  are  capable  ol 
producing  mental  disorders,  are  characterized  largely  by  impai-raent  of  the 
mental  faculties  rather  than  the  establishment  of  permanent  derange- 
ments of  the  intellect,  although  the  latter  often  exist  in  the  earlv  stage  in 
a  prominent  degree.  After  this  stage  is  passed,  however,  if  the  phe- 
nomena do  not  cease  entirely,  they  are  more  likely  to  be  resolved  into 
mental  impairments  tending  toward  imbecility  or  mental  incapacity  rather 
than  into  intellectual  hallucinations  or  insanity  proper.  While  the  class 
of  causes  that  are  addressed  to  the  mental  faculties  direct,  are  vjry  liable  to 
produce  the  reverse  result,  namely,  permanent  hallucinations,  illusions 
and  reisoning  from  false  premises,  yet  often  maintaining  much  acuteness 
and  quickness  in  their  mental  processes  through  a  series  of  years. 

Varieties  of  Ins  an' ty. — The  laws  of  England  and  of  most  of  the  Sates 
of  this  country  recognize  two  varieties  of  insanity,  diagnostically  called 
in  the  English  law,  dementia  naturalis  and  dementia  accidentalis,  cor- 
responding with  the  more  common  words  idiocy  and  lunacy:  dementia 
naturalis  meaning  idiocy  from  birth,  vf\\\\e  dementia  accidentalis  includes 
all  those  cases  that  arise  from  any  c.iuse  after  the  mind  has  on<"e  been 
developed  to  activity.  Those  included  under  the  second  class,  dementia 
accidentalis^  or  lunacy,  may  be  further  divided  conveniently  for  Durposes 
of  diagnosis  and  recognition  into  two  subdivisions,  namely,  mania  and 
•monomania.  Cases  of  dementia  naturalis  or  idiocy  are  also  divisible 
into  two  subordinate  classes  which  may  be  designated  as  dementia,  and 
amentia.  The  first  meaning  impairment  of  mind,  and  the  second,  absence 
or  complete  loss  of  mind.  Of  course  there  is  no  clear  line  of  demirkation 
between  these  two  subordinate  divisions  of  the  class  of  idiots,  for  they 
manifest  all  possible  stages  or  grades  of  mental  impairment,  from  that 
which  falls  only  a  little  below  the  regular  order  of  intellect,  to  that  of  com- 
plete absence  of  all  manifestation  of  intelligence,  constituting  the  amen- 
tia. The  division  of  the  second  class  into  mania  and  monomania  is  founded 
upon  the  fact  that  there  are  many  of  the  insane  who  manifest  derange- 


798  MENTAL  DERANGEMENTS. 

ments  of  the  mental  faculties  generally,  and  are  not  able  to  control  the 
mental  processes,  so  as  to  reason  correctly  upon  any  subject.  While  there 
are  many  others  who  reason  correctly,  and  as  far  as  can  be  detected  mani- 
fest all  their  mental  operations  in  a  natural  manner  in  relation  to  all  sub- 
jects and  processes  except  perhaps  a  single  topic  on  which  they  reason 
altogether  incorrectly.  The  mind  is  said  in  such  cases  to  be  deranged 
upon  one  subject,  or  upon  a  particular  class  of  subjects,  while  it  is 
apparently  unaffected  in  reference  to  all  other  subjects.  You  will  mark 
tiiat  this  derangement  is  limited  to  some  particular  topic  orclasiof 
topics  and  not  limited  to  some  particular  faculty  of  the  mind.  This 
distinction  has  not  always  been  kept  in  mind,  and  has  led  to  the  idea 
that  the  mind  is  capable  of  being  deranged  in  one  or  two  of  its 
faculties  and  not  in  others.  I  have  seen  no  specimens  of  that  char- 
acter. But  the  mental  derangement  in  regard  to  particular  topics  or 
particular  subjects  is  of  very  common  occurrence.  The  recognition  of 
monomania,  or  derangement  in  relation  to  particular  subjects  has  led  more 
recently  to  the  multiplication  of  forms  of  insanity  to  a  degree  w^hich  has 
seemed  to  me  excessive.  An  effort  has  been  made  to  show  the  existence 
of  actual  mental  derangements  as  the  cause  of  a  large  portion  of  the  crim- 
inal practices  existing  in  the  community.  Once  recognizing  the  liability 
to  derangements  upon  particular  topics  or  subjects  of  thought,  the  at- 
tempt has  been  made  to  explain  many  atrocious  criminal  acts  on  the 
theory  that  the  party  committing  those  acts  was  insane  on  the  subject  relat- 
ing to  them.  For  instance,  the  taking  of  property,  or  theft,  has  been  recog- 
nized as  a  form  of  insanity  called  kleptomania.  The  disposition  to  reck- 
lessly set  fire  to  buildings  has  been  regarded  as  pyromania  or  as  a  form 
of  insanity  or  insane  impulse  to  commit  arson.  The  exhibition  of  sudden 
and  violent  anger  to  the  extent  of  committing  violent  assaults  and  some- 
times murder,  has  been  explained  by  alleging  the  existence  of  impulsive 
insanity.  But  if  you  adopt  the  reasoning  of  a  considerable  number  of 
specialists  of  the  present  time  in  the  department  of  psychological  medicine 
and  carry  it  to  its  logical  results,  you  will  be  led  to  a  position  from  which 
you  will  be  wholly  unable  to  maintain  a  line  of  distinction  between  crime 
proper  and  the  freaks  of  insane  impulses,  and  the  special  mental  derange- 
ments upon  particular  subjects.  And  you  will  be  compelled,  as  some  have 
already  done,  to  regard  all  crime  as  only  the  result  of  mental  derange- 
ments, and  further  that  such  mental  derangements  are  founded  upon  faulty 
physical  organization. 

Of  course  such  a  position  involves  a  denial  of  the  justice  of  all  punish- 
ment, as  well  as  an  obliteration  of  all  distinctions  between  virtue  and 
vice  and  between  right  and  wrong.  I  make  these  allusions  to  prevalent 
tendencies  simply  to  put  you  on  your  guard  against  being  led  by  such 
reasoning  to  excesses,  and  not  by  ^ny  means  to  discourage  close  and  care- 
ful investigation.  Very  many  attempts  have  been  made  to  give  a  defini- 
tion of  insanity.  A  well  known  writer  on  mental  philosophy,  John 
Locke,  defined  insanity  to  be,  reasoning  correctly  from  false  premises. 
The  equally  celebrated  Dr.  Abernethy  of  London,  defined  insanity  to  be 
the  loss  of  the  faculty  of  attention;  while  Dr.  Connolly,  having  much  ex- 
perience personally  in  the  care  of  the  insane,  defined  the  disease  to  be, 
loss  of  the  power  of  comparison  and  judgment.  It  requires  but  a  moder- 
ate amount  of  familiarity  with  the  insane  to  perceive  that  all  these  defini- 
tions are  correct  when  applied  to  certain  classes  of  the  insane.  You  could 
hardly  enter  any  asylum  for  this  class  of  individuals  containing  a  score 
of  patients,  without  finding  some  of  them  who  would  reason  as  acutely  as 
the  best  trained   intellects  are  capable  of  doing,  making  all   their  deduc- 


SYMPTOMS.  7yy 

tons  in  strict  harmony  with  the  premises  that  they  assume.  But  tho 
promises  themselves  would  be  false.  Consequently  their  deductions  lead 
them  into  error,  constituting  their  derangement.  Others  would  be  found 
among  a  similar  number  who  would  exactly  correspond  with  Dr. 
Abernethy's  definition,  that  is,  loss  of  the  power  of  attention.  The  mind 
would  flit  from  topic  to  topic,  notwithstanding  all  your  efforts  to  fix  their 
attention  upon  any  one  train  of  thouglit.  Such  individuals  are  common 
amon2:  those  who  are  laborino-  under  mania  or  general  insanitv. 

Perhaps  there  is  no  more  prominent  symptom  among  them  than 
this  inal)ility  to  fix  the  attention  so  as  to  hold  any  two  trains 
of  thought,  or  to  keep  the  mind  upon  any  two  objects  long  enough 
to  make  a  comparison  or  deduction.  And  equally  easy  is  it  to  find 
in  a  limited  number  of  the  insane  those  who  would  correspond 
with  the  definition  of  Dr.  Connolly,  the  loss  of  the  power  of  com- 
parison and  judgment.  Indeed,  this,  when  you  analyze  it,  hardly  differs 
from  that  of  Dr.  Abernethy.  The  loss  of  the  power  of  comparison  is 
nothing  more  nor  less  than  the  loss  of  the  power  to  fix  the  attention  long 
enough  upon  two  objects  or  two  trains  of  thought  to  make  a  comparison. 
Of  course,  there  can  be  no  judgment  or  inference  where  the  attention  can 
not  be  fixed  long  enough  to  allow  of  a  comparison.  The  comparison  of 
different  things  and  trains  of  thought  is  an  essential  requisite  to  the  i'orm- 
ingof  a  conclusion  or  judgment.  Perhaps  one  of  the  most  practical  dis- 
tinctions to  be  made  in  the  classification  of  mental  derangements  consists 
in  drawing  a  line  between  those  persons  who  are  insane  and  those  whose 
mental  unsoundness  consists  directly  in  impairment  in  one  or  more  of  the 
mental  faculties,  which  would  cause  them  to  be  properly  called  weak  or 
incapable,  but  in  the  operation  of  whose  mind  there  is  no  apparent 
illusion,  false  impression  or  hallucination,  and  consequently  not  any 
drawing  of  erroneous  conclusions,  or  what  is  diagnostically  called 
delusions,  but  simply  impairment  in  the  readiness  of  mental  action.  Such 
cases  exhibit  slowness  of  thought  and  of  speech,  difficulty  apparently  for 
the  mind  to  continue  a  train  of  thought,  as  exhibited  frequently  by  losing 
it  in  the  midst  of  a  sentence  and  being  unable  to  finish  it.  Such  patients 
constitute  a  class  that  may  be  properly  styled  incapacitated  or  unsound 
in  mind,  but  not  technically  insane.  The  other  class  would  consist  of  ail 
those  whom  I  would  call,  technically  and  properly,  mentally  deranged  or 
insane;  not  simply  weakened  in  mental  action,  but  the  mental  processes 
more  or  less  actually  turned  out  of  their  normal  channels  of  operation. 
And  I  think  all  without  exception  belonging  to  this  class  are,  when  the 
mental  disorder  has  become  well  established,  affected  with  certain  men- 
tal phenomena,  which  may  be  ranged  under  three  heads,  namely: 
illusions,  hallucinations  and  delusions.  By  illusions  I  mean  an  erroneous 
conception  of  a  real  object.  Perhaps  one  of  the  most  common  that  3'ou 
will  meet  with  is  the  illusion  that  the  individual  who  is  insane  is  himself 
some  person  entirely  different  from  his  real  character.  It  m  ly  be 
the  illusion  that  he  is  a  king,  a  popular  officer,  a  beggar,  or  the  maker 
of  the  universe,  constituting  an  illusion  in  reference  to  the  real  object, 
but  perverting  the  character  of  that  object.  Or  it  maybe  an  illusion  con- 
cerning objects  not  personal,  but  of  a  strictly  material  character  discon- 
nected from  the  individual,  as  when  the  friencis  or  individuals  around  or 
connected  with  the  insane  person  are  regarded  by  him  as  persons  entirely 
different  from  what  they  really  are;  giving  to  each  of  them  a  name  and 
character  that  is  purely  fictitious.  The  illusion  may  consist  in  the  im- 
pression, fixed  and  indelible,  that  the  composition  of  the  body  is  entirely 
different  from  that   which  is  natural.     For  instance,   a  lady  of  very  high 


800  MENTAL    DERAKGEMENTS. 

rank  in  England,  in  former  times,  is  reported  to  h:ive  labored  for  years 
under  the  illusion  tliat  iier  own  body  was  made  of  glass,  rendering  her 
extremely  reluctant  to  have  any  one  approach  her  through  fear  that  such 
contact  might  break  her  to  pieces.  Particular  articles  of  furniture  are 
liable  to  be  invested  with  illusions  of  the  same  character.  The  sense  of 
taste  and  hearing  also,  as  well  as  sight  may  be  the  seat  of  similar  illusions, 
as  when  sounds  are  construed  entirely  different  from  what  they  really  are, 
and  sweet  substances  are  thought  to  be  sour  and  sour  sweet,  or  bitter 
palatable.  By  hallucinations  are  meant  the  conception  in  the  mind  of  the 
insane  of  the  presence  or  proximity  of  bodies  or  phenomena  that  have  no 
real  existence,  as  the  hearing  of  noises  and  conversation  where  no  such  ex- 
ist. Hallucinations  may  equally  reach  the  mind  through  the  organs  of  vision 
and  lead  to  the  supposition  that  objects,  animals,  friends  or  other  parties 
are  present,  and  apparently  to  their  conceptions  really  present  before 
them,  that  have  no  existence,  while  delusions  are  the  conclusions  or  judg- 
ments that  the  insane  person  forms  from  the  influence  of  these  illusions  and 
hallucinations.  Acting  and  thinking  as  though  the  hallucinati  ns  and 
illusions  are  real,  the  insane  person  is  of  course  led  to  erroneous  conclu- 
sions, and  from  erroneous  conclusions  to  delusions  and  erroneous  acts, 
not  infrequently  of  the  most  injurious  and  dangerous  character.  There 
are  almost  all  forms  of  these  illusions  and  hallucinations  of  which  you  can 
conceive.  And  not  infrequently  they  take  the  form  of  jealousy  or  the 
investing  of  certain  parties  with  false  attributes,  perhaps  investing  their 
very  best  friends,  members  of  their  own  families,  with  the  qualities  of  an 
enemy,  conspiring  with  others  to  invade  the  domestic  circle,  rob  them  of 
their  property,  or  do  them  bodily  injury. 

Of  a  similar  illusory  nature  is  that  form  of  insanity  which  causes  the 
husband  to  attribute  to  his  wife  want  of  fidelity,  and  to  put  a  false  con- 
struction upon  almost  every  movement  that  she  makes,  or  the  wife  the 
same  in  regard  to  the  husband,  to  such  a  degree  that  the  suspected  party 
can  not  transact  the  most  trivial  business  with  other  parties  without  almost 
every  word  and  act  being  construed  in  a  false  light,  or  regarded  as  evi- 
dence of  some  criminal  intention.  These  are  usually  classed  under  the 
general  head  of  jealousy,  yet  they  are  all  resolved  either  into  illusions  or 
hallucinations.  But  I  said  in  the  beginning  that  one  of  the  leading  ob- 
jects in  alluding  to  this  subject  of  insanity,  was  to  call  your  attention  to 
those  symptoms  and  conditions  which  characterize  the  forming  stage  of 
insanity  and  their  diagnostic  value,  that  you  might  be  the  better  pre- 
pared, not  only  to  detect  the  existence  of  mental  disorders  early,  but  also 
by  early  and  judicious  treatment  to  arrest  its  progress  and  save  the  in- 
dividual from  so  great  a  calamity  as  the  full  development  of  mental 
disorder.  And  this  leads  me  to  a  brief  review  of  the  symptoms  and  prog- 
ress of  some  of  the  chief  forms  of  insanity  from  their  incipient  beginning 
to  their  full  development. 

Symjytoms. — Perhaps  one  of  the  earliest  and  most  important  symptoms 
of  the  approach  of  insanity  consists  in  a  marked  change  in  the  individual 
from  his  ordinary  or  natural  mode  of  thought  and  demeanor.  A  marked 
alteration  in  this  respect  is  always  worthy  of  notice.  Among  the  very 
earliest  symptoms  are,  with  one  class,  the  manifestation  of  self-conceit,  or 
assumed  importance  or  positiveness  that  is  unnatural  to  them.  Another 
class,  instead  of  exhibiting  self-conceit  and  arrogant  assumptions,  show  a 
degree  of  despondency,  distrust  and  indisposition  to  freedom  of  conversa- 
tion, or  manifest  a  desire  to  remain  silent  to  a  degree  quite  unnatural  and 
contrary  to  their  usual  habit.  Perhaps  a  still  larger  class  show  their  first 
manifestations  by  distrust  or  suspicion  of  some  particular  party  or  some 


SYMPTOMS.  801 

limited  number  of  parties,  or  at  times  in  reference  to  everybody,  causing 
them  to  act  every  day  as  thoug-h  making  an  effort  to  conceal  their  suspi- 
cions. Yet  by  a  very  moderate  amount  of  intercourse  their  attempts  at 
concealment  fail,  and  they  soon  betray  the  distrust  or  suspicion  which 
they  evidently  feel,  and  which  is  persistent  with  them  from  day  to  day, 
causing  them  to  be  apparently  non-commimicative  and  reluctant  to  speak 
of  their  plans,  their  movements,  or  anything  that  pertains  to  the  object  of 
their  distrust.  With  all  these  changes  from  the  natural  condition  of  the 
individual  as  early  traits,  there  is  almost  invariably  an  impairment  of  the 
ability  to  sleep.  Their  nights  become  disturbed  and  wakeful.  If  they 
retire  as  usual,  they  do  not  sleep.  They  are  forced  to  get  up  much  ear- 
lier in  the  morning,  sometimes  in  the  middle  of  the  night.  These  changes 
from  the  natural  condition,  or  tone  of  mind  and  feeling  in  any  direction, 
maintained  through  many  days  or  weeks  in  succession,  should  always 
lead  to  a  careful  consideration  of  the  causes,  and  it  will  seldom  fail  to 
prove  the  precursor  of  some  form  of  mental  derangement.  If  to  these 
slighter  and  more  obscure  alterations  from  the  natural  mental  condition 
of  the  patient  we  add  somewhat  uniform  wakefulness  at  night,  sometimes 
a  continuous  pain  in  the  head,  and  the  manifestation  of  unusual  despond- 
ency without  adequate  cause,  or  on  the  other  hand,  undue  excitement, 
equally  without  adequate  cause,  with  occasional  expressions  indicating  a 
suspicious  disposition,  or  an  unusual  interpretation  of  the  acts  of  others, 
perhaps  of  intimate  friends,  it  will  show  not  only  that  mental  derange- 
ment is  approaching,  but  that  it  has  already  commenced.  And  if  these 
deviations  simply  continue  to  increase  from  day  to  day,  the  reasoning 
faculties  will  soon  so  far  loose  their  control  that  the  illusions  or  false 
conceptions  formed  in  the  mind  of  the  patient  will  inevitably  betray  him 
into  the  more  open  manifestation  of  insanity.  The  cases  that  have  al- 
ready been  alluded  to,  are  those  which  commence  slowly,  and  usually 
lead  to  what  may  be  termed  chronic  forms  of  mental  derangement.  They 
may  persist  in  their  development  till  the  mind  becomes  deranged  upon 
all  subjects,  constituting  general  insanity.  Or,  the  insane  trains  of 
thought  may  be  confined  to  particular  topics,  and  remain  there  throughout 
the  whole  course  of  the  disease,  constituting  partial  insanity  or  monoma- 
nia. The  disease  may  present  a  great  variety  of  deviations.  After  the 
individual  has  been  led  into  the  first  deviation  from  the  natural  train  of 
thought  he  will  very  generally  assume,  and  act  upon  the  idea  that  some 
particular  individuals  or  agents  have  caused  that  train  of  thought,  and 
this  will  give  character  generally  to  all  the  subsequent  insane  develop- 
ments; the  derangement  of  mind  will  be  limited  to  these  individuals  or 
topics.  It  may  take  the  direction  of  extreme  depression,  under  the  im- 
pression that  they  are  lost;  that  the  day  of  salvation  or  any  future  happi- 
ness for  them  has  gone  by;  or  it  may  take  the  opposite  direction,  that  of 
being  elated  with  the  idea  that  they  are  already  passed  into  the  state  of 
perpetual  enjoyment,  or  that  they  are  some  high  religious  dignitary,  dis- 
pensing happiness  to  others.  Cases  of  the  first  kind  are  much  more  nu- 
merous than  the  latter,  and  constitute  some  of  the  most  typical  instances 
of  insanity  that  we   meet  with. 

Another  very  frequent  train  of  insane  thought  has  reference  to  the 
character  and  actions  of  the  patient's  most  intimate  friends,  and  has  for 
its  basis,  jealousy  or  suspicion.  It  may  relate  to  property,  the  suspicion 
being  that  certain  parties  are  in  conspiracy  to  deprive  them  of  their  prop- 
erty. And  in  relation  to  that  topic  no  amount  of  reasoning  can  correct 
their  delusions,  while  upon  all  other  subjects  they  will  converse  and  act 
as  rationally  as  other  parties.     The  suspicion  may  fall  upon  some  mem- 

51 


802  MENTAL    DERANGEMENTS. 

ber  of  their  own  family,  the  husband  suspecting  the  chastity  or  conduct 
of  the  wife,  or  the  wife  that  of  the  husband  not  only  in  relation  to  fidel- 
ity to  the  marriage  contract,  but  in  relation  to  their  being  in  conspiracy 
with  other  parties  to  put  the  patient  out  of  existence.  The  suspicion  not 
I  infrequently  fastens  itself  upon  their  most  intimate  friends  or  family  rela- 
itives.  And  under  such  circumstances  often  the  first  manifestation  of 
their  illusion  is  a  refusal  to  eat  under  the  suspicion  generally  that  what 
is  prepared  for  them  has  been  poisoned.  They  will  refuse  to  eat  at 
first,  often  without  acknowledging  why.  For  the  same  reason  they  will 
often  refuse  to  take  medicine  through  fear  of  being  poisoned  by  it.  Often 
they  will  remain  awake  the  greater  part  of  the  night,  watching  for  some 
anticipated  movement  against  themselves  by  the  parties  they  suspect. 


LECTURE    LXXXIII. 

Mental  Derangements  Continued— Clinical  History,  Diagnosis,  Prognosis  anJ  Treatment. 

GENTLEMEN:  At  the  close  of  the  preceding  lecture  I  was  direct- 
ing your  attention  to  the  various  phases  of  insanity.  There  is  hardly 
a  topic  that  ordinarily  occupies  the  human  mind  but  what  may  become 
the  subject  of  insane  delusions,  constituting  what  is  denominated  mono- 
mania or  partial  insanity,  while  on  all  other  topics  the  individual  retains 
his  usual  correctness  of  mental  operations  and  maintains  very  good  gen- 
eral health  in  many  cases  for  years.  If  you  choose  to  look  through  the 
special  works  upon  insanity  or  the  treatises  upon  medical  jurisprudence, 
in  the  chapters  devoted  to  insanity  in  its  various  forms  and  relations,  you 
will  find  the  details  of  many  interesting  cases  of  the  various  forms  of 
monomania.  As  I  said  before,  these  forms  do  not  always  affect  the 
reasoning  or  the  intellectual  faculties  but  are  sometimes  confined  to  the 
emotions  and  passions.  And  when  thus  confined  they  are  capable  of  pro- 
ducing erratic  and  sometimes  highly  criminal  acts,  which  are  difficult  for 
those  who  have  not  made  the  matter  a  subject  of  study  to  understand 
or  excuse.  The  individual  retains  apparent  appreciation  of  right  and 
wrong  and  his  power  of  reasoning  as  well  as  ever  upon  almost  every  topic, 
and  yet  is  subject  to  certain  impulses  apparently  beyond  his  control,  of  a 
criminal  character.  I  allude  now  to  "those  impulses  which  have  been 
manifested  to  commit  assaults  upon  other  parties,  as  in  the  case  of  a  sud- 
den impulse  to  destroy  life  or  commit  murder.  This,  however,  is  not 
always  explainable  upon  a  sudden  impulse,  but  sometimes  originates  from 
an  insane  impression  of  having  received  a  direct  command  from  the  deity, 
as  when  a  father  kills  one  or  more  of  his  children  under  a  direct  impres- 
sion that  he  is  ordered  to  do  it  by  the  deity  and  can  not  help  himself,  or 
as  in  a  case  that  occurred  in  this  city  only  a  few  years  since,  where  a  father 
who  had  been  deranged  upon  a  general  or  religious  theme  and  who  had 
been  properly  adjudicated  insane  and  confined  in  an  asylum,  was  thought 
by  the  superintendent  to  have  recovered  and  consequently  was  allowed  to 
return  to  his  home.  Within  a  few  days  after  his  return,  however,  he  de- 
liberately killed  his  wife  in  open  day,  under  the  fixed  impression  that  he 
was  commanded  by  the  deity  to  sacrifice  the  dearest  object  of  his  aff^ec- 
tions.     And  as  that  was  his  wife   he  deliberately  proceeded  before  her 


SYMPTOMS.  803 

face  to  shoot  her  dead.  That  this  was  an  insane  act  purely,  there  can  be 
no  doubt.  Many  cases  have  occurred  of  the  destruction  of  wife,  children 
or  members  of  the  family,  under  delusions  operating-  upon  the  mind  in  a 
similar  manner. 

We  may  explain  sometimes  possibly,  the  acts  of  criminals  in  commil- 
ting  arson  or  murder,  through  the  processes  of  mental  derangement.  But 
it  requires  very  great  care  to  distinguish  between  tlie  actually  iusane  in 
these  cases  of  emotional  or  impulsive  insanity,  and  those  of  true  deliber- 
ate criminality.  For  such  differences,  however,  I  must  refer  you  again  to 
that  portion  of  works  on  medical  jurisprudence,  which  treat  of  the  crim- 
inal relations  of  the  insane.  When  insanity  has  approached  in  a  slow, 
obscure  manner  as  I  have  described,  and  has  finally  established  either 
general  derangement  of  the  mental  faculties,  or  a  limited  derangement 
having  reference  to  particular  topics  and  trains  of  thought,  there  is  little 
tendency  to  any  self-limit  in  the  progress  of  the  affection,  particularly  so 
long  as  the  objects  which  are  the  subject  of  the  insane  thought  are  within 
sight  or  proximity  of  the  patient.  If  they  are  separated  entirely  from  such 
relations  and  placed  at  an  early  period  under  the  control  of  strangers,  as 
when  removed  to  institutions  especially  for  the  care  of  the  insane,  a  large 
proportion  are  capable  of  recovery.  The  proportion  will  be  much  larger 
than  if  left  within  the  circle  and  in  near  contact  with  the  individuals  and 
circumstances  under  which  the  derangement  first  developed.  Cases  of 
general  insanity  often  originate  in  a  sudden  and  acute  manner  as  I  have 
already  indicated,  especially  when  the  exciting  causes  are  such  as  act 
with  a  high  degree  of  intensity  upon  the  mind.  For  instance,  when 
the  mind  receives  some  violent  shock,  as  in  sudden  loss  of  large  amounts 
of  property  or  of  immediate  relatives,  or  when  they  are  placed  in  circum- 
stances where  they  are  under  great  mental  apprehension  of  some  disease, 
or  the  approach  of  some  sudden  accident,  striking  terror;  in  all  such,  the 
intense  mental  impressions  are  capable  of  producing  the  most  sudden  and 
rapidly  developed  general  derangement  of  the  mind,  so  rapid  sometimes 
that  the  individual  passes  almost  immediately  into  a  state  of  frenzy,  with 
loss  of  all  control  over  the  intellectual  faculties,  constituting  general  acute 
mania.  In  such  cases  the  symptoms  are  often  very  violent.  The  individ- 
ual exhibits  a  wild  or  excited  expression  of  countenance,  often  manifest- 
ing the  most  violent  outbursts  of  temper  and  emotion,  ready  in  some  in- 
stances to  assault  their  best  friends  with  the  utmost  violence,  or,  in  their 
terror,  to  plunge  themselves  without  the  slightest  hesitation  from  windows 
at  any  height  above  ground,  where  the  fall  would  be  immediate  destruc- 
tion, and  without  any  disposition  to  sleep  for  many  days  and  nights  in  suc- 
cession. These  are  cases  of  acute  general  mania  and  yet  amidst  it  all, 
you  can  generally  trace  certain  hallucinations  and  illusions  that  are  the 
basis  of  their  derangement. 

Another  form  of  acute  general  mania  is  that  which  attacks  lying-in 
women  and  is  called  puerperal  mania.  The  disease  frequently  develops 
within  a  few  days  after  confinement,  but  in  some  cases  not  until  several 
weeks  have  elapsed.  The  first  indications  of  the  approach  of  this  form 
of  disease  are  simply  change  in  the  individual's  modes  of  expression  and 
thought,  saying  things  that  are  odd  and  unusual  for  them,  refusing  to 
take  nourishment  and  unable  to  sleep  at  night.  These  symptoms  usually 
progress  so  rapidly  that  in  from  one  to  three  days  the  patients  are  found 
to  be  in  a  condition  of  general  mental  derangement.  They  are  almost 
always  suspicious  of  those  immediately  around  them,  so  much  so  that  it  is 
extremely  difficult  to  induce  them  to  take  sufficient  nourishment  through 
fear  of  being  poisoned  by  their  supjoosed  enemies.     In  almost  all  cases  of 


804  MES-TAL   DEEANGEMENTS. 

acute  general  mania  the  patient  becomes  rapidly  reduced  by  the  refusal 
to  take  adequate  nourishment,  the  want  of  sleep,  and  the  constant  mental 
excitement,  as  indicated  by  their  becoming  more  pale,  the  pulse  quicker, 
softer,  more  easily  compressed,  the  extremities  often  cold,  and  in  the 
most  severe  cases  this  exhaustion  will  continue  to  increase  unless  they 
are  relieved  by  appropriate  treatment  until  it  reaches  a  fatal  termination; 
sometimes  in  the  course  of  one  or  two  weeks,  but  more  frequently  not  till 
the  end  of  five  or  six  weeks.  AVhile  some  cases  will  thus  run  through 
an  acute  course  to  a  fatal  result,  far  the  larger  number  after  the  first  two 
or  three  weeks  become  modified  in  the  intensity  of  the  mental  derange- 
ment, so  far  that  the  patient  catches  now  and  then  short  periods  of  sleep, 
more  nourishment  is  taken  and  the  physical  system  is  consequently  sus- 
tained while  the  mental  derangement  goes  on  in  what  may  be  called  a 
chronic  form.  In  such  cases  after  assuming  the  chronic  form  as  well  as 
in  those  that  may  be  said  to  be  chronic  from  the  beginning,  there  is  a  tend- 
ency to  ultimate  atrophy  and  impairment  of  nutrition  especially  in  cer- 
tain portions  of  the  cerebral  substance.  Perhaps  the  parts  most  fre- 
quently involved  where  atrophy  and  wasting  can  be  detected,  or  in  the 
acute  cases  that  terminate  fatally  at  the  early  period  where  hyperaemia 
and  increased  vascularity  are  most  noticed,  are  in  the  central  ganglia, 
especially  the  corpora  striata  optic  thalami,  and  to  some  extent  the  gray 
matter  upon  the  surface  of  the  cerebral  hemispheres.  The  parts  least 
affected  are  the  posterior  portions  of  the  cerebrum.  In  long  continued, 
general  insanity,  there  is  in  most  instances  a  noticeable  degree  of  atrophy 
of  some  portions  of  the  cerebral  substance,  more  particularly  of  the  gray 
material,  either  of  the  convolutions  upon  the  hemispheres  or  the  ganglia 
at  the  center  as  I  have  already  mentioned.  This  atrophy  has  sometimes 
extended  through  the  medulla  to  the  lateral  gray  matter  of  the  spinal 
cord  and  become  associated  with  general  atrophy  of  the  muscular  system, 
constituting  what  I  have  already  alluded  to  when  speaking  of  the  inflam- 
matory affections  of  that  portion  of  the  cord  as  the  general  atrophy  of  the 
insane-  This  brief  outline  of  the  premonitory  symptoms  and  the  more 
prominent  phenomena  accompanying  the  different  degrees  and  stages  of 
insanity,  and  the  tendency  of  the  disease  either  to  assume  the  chronic 
form  or  to  lead  to  such  changes  as  may  terminate  early  fatally,  are  suf- 
ficient to  give  you  that  degree  of  knowledge  which  every  practitioner  of 
medicine  should  possess.  As  I  have  before  intimated  a  whole  lecture 
could  be  readily  taken  up  in  describing  the  different  phases  of  mania  and 
monomania  without  exhausting  the  subject. 

Pathology. — I  have  just  stated  to  you  that  where  death  takes  place  dur- 
ing the  progress  of  acute  mania,  there  is  usually  found  more  or  less  hy- 
persemia  or  accumvilation  of  blood  in  the  vessels  of  the  convolutions  upon 
the  hemispheres  of  the  brain,  and  in  the  corpora  striata  and  other  portions 
of  gray  matter  at  its  base.  The  microscope  reveals  still  further  molecular 
disturbance  in  the  structure  of  the  parts  where  the  most  hypersemia  exists, 
probably  closely  analogous  to  the  ordinary  changes  that  accompany  in- 
flammatory action;  and  in  those  chronic  cases  that  have  been  of  long 
duration,  the  anatomical  changes  as  previously  remarked  are  those  of 
atrophy  or  diminution  of  nerve  structure,  with  perhaps  some  slight  degree 
of  sclerosis  or  hypertrophy  of  the  connective  tissue.  And  in  very  many 
cases  where  death  has  taken  place  by  some  accident  during  the  progress 
of  ordinary  cases  of  insanity,  both  general  and  partial,  a  close  scrutiny  from 
dissections,  and  from  microscopic  examinations,  have  failed  to  detect  any 
characteristic  lesion  in  the  nerve  structure  or  any  part  of  the  nervous 
centers.     And   I   am   compelled  to  admit  that  many  cases  of  insanity  are 


PEOGJfOSIS.  805 

not  explainable  from  any  recognizable  change  or  disease  in  the  physical 
structures  of  the  brain  and  parts  with  which  the  mind  is  associated.  I 
do  not  mean  that  all  insanity  is  unaccompanied  by  these  physical  changes. 
I  am  well  satisfied  that  there  are  many  forms  or  cases  of  insanity  that 
have  their  primary  origin  directly  in  the  structural  changes  as  the  starting 
point  of  morbid  action,  but  there  are  others  in  which  the  primary  impres- 
sions are  upon  the  faculties  of  the  mind,  and  whatever  changes  take  place 
in  the  physical  structure  of  the  brain  are  secondary,  or  the  result  of  the 
persistent  disturbance  of  function,  and  not  primary  as  the  cause  of  that 
disturbance.  In  other  words  we  may  have  mental  derangements  from 
causes  that  influence  mental  action  alone  as  the  primary  departure  from 
the  healthy  standard  independent  of  any  prior  structural  lesion,  I  am 
aware  that  some  of  those  occupying  high  positions  and  justly  regarded  as 
aut'iorities,  hold  to  the  doctrine  that  there  is  no  such  thing  as  a  diseased 
m  nd,  independentof  morbid  conditions  of  nerve  structure.  But  certainly 
no  facts  derived  from  actual  examinations,  with  all  the  modern  appliances 
for  making  such  examinations  minute,  have  yet  been  developed  sufficient 
to  justify  that  conclusion. 

l-^rognosis. — The  prognosis  differs  much  in  accordance  with  the  kind  of 
insanity  and  mental  derangement  that  exists,  and  its  mode  of  origin.  A 
large  proportion  of  acute  cases  are  susceptible  of  being  conducted  to  a 
reasonably  early  recovery.  To  this  class  belong  those  of  puerperal  mania, 
nearly  all  of  which,  under  favorable  circumstances  and  judicious  manage- 
ment, ultimately  recover.  Perhaps  not  quite  to  so  great  an  extent,  and 
still  sufficiently  so  to  include  a  majority  of  cases,  those  arising  from  causes 
that  are  temporary  or  of  short  duration,  however  intense  in  their  opera- 
tion at  the  time.  The  cases  which  are  most  likely  to  be  persistent  and 
to  resist  treatment  are  such  as  come  on  slowly  from  causes  that  act  with 
only  moderate  degree  of  intensity,  but  persistently  through  long  periods; 
of  time.  They  consequently  develop  the  mental  derangements  in  the 
manner  that  I  first  described,  so  obscurely,  that  the  attacks  are  hardlt 
noticeable  until  weeks  and  perhaps  months  have  passed  by,  and  where  the 
causes  still  exist,  and  the  individual  is  left  within  the  reach  of  their  in- 
fluence. Another  element  which  influences  the  prognosis  is  that  of  hered- 
itary predisposition.  As  a  rule  those  cases  of  insanity  that  are  induced 
by  temporary  causes  without  any  previous  hereditary  predisposition  on 
the  part  of  the  patient  are  much  more  likely  to  recover  than  where  any 
strong  family  tendency  or  hereditary  influence  favors  the  development  of 
the  disease.  The  latter  influence  also  tends  greatly  to  induce  relapses 
after  recovery  or  partial  recovery  has  occurred,  Notwithstanding,  it  may 
be  said  as  a  general  rule  that  the  prognosis  in  any  given  case  will  be  im- 
proved or  made  favorable,  just  in  proportion  as  the  patient  can  be  taken 
under  the  most  judicious  management  early  in  the  progress  of  his  disease, 
and  separated  as  completely  as  possible  from  all  association  with  the  in- 
dividuals and  circumstances  under  which  the  disease  was  developed. 
Consequently  it  is  of  very  great  importance  that  insanity  be  detected 
early,  and  that  the  most  efficient  and  judicious  steps  be  taken  for  counter- 
acting it  by  removal  of  the  causes  or  the  removal  of  the  patient  from  their 
further  influence,  so  far  as  it  is  possible  to  do. 

The  timely  administration  of  such  remedies  as  may  have  influence  in 
counteracting  the  early  symptoms  of  the  disease  is  also  important.  Each 
individual  case  must  be  treated  upon  its  own  merits.  The  almost  con- 
stant tendency  of  the  insane  to  refuse  medicine  and  defeat  all  efi'orts 
at  its  administration  at  regular  intervals  while  left  under  the  control  of 
friends  or  ordinary  nurses,  and  the  continued  action  of  the  causes  that  have 


806  MENTAL    DERANGEMENTS. 

given  rise  to  tbe  disease,  make  it  desirable  to  remove  the  patient  to  otlier 
places,  and  in  association  with  entirely  new  parties,  just  as  early  as  they 
possess  the  symptoms  or  give  positive  evidence  of  the  existence  of  mental 
derangement,  whether  it  be  general  or  partial.  And  often  after  the  men- 
tal s\^mptoms  that  I  have  pointed  out  to  you  are  recognized,  if  judicious 
measures,  are  taken  as  far  as  possible  without  betraying  to  the  patient  the 
suspicion  that  mental  derangement  is  approaching,  and  at  the  same  time 
the  closest  and  most  careful  attention  be  paid  to  the  physical  health  of 
the  patient,  seeing  that  the  digestive  organs  are  kept  in  good  order,  the 
bowels  regular,  and  if  possible  from  six  to  seven  hours  of  good  sleep 
secured,  the  development  of  the  disease  will  in  many  cases  be  arrested  at 
its  beginning  and  all  the  subsequent  evils  prevented.  Usually  the  reme- 
dies most  likely  to  act  favorably  by  procuring  sleep  for  this  class  of 
patients  in  the  forming  stages  of  mental  derangements  are  not  opiates; 
for  while  they  will  frequently  produce  the  required  amount  of  sleep,  they 
so  far  tend  to  restrain  secretions  and  impair  appetite,  that  they  lead  to 
secondary  conditions  of  the  system  that  are  more  favorable  for  the  further 
development  of  the  mental  derangement,  than  though  the  remedies  had 
not  been  given  at  all.  I  have  found  no  combination  of  remedies  that  in 
so  many  cases  produce  an  amount  of  quiet  natural  sleep,  with  no  second- 
ary ill  effects,  as  that  of  the  bromide  of  potassium,  sodium  or  ammonium 
in  connection  with  digitalis  and  hyoscyamus.  These  three  remedies,  giv- 
en either  separately  or  conjoined  in  he  same  prescription,  so  that  their 
effects  shall  be  developed  during  the  evening  at  such  time  as  would  be 
the  natural  hour  for  retiring  to  sleep,  will  usually  produce  a  better  effect 
than  can  be  obtained  from  anything  else.  After  the  disease  has  made  a 
fair' beginning,  and  especially  after  the  sleeplessness  is  fully  developed, 
the  mind  positively  suffering  some  derangement,  it  will  often  require 
larger  doses  than  usual  to  produce  the  desired  effect.  But  there  is  little 
danger  in  pusning  these  three  remedies  conjointly,  sufficient  to  produce 
the  desired  effect,  if  the  patient  can  be  induced  to  take  them,  or  if  not 
they  can  sometimes  be  used  by  enema.  In  my  hands  they  act  much  more 
favorably  together  than  either  of  them  alone.  During  the  periods  of  high 
excitement,  it  may  sometimes  be  desirable  to  combine  chloral  with  the  bro- 
mide, but  my  own  observation  in  the  use  of  chloral  has  led  me  to  regard  it 
as  very  liable  to  be  irregular  and  often  slow  in  developing  its  effects.  I 
have  repeatedly  seen  it  given  in  full  doses  as  early  as  seven  or  eight 
o'clock  in  the  evening  when  its  effects  in  inducing  sleep  did  not  follow 
until  after  midnight,  and  then  the  patient  awakes  in  the  morning  dull, 
stupefied,  and  often  remains  more  or  less  incoherent  all  the  remainder  of  the 
day.  Aside  from  the  use  of  such  remedies  as  are  calculated  to  keep  the 
evacuations  from  the  bowels,  and  the  action  of  the  important  secretory 
organs,  like  the  kidneys  and  skin,  free,  it  is  not  desirable  to  trouble  the 
insane  with  frequent  doses  of  medicine.  Simply,  either  by  diet,  or  by  such 
remedies  as  will  accomplish  the  purposes  I  have  just  named,  and  the  use  of 
those  remedial  agents  that  are  most  efficient  in  inducing  quiet,  natural 
sleep  with  the  least  tendency  to  leave  secondary  unpleasant  effects,  ad- 
ministered at  the  proper  time  in  the  evening,  and  leaving  the  patient  dur- 
ing the  day  but  little  annoyed  by  anything  except  taking  the  necessary 
amount  of  nourishment,  is  a  better  plan  than  to  pursue  more  active,  con- 
tinuous medication.  Equally  necessary  with  the  medical  treatment  is  the 
adoption  of  the  most  judicious  means  for  inducing  the  patient  to  take  the 
necessary  amount  of  nourishment.  And  this  leads  directly  to  another 
part  of  the  management  of  the  insane,  which  is  of  the  utmost  importance. 
This  is  what  may  be  termed  the  mental  or  moral  management.     More  will 


TREATMENT.  807 

depend  upon  this  than  all  other  circumstances  comhined.  A  mind  that 
is  disordered  in  such  a  way  that  the  reasoning  faculties  do  not  control 
the  attention,  the  emotions,  passions  and  trains  of  thought  is  not  in  a  con- 
dition for  argumentation.  One  of  the  most  common,  and  most  injurious 
influences  that  are  brought  to  bear  upon  the  insane,  is  the  disposition  on 
the  part  of  their  friends  to  be  continually  trying  to  convince  them  of  the 
error  of  their  thoughts  and  delusions,  and  consequently  to  keep  them  ex- 
cited by  arguments  till  perhaps  both  patient  and  attendants  become  irri- 
tated by  their  mental  contest.  Any  such  conversation  only  aggravates  the 
deranged  condition  of  the  patient,  and  adds  to  the  certainty  of  prolonging 
the  disease.  All  the  attendants  upon  the  insane  should  be  rigidly  required 
to  avoid  the  least  appearance  of  excitement  and  of  a  disposition  to  contra- 
dict and  argue.  The  uniform  tendency  should  be  to  soothe,  encourage 
and  kindly  influence  the  mind  of  the  patient  in  such  a  way  as  to  gain  his 
confidence  by  leading  him  to  think  you  understand  his  wishes,  and  will 
aid  him  as  far  as  possible.  Even  so  far  humor  his  impulses  and  insane 
trains  of  thought  as  may  be  necessary  to  gain  his  confidence,  and  make 
him  think  you  are  his  protector.  It  is  so  difficult  to  get  most  members  of 
the  families  interested  in  the  insane  to  take  such  a  course  and  assiduously 
avoid  combating  what  appear  to  them  as  groundless  fancies,  that  it  con- 
stitutes one  of  the  reasons  why  it  is  desirable  as  early  as  possible  after 
insanity  is  fairly  developed  to  remove  the  insane  parties  entirely  from  the 
care  of  their  immediate  friends.  The  same  principle  that  I  have  laid  down  for 
the  mental  management  of  the  insane  by  kindness  and  by  seeking  their 
confidence  leads  to  the  rule  that  you  should  avoid  as  long  as  possible  the 
resort  to  physical  force  as  a  means  of  restraint.  The  straight  jacket  and 
the  direct,  positive  restraint  by  any  species  of  mechanical  appliance  of 
force  should  be  resorted  to  only  in  the  last  extremity,  and  when  no  other 
mode  will  prevent  the  patient  from  a  degree  of  violence  directly  danger- 
ous to  their  own  existence  or  that  of  those  around  them.  It  is  remarkable 
to  what  extent  some  persons  of  experience  and  natural  tact  will  control 
the  insane  by  mental  management  alone  without  the  least  appeara^nce  of 
restraint  or  controversy.  Such  management  will  do  more  to  secure  an 
early  return  to  a  sane  condition  of  mind  than  all  the  other  influences  that 
can  be  brought  to  bear. 

As  I  have  often  spoken  of  the  removal  of  the  insane  from  the  care  of 
their  friends,  you  will  be  ready  to  ask  whether  it  is  desirable,  as  a  uniform 
rule,  that  they  should  be  removed  as  early  as  possible  after  the  insanity 
becomes  clearly  evident,  to  some  institution  or  asylum  expressly  for  their 
care.  I  answer,  that  such  a  removal  to  some  kind  of  an  asylum  away 
from  their  friends,  and  the  immediate  circumstances  under  which  their 
disease  developed,  is  necessary  and  desirable,  as  early  as  it  is  possible  to 
do  so.  But  it  is  by  no  means  a  matter  of  indifference  as  to  the  kind  of 
institution  to  which  they  are  removed.  Much  good  would  result  from 
careful  discrimination  in  this  respect.  There  are  very  many  of  the  insane, 
who  could  be  removed  with  benefit  to  private  asylums,  under  the  care  of 
skillful  superintendents  and  nurses,  where  there  are  only  limited  numbers 
of  the  insane  under  treatment,  and  consequently  where  it  would  appear  to 
the  patient  much  more  like  a  home,  than  like  a  public  institution,  with  its 
surroundings.  There  are  some  other  forms  of  insanity,  quite  harmless, 
involving  no  tendency  to  violence,  in  which  the  individuals,  if  removed 
from  their  immediate  surroundings  simply  to  some  other  family  or  place, 
where  their  associations  would  be  different,  and  where  they  would  be  un- 
der the  immediate  care  of  some  person  skilled  in  their  management, 
would  do  better  than  in  a  private  asylum.     But  there  are  many  other  in- 


808  MENTAL    DERANGEMENTS. 

sane  persons,  especially  those  who  are  affected  with  general  insanity,  who 
Avill  be  better  provided  for  in  a  public  asylum,  built  expressly  for  the  care 
of  the  insane,  with  all  the  necessary  furniture  and  attendants  for  their  pro- 
tection and  care,  and  where  every  circumstance  and  surrounding  imparts 
to  them  a  kind  of  awe  or  restraint.  There  is  not  enough  attention  paid 
to  the  classification  of  the  insane.  As  I  have  said,  there  are  some  who  can 
be  safely,  and  most  successfully  treated,  on  what  has  been  in  modern  times 
termed  the  family  or  cottage  plan,  where  they  can  have  the  aid  of  other 
members  of  the  family,  and  be  continually  subject  to  the  watchful  eye  of 
a  judicious  attendant.  Others  will  be  more  properly  accommodated  in 
well  regulated  private  asylums  in  which  only  a  limited  number  of  patients 
are  received.  There  are  some  others,  as  I  have  just  stated,  who  can  be 
with  more  propriety  assigned  to  public  asylums,  if  they  are  provided  with 
a  sufficient  number  of  attendants  or  nurses  and  under  judicious  supervis- 
ion. Perhaps,  before  leaving  the  subject  of  insanity,  1  should  say  a  word 
or  two  in  regard  to  that  form  of  disease  which  has  been  denominated  by 
some  methomania,  or  mental  derangement  consisting  in  an  uncontrolla- 
ble disposition  to  indulge  in  the  use  of  intoxicating  beverages.  It  is 
claimed  by  many  at  the  present  time  that  inebriety,  or  habitual  indul- 
gence in  the  use  of  intoxicating  drinks  to  an  injurious  extent,  is  a  disease, 
rather  than  the  result  of  vicious  habits.  There  are  others  who  place 
great  importance  upon  what  is  termed  the  hereditary  disposition  to  ine- 
briety. They  teach  that  in  a  large  portion  of  those  who  become  habitual 
drunkards,  either  periodically  or  continuously,  that  such  habit  is  the  re- 
sult of  a  defect  in  their  organizations  derived  more  or  less  directly  from 
hereditary  influence,  developed  by  the  same  habits  in  their  ancestors. 
Of  course  the  inference  of  such,  is,  that  the  inebriety  being  the  result  of 
physical  conformations,  or  morbid  conditions  of  the  nervous  system,  it  is 
to  be  treated  as  such.  The  fact  that  there  are  very  many  persons  in  the 
most  civilized  communities,  who  develop  at  an  early  period  of  adult  life 
a  remarkable  disposition  to  indulge  in  the  use  of  intoxicating  drinks  at 
certain  periods  of  time,  constituting  what  are  known  as  periodical  drunk- 
ards, is  familiar  to  every  one,  and  they  constitute  enigmas  to  most  people. 
They  will  abstain  entirely  from  the  use  of  all  intoxicating  drinks,  be  ap- 
parently in  good  health,  attentive  to  all  their  duties  and  industries  every 
day,  for  from  one  to  six  months  perhaps,  and  then  without  any  visible 
cause  go  directly  into  the  period  of  drinking,  keep  themselves  in  a  state 
of  daily  intoxication,  usually  till  their  digestive  organs  become  so  de- 
ranged and  irritated  as  to  cause  them  to  reject  their  drink,  as  well  as  their 
food,  and  thus  compel  them  to  desist.  Others  stoja  simply  because  their 
money  is  exhausted,  and  perhaps  end  in  either  threatened  or  actually  de- 
veloped delirium  tremens,  or  there  are  many,  as  explained,  who,  having 
nothing  further  to  buy  drink  with,  would  be  compelled  to  desist  for  a  few 
days.  In  either  case,  having  stopped  until  sober,  they  resume  their 
ordinary  diet,  soon  return  quietly  to  their  work,  and  are  apparently  as 
free  from  the  disposition  to  drink  again  for  a  similar  period  as  any  other 
person  in  the  community.  These  periods  of  dissipation  or  inebriety  usu- 
ally increase  slowly  in  frequency  with  each  individual,  so  that  parties  who 
would  have  at  first  only  one  of  them  in  a  year,  in  process  of  time  come  to 
have  what  they  call  their  drinking  sprees  every  three,  four  or  six  weeks, 
till  it  completely  destroys  their  ability  to  maintain  their  position  in 
society,  or  to  carry  on  their  business  successfully,  and  they  consequent- 
ly become  ruined,  both  in  health  and  in  their  social  and  pecuniary 
relations. 

It  is  a  mystery  v/hy  an  individual  after  frequently  experiencing  all  the 


TREATMENT/  809 

evil  effects  of  drinking,  again  and  again,  should  be  able  to  abstain  rigidly 
and  apparently  without  effort  for  months  at  the  time,  and  yet  persistently 
return  at  stated  periods  to  the  same  practice  and  undergo  the  same  evil 
effects.  There  is,  no  doubt,  some  obscure,  but  persistent  morbid  condi- 
tion of  the  central  portions  of  the  nervous  system  in  these  cases.  When 
the  habit  has  become  fixed,  such  individuals  should  be  provided  for  by 
proper  legal  enactments,  by  which  they  can  be  so  far  restrained  legally, 
as  to  absolutely  prohibit  their  obtaining  intoxicating  drinks  or  indulging 
in  their  use  when  their  paroxysms,  or  disposition  to  do  so,  shall  come  on. 
There  is  just  as  much  propriety  in  doing  this,  as  there  is  in  restraining  a 
person  insane  in  any  other  way  or  in  any  other  form.  Because  these 
periodical  drunks  are,  as  has  been  proven  over  and  over  again  through  the 
generations  that  are  past,  dangerous  both  to  the  patients  and  the  com- 
munities in  which  they  live,  and  on  the  principle  of  danger  to  themselves 
and  the  community,  they  become  proper  subjects  for  legal  restraint.  The 
same  rule  in  reference  to  legal  restraint  applies  more  forcibly  to  inebriates 
who  become  habitually  and  continuously  subject  to  inebriation,  just  as 
certainly  as  the  means  for  gratifying  their  unnatural  desire  is  within  their 
reach.  You  might  as  well  expect  a  horse  to  refuse  to  put  his  nose  in  a 
manger  to  eat  his  oats  when  he  is  hungry,  the  oats  being  there,  as  to  ex- 
pect one  of  these  confirmed  habitual  inebriates  to  abstain  from  taking  his 
drink,  while  left  with  drink  directly  before  him.  He  may  reason  and 
resolve  to  take  no  more  than  a  swallow,  but  the  moment  this  has  reached 
the  brain  the  appetite  implanted  in  his  perverted  nervous  organization  is 
started  and  drink  will  be  taken  in  spite  of  any  number  of  resolutions  and 
pledges.  .  I  am  speaking  now  only  of  those  who  are  confirmed  habitual  ine- 
briates. There  was  a  time  when  those  of  this  class,  and  all  the  classes  of 
periodical  drunkards,  had  power  of  self-control  if  they  had  chosen  to  ex- 
ercise it;  for  admitting  that  there  may  have  been  some  defect  in  their 
physical  organization  that  constituted  a  predisposition  or  weakness,  and 
made  them  more  ready  to  succumb  to  the  influence  ofa'cohol,  more  ready 
to  acquire  what  is  called  a  taste  for  it,  still  after  admitting  all  this,  in  the 
early  stage  of  their  progress  these  parties  are  capable  of  self-control  and 
of  abstinence,  as  proved  by  the  voluntary  reform  of  thousands.  Even 
their  predisposition  does  not  consist  in  any  taste  for  alcohol.  There  is,  in- 
deed, no  special  taste  for  any  particular  article  of  drink  whatever.  The 
predisposition  consists  simply  of  that  kind  of  nervous  weakness  or  feeling 
of  exhaustion  or  readiness  to  be  made  weary,  that  makes  them  desire 
something  to  relieve  such  feelings.  The  sensations  themselves  are  no 
more  suggestive  of  whisky  than  of  milk  or  bread;  it  is  only  by  trial  or 
actual  experience  that  such  parties  learn  the  anaesthetic  effects  of  alcoholic 
drinks  in  diminishing  their  morbid  nervous  sensations  to  a  greater  extent 
than  the  effects  of  milk  or  water.  Having  acquired  this  knowledge  by 
trial,  they  resort  to  it  again  and  again;  and  each  time  they  resort  to  one  of 
these  agents,  its  anesthetic  influence  helps  to  produce  secondarily  the  very 
weakness  that  originally  constituted  their  only  defect.  The  great  error 
which  helps  to  keep  up  the  resort  to  alcoholic  beverages,  of  whatever  kind, 
whether  fermented  or  distilled,  to  remove  a  conscious  weakness,  the  result 
of  a  condition  of  the  nervous  system  in  persons  of  defective  natural  devel- 
opments or  of  special  hereditary  tendencies,  is  the  universal  practice  of 
speaking  of  alcoholic  beverages  as  stimulating  and  supporting  agents. 
This  is  the  idea  inculcated  froiu  infancy  up  by  the  common  language  of 
every  household  as  well  as  by  the  larger  proportion  of  the  members  of 
our  own  profession.  And  it  is  this  idea  in  the  minds  of  the  great  majority 
af  individuals,  whenever  weakness,  weariness  or  physical  discomfort  exists, 


810  uncla'ssified  diseases. 

that  at  once  suggests  the  alcoholic  preparations  as  the  agents  they  neefl 
to  relieve  their  discomfort.  And  the  deception  is  readily  confirmed  in 
them  by  the  temporary  anaesthetic  effect  of  the  alcohol  in  diminishing  the 
sensibility  of  the  brain,  and  relieving  them  of  the  consciousness  of  their 
previous  morbid  impression,  while  in  fact  it  neither  stimulates  nor  sup- 
ports, but  is  a  direct  and  positive  sedative,  debilitating  both  nervous  and 
muscular  structures,  and  diminishing  the  atomic  changes  throughout  the 
organization.  In  calling  your  attention  to  the  class  of  inebriates  who  have 
been  ranked  by  some  in  modern  times  as  laboring  under  a  species  of 
derangements  called  methomania,  my  object  is  simply  to  remind  you  that 
as  physicians  it  is  your  duty  to  study  these  cases,  and  to  bring  the  whole 
weight  of  your  influence  upon  those  who  depend  upon  you  as  guides  in 
reference  to  their  health,  to  correct  the  errors  under  which  so  many  in 
every  community  labor  in  regard  to  the  real  nature  and  effects  of  alcoholic 
beverages.  I  have  thus,  gentlemen,  completed  the  consideration  of  the 
diseases  which  I  had  grouped  under  the  head  of  nervous  aff'ections,  and 
therefore  come  to  the  last  division  of  our  course,  in  which  I  propose  to 
consider,  briefly  as  possible,  a  number  of  morbid  conditions  arranged  un- 
der the  head  of  miscellaneous  topics,  which  are  of  frequent  occurrence  in 
the  ordinary  routine  of  practice,  often  troublesome  to  manage  and  con- 
sequently of  much  importance  both  to  the  practitioner  and  to  the  patient. 


LECTURE  LXXXIV. 


Miscellaneous  or  Unclassified  Diseases— Their  Variety,  and  General  Remarks  on   their  Causes 
and  Tendencies. 

GENTLEMEN:  The  practitioner  of  medicine  is  called  upon  for  advice 
in  relation  to  a  considerable  variety  of  ailments,  usually  of  a  chronic 
and  more  or  less  persistent  character,  which  are  not  capable  of  being 
classed  properly  in  either  of  the  divisions  or  classes  of  disease  that  we 
have  had  under  consideration  during  the  present  term.  Most  of  the  af- 
fections to  which  I  allude  have  their  origin  either  from  hereditary  predis- 
position, or  from  the  habitual  errors  and  evil  influences  that  grow  out  of 
the  habits  of  civilized  society,  and  the  various  occupations  pursued  among 
men.  That  the  faulty  condition  of  the  physical  structure  of  parents  may 
be  transmitted  more  or  less  distinctly  to  their  childran  there  can  be  little 
doubt.  And  throughout  all  ranks  of  society  in  this  and  other  civilized 
countries,  thei'e  are  to  be  found  many  individuals  who  have  inherited  such 
a  degree  of  imperfection  in  one  or  more  of  the  groups  of  organs  which 
make  up  the  animal  economy,  as  to  cause  the  frequent  occurrence  of  im- 
perfections in  the  performance  of  functions,  and  consequently  sufferings 
that  induce  them  to  seek  the  aid  of  a  physician.  In  one  class  of  cases 
this  defect  may  relate  particularly  to  the  organs  of  respiration,  in  another 
to  that  of  digestion,  in  others  to  the  development  of  the  different  portions 
of  the  nervous  system,  while  in  still  others,  the  defects  will  relate  more  to 
the  organs  of  generation.  Such  individuals  will  be  regarded  everywhere, 
by  their  medical  advisers,  as  strongly  predisposed  to  this  or  that  manifes- 
tation of  disease,  sometimes  without  exciting  causes,  but  more  particu- 
Jarly,  on  the  occurrence  of  even  tha  slightest  provoking  cause.     But  inde- 


CAUSES.'  811 

pnnfleiitly  of  hereditary  influences,  there  are  hal)its  of  life  and  practices 
prevalent  in  civilized  society,  which  have  a  tendency  to  influence  chil- 
dren from  a  very  early  period  throughout  their  entire  development  to  ma- 
turity or  adult  a;:^e.  Those  circumstances  are  sometimes  connected  vv^ith 
the  pi'Ocess  of  education  in  schools,  sometimes  connected  with  their  occu- 
pations when  they  commence  some  definite  occupation  early,  and  in  other 
instances,  simply  growing  out  of  the  ordinary  modes  of  dress  and  diet, 
and  the  degrees  of  confinement  in-doors,  or  limit  of  exercise  in  the  open 
air.  It  requires  but  a  little  practical  experience  and  reflection  to  see  that 
a  large  percentage  of  the  children  of  both  sexes,  and  especially  of  the 
female  sex,  who  are  born  of  parents  themselves  healthy,  and  in  circum- 
stances favorable  pecuniarily  and  socially,  that  the  predominance  of  at- 
tention is  given  throughout  the  whole  period  of  their  education  to  the 
cultivation  of  the  intellectual  faculties  and  acquisition  of  knowledge,  to 
the  great  neglect  of  attention  to  the  equal  exercise  of  the  muscular  struct- 
ures in  different  parts  of  the  body,  and  consequently  to  the  equal  develop- 
ment of  the  physical  system.  This  leads  to  the  development  in  every 
community  of  a  large  number,  who,  during  the  whole  period  of  adult  life, 
suffer  more  or  less  from  the  predominant  development  of  nervous  excita- 
bility, with  corresponding  enfeeblement  of  the  functions  of  digestion 
and  excretion.  Such  parties  maj^  pass  a  large  portion  of  life  without  any 
attack  of  a  definite,  well  defined  form  of  disease,  such  as  typical  forms  of 
fever,  or  of  a  well  marked  local  inflammation,  and  yet  have  such  derange- 
ment of  the  functions  of  a  minor  character  as  to  make  them  need  medical 
advice  almost  every  month  in  the  year.  Other  classes  by  the  nature  of 
their  occupation  are  induced  to  remain  too  much  in-doors,  sometimes  oc- 
cupying daily  certain  positions  many  hours  in  succession,  and  taking  no 
habitual  regular  exercise  out  of  doors  from  time  to  time,  to  counteract  the 
evils  of  that  which  their  labor  induces,  acquire  certain  inequalities  in 
the  performance  of  the  functions  of  the  body.  Prominent  among  these  is 
a  lessening  of  the  efficiency  of  the  respiratory  movements  and  consequent 
impairment  of  the  changes  which  take  place  in  the  blood  while  passing 
through  the  pulmonary  organs,  constituting  deficient  oxygenation  and  de- 
carbonization  of  the  blood.  This  in  turn  lessens  almost  every  secretion, 
because  blood  deficient  in  the  supply  of  oxygen  does  not  maintain  the  activ- 
ity of  the  secretory  cells,  causing  deficiency  of  secretion  from  the  mucous 
membrane  of  the  alimentary  canal,  including  the  gastric  juice,  with  conse- 
quent derangements  in  the  digestion  of  food  ai,d  in  the  regularity  of  the 
alvine  evacuations.  The  same  defective  condition  of  the  blood  renders  it 
incapable  of  sustaining  a  healthy  tone  of  the  nervous  and  muscular  struct- 
ures, indicated  by  general  lassitude  and  lack  of  power  of  endurance.  Such 
patients,  without  any  marked  structural  changes  in  any  of  the  organs, 
will  have  as  results  from  this  impairment  in  the  various  functions,  a 
constant  tendency  to  accumulate  enough  of  the  products  of  tissue  disinte- 
gration in  the  blood  to  induce  once  in  from  one  to  three  weeks  a  sick 
headache,  a  paroxysm  of  indigestion   or  some  other  painful  illness. 

This  kind  of  headache  is  termed  sick  headache  or  migraine,  because 
soon  after  the  commencement  of  the  pain  in  the  head,  the  morbid  in- 
fluence is  radiated  through  the  pneumogastric  nerve  to  the  stomach  in 
such  degree  as  to  cause  active  vomiting.  The  patient,  deprived  of 
nourishment,  placed  at  rest,  and  subjected  to  thorough  and  repeated 
vomiting,  not  only  ejects  the  contents  of  the  stomach,  but  relaxes  the  skin 
while  under  the  influence  of  the  nausea  and  increases  the  exhalations  from 
that  source.  These  changes  are  generally  accompanied  by  the  adminis- 
tration of  some   medicine  that  will  operate   upon   the   bowels.     By  such 


812  UNCLASSIFIED    DISEASES. 

increased  eliminations,  in  the  course  of  twenty-four  or  thirty-six  hours, 
the  retained  effete  materials  that  had  been  accumulating  for  one,  two  or 
three  weeks,  are  thrown  off.  The  derangements  of  the  system  being  thus 
corrected,  the  headache  disappears,  and  the  patient,  without  pain  or  sick- 
ness, but  feeling  less  than  his  usual  strength,  has  a  return  of  his  appetite, 
and  resumes  his  work.  Being  subjected  again  to  the  same  causes,  in 
about  the  same  period  of  time,  the  former  derangements  are  re-established, 
and  culminate  in  another  attack  of  headache  and  vomiting.  And  thus 
manv  patients  go  on  with  such  a  train  of  evils  through  years,  and  some- 
times a  large  part  of  their  lives.  In  other  instances,  a  similar  train  of 
causes  operating  upon  persons  with  less  nervous  excitability  or  cerebral 
sensitiveness,  they  will  escape  the  headaches  and  vomitings  from  the 
imperfect  performance  of  the  functions  of  excretion,  but  will  become  more 
constipated,  the  gastric  secretion  less  and  less  abundant,  and  consequently 
digestion  being  performed  less  perfectly,  they  come  to  assume  the  con- 
dition of  confirmed  dyspeptics,  or  to  suffer  for  a  time  daily  from  imperfect 
digestion  of  food.  There  is  usually  no  burning  in  the  stomach,  no  general 
fever,  pulse  quiet,  and  temperature  natural.  They  seldora  emaciate,  but  on 
the  contrary  sometimes  have  a  redundancy  of  fatty  deposit  in  the  tissues. 
They  hardly  take  a  fair  meal,  however,  from  one  end  of  the  year  to  the 
other  without  having  it  lay  like  a  weight  in  the  stomach  for  one  or  two 
hours  after  eating.  And  generally  after  the  first  hour  has  passed,  there 
will  commence  o-eneration  of  more  or  less  gases,  most  of  the  time  taste- 
less, but  abundant  in  quantity.  They  will  keep  up  eructations  or  belch- 
ing of  gases  for  an  hour  or  more,  after  which  all  the  symptoms  pretty 
rapidly  decline,  and  the  patient  is  feeling  comparatively  comfortable 
until  the  next  meal,  when  he  goes  through  the  same  process.  And 
thus  from  day  to  day  he  labors  under  the  influence  of  gastric  discom- 
fort after  each  meal,  rendering  his  mind  despondent  and  gloomy,  his 
nights  often  broken  and  uncomfortable  by  dreams  of  an  unpleasant 
character,  until  he  becomes  habitually  gloomy,  and  feels  often  that  life  is 
a  burden.  Most  of  these  patients,  in  addition  to  the  disturbances  of  the 
stomach  just  indicated,  have  habitually  an  inactive  condition  of  the 
bowels,  requiring  frequenth^  the  use  of  laxative  medicine  to  afford  them 
relief.  The  urinary  secretion  is  also  high-colored,  and  when  allowed  to 
stand  sometimes  throwing  down  an  excess  of  phosphates  or  ammoniacal 
salts,  in  the  form  of  a  white  precipitate,  which  generally  causes  much 
anxiety  on  the  part  of  the  patient  from  fear  of  the  supervention  of  serious 
disease  of  the  kidneys.  But  this  class  of  patients  seldom  have  anything 
more  than  funclional  derangement  of  the  urinary  organs.  Indeed,  the 
continued  activity  of  the  kidneys  in  eliminating  an  increased  quantity  of 
the  products  of  disintegration  or  natural  tissue  changes,  constitutes  the 
most  reliable  conservative  process  for  keeping  such  patients  from  more 
dangerous  functional  derangements.  The  bowels  being  constipated,  the 
skin  dry,  the  kidne^^s  are  more  persistent  in  executing  their  function  than 
any  other  eliminating  organs  or  structures  in  the  system.  Another  class 
of  patients  whom  you  will  meet  with,  on  whom  have  been  operative  some 
of  the  same  causes  that  I  have  already  pointed  out,  when  their  derange- 
ments have  arrived  at  that  degree  of  development  characterized  by 
deficient  gastric  secretion  and  consequent  indigestion,  instead  of  going 
on  to  the  development  of  disturbance  of  the  brain  and  paroxysms  of  sick 
headache,  or  of  habitual  constipation  and  complete  indigestion,  stop  at  a 
point  where  the  disorder  of  digestion  is  only  moderate.  This  moderate 
gastric  disturbance,  however,  is  sufficient  to  establish  a  certain  grade  of 
morbid  sensitiveness  in  the  branches  of  the  pneumogastric  nerve  through 


SYMPTOMS.  813 

which  the  morbid  sensations  induced  by  the  contact  of  food  in  the 
stomach  are  reflected  directly  back  along  that  nerve,  sometimes  only  to 
the  point  where  the  cardiac  branches  leave  the  pneumogastric  trunk,  and 
produce  disturbance  in  the  heart's  action.  And  consequently  within  a 
given  time  after  each  meal,  the  patient  no  sooner  begins  to  feel  slight 
indications  of  uneasiness  in  the  epigastrium,  or  stomach  proper,  than  his 
face  becomes  flushed,  a  sense  of  heat  comes  over  him,  and  the  heart 
begins  to  beat  with  a  much  greater  degree  of  frequency  and  force  than 
natural.  After  one  or  two  hours  he  will  be  in  great  anxiety  of  mind  from 
the  excited  or  irregular  action  of  the  heart.  For  the  cardiac  disturbance 
may  consist  of  simply  increased  frequency  and  force  of  beat,  or  it  may  be 
more  or  less  irregular,  beating  rapidly  and  forcibly  three  or  four  beats 
and  skipping  one,  or  intermitting,  or  without  the  actual  intermissiorj, 
varying  so  rapidly  from  rapidity  and  force  to  that  of  slowness,  as  to 
create  almost  constantly  the  impression  in  the  mind  of  the  patient  that 
there  is  serious  disease  of  the  heart,  and  he  consequently  becomes  very 
despondent.  Not  infrequently  the  chief  cardiac  disturbance  comes 
during  the  night,  especially  in  parties  who  are  in  the  habit  of  drinking  too 
much  strong  tea.  They  no  sooner  get  quiet  in  bed,  or  at  most  begin  to 
catch  short  periods  of  sleep,  than  the  heart  will  begin  its  unpleasant  ex- 
citement and  irregularity  of  movements,  and  they  will  feel  obliged  to  sit 
upright  in  bed  sometimes  half  the  night,  with  the  hands  over  the  cardiac 
region,  and  the  mind  filled  with  anxiety  from  the  impression  that  they  are 
in  danger  from  serious  disease  of  that  organ.  As  morning  comes  on,  the 
stomach  becomes  emptied  of  its  contents,  the  reflex  irritability  subsides, 
and  the  patient  is  cj^uiet  and  comfortable.  The  most  careful  examination 
in  the  morning  would  detect  no  error  in  the  circulation  whatever,  or  in 
the  movements  and  sounds  of  the  heart.  Closely  allied  to  these  cases  are 
those  in  which  the  reflex  disturbance  extends  Irom  the  stomach  to  the  re- 
current branches  of  the  pneumogastric  nerve,  causing  contraction  or  a 
sense  of  choking  in  the  neck.  This  symptom  is  frequently  associated 
with  the  irregular  and  excited  cardiac  movements  just  described,  causing 
the  patient,  for  the  time  being,  the  most  distressing  feelings  of  impending 
death  from  suft'ocation  or  complete  suspension  of  the  action  of  the  heart. 
I  allude  to  these  modes  by  which  distressing  symptoms  of  various  kinds 
are  developed,  of  a  character  difficult  to  classify,  and  yet  of  so  frequent 
occurrence  as  to  constitute  an  important  part  of  every  phvsician's  practice 
who  may  reside  in  a  populous  community,  as  represented  by  cities  or 
large  villages.  Yet,  as  in  other  ailments,  the  patient  will  be,  in  many 
instances,  anxious  for  the  doctor  to  give  him  the  name  of  his  disease.  He 
wants  this  not  only  for  his  own  satisfaction,  but  that  he  may  tell  all  his 
neighbors  also.  This  anxiety  to  have  a  name  given  to  their  disease  has 
induced  many  members  of  the  profession  to  use  certain  vague  terms  that 
satisfy  the  popular  mind  without  conveying  any  definite  knowledge.  In 
former  times,  nearly  all  of  these  ailments  were  classified  under  the  head  of 
biliousness.  Simply,  because  when  the  doctor  was  pressed  to  know  what 
the  matter  was,  he  found  it  more  convenient  to  give  them  a  name  that 
they  would  think  they  knew  something  about,  than  to  try  to  explain  the 
complex  derangements  of  function  which  really  constituted  their 
difficulties,  and  which  if  he  explained  ever  so  minutely  not  one  in  a 
hundred  of  the  patients  would  be  capable  of  understanding  his  explana- 
tion. Hence,  the  common  practice  of  telling  such  persons  that  they  are 
bilious  had  led  to  the  almost  universal  adoption  of  this  term  for  covering 
most  of  the  nameless  or  unclassified  ailments  in  the  community.  In 
recent  times,  however,  biliousness  has  found  a  popular  competitor  in   the 


814  UNCLASSIFIED    DISEASES. 

expressions  nervous  prostration,  nervous  exhaustion  or  neurasthenia. 
These  latter  names  are  especially  applied  to  such  cases  as  involve  head- 
aches, sleeplessness,  palpitations,  and  all  the  other  troubles  in  which  the 
nervous  phenomena  are  most  prominent.  I  would  not  do  justice  in  these 
general  observations,  however,  if  I  failed  to  mention  another  class  of  cases 
consisting  almost  entirely  of  members  of  the  female  sex,  v^ho,  through 
errors  consisting  chiefly  in  the  modes  of  dress,  such  as  leaving  the  feet 
and  ankles  imperfectly  protected  during  the  cold  seasons  of  the  year 
■while  a  large  proiDortion  of  the  weight  of  all  their  clothing  is  hung  upon 
the  body  by  close  attachments  directly  around  the  waist,  and  that  part  of 
the  trunk  on  a  horizontal  line  with  the  epigastrium.  By  such  methods 
the  epigastric  and  hypochondriac  regions  are  compressed,  thereby 
crowding  the  abdominal  viscera  downward,  and  on  the  one  hand  favoring 
depression  of  the  pelvic  organs  and  on  the  other  limiting  materially  the 
freedom  of  the  expansion  of  the  lower  part  of  the  chest.  This  lessens  by 
a  few  cubic  inches  the  volume  of  air  habitually  taken  at  each  inspiration, 
and  correspondingly  lessens  the  efficiency  of  the  oxygenation  and  decar- 
bonization  of  the  blood.  A  large  class  of  females  coming  to  maturity 
under  such  modes  of  dress  suffer  almost  continuously  from  some  degree 
of  impairment  of  the  digestive  functions,  habitual  torpor  or  inactivity  of 
the  bowels,  a  ready  nervous  excitability,  giving  rise  frequently  to  head- 
aches, sometimes  to  palpitations,  especially  if  they  indulge  early  in  the 
use  of  tea  and  coffee;  imperfect  rest  at  night,  but  more  prominently  than 
all,  pains  in  the  back  and  loins  whenever  much  upon  their  feet,  either 
in  standing  or  walking.  Many  of  this  class  also  suffer  pains  in  the 
inguinal  regions  or  in  the  direction  of  the  uterine  ligaments  whenever 
any  considerable  exercise  is  taken,  and  during  the  early  part  of  adult  life 
are  almost  certain  to  have  severe  suffering  during  every  period  of 
menstruation,  more  particularly  a  day  or  two  preceding  the  commence- 
ment of  the  flow,  or  during  the  first  day  of  the  flow  itself.  In  some 
instances  these  pains  are  moderate,  in  others  excruciatingly  severe;  so 
much  so,  that  each  period  leaves  them  more  or  less  debilitated  and  de- 
pressed, requiring  half  of  the  interval  before  the  next  period  to  recover 
from  its  effects.  Many  who  do  not  thus  suffer  pains  at  this  time,  either 
have  the  flow  too  often,  as  every  three  weeks  instead  of  four;  and  if  not 
too  often,  so  freely  as  to  occasion  an  excessive  loss  of  blood.  Whether 
the  flow  is  excessive  or  not,  a  leucorrhoeal  discharge  is  apt  to  follow  for 
a  week  or  ten  days  after  the  true  menstrual  flow  has  ceased.  In  nearly 
all  such  cases,  the  leucorrhoeal  discharge  is  thin,  white  and  of  a  serous 
character.  Occasionally  it  will  be  more  purulent,  and  sometimes  more 
decidedly  of  a  mucous  character.  This  latter  class  always  or  almost 
always  present  a  pale,  angemic  aspect  and  are  very  easily  tired.  They 
complain  of  weariness  on  the  slightest  exertion  and  are  incapable  of  en- 
during more  than  a  very  moderate  amount  of  fatigue. 

If  you  would  discharge  your  whole  duty  as  a  medical  adviser  of  such 
patients,  in  the  attempt  to  remove  their  difficulties,  and  render  their  lives 
more  happy  and  of  longer  duration,  instead  of  limiting  your  efforts  to  the 
mere  function  of  temporarily  warding  off  whatever  evils  may  be  present 
at  the  time,  you  will  in  addition  faithfully  and  honestly  endeavor  to  re- 
move the  causes  which  have  led  to  their  suffering.  There  is  no  depart- 
ment in  the  whole  field  of  practice  which  affords  the  physician  who  would 
acquire  a  reputation  in  the  beginning  of  his  professional  career,  that  is  so 
important  if  well  cultivated,  as  that  occupied  by  the  great  class  of  chronic 
invalids.  For  it  is  the  large  class  of  patients  who  are  suffering  from  these 
unclassified  ailments,  consisting  in  impairments  of  one  or  more  important 


SPASMODIC    ASTHMA.  815 

functions,  rendering  them  supplicants  who  go  from  one  physician  to  an- 
other, and  then  from  the  physician  to  the  mountebank  or  medical  pre- 
tender, and  from  him  to  the  newspapers,  and  the  drug^  manufacturers  for 
their  advertised  nostrums,  for  the  simple  reason  that  the  physicians  they 
had  consulted  failed  to  take  that  interest  in  the  cases  which  is  necessary 
to  trace  out  their  orio^in,  and  to  faithfully,  honestly,  and  yet  kindly,  inform 
them  of  the  sources  of  their  evils  and  impress  upon  them  the  necessity 
of  correcting-  and  obviating  the  causes,  as  an  absolute  prerequisite  to  any 
permanent  improvement.  Having  made  these  general  observations  sufE- 
ciendy  simple  to  indicate  to  you,  in  general  terms,  the  sources  to  which 
you  are  to  look  in  tracing  out  the  causes  which  may  have  been  operative 
in  producing  the  affections  you  may  be  called  upon  to  treat,  belonging  to 
the  class  now  under  consideration,  I  will  proceed  to  the  consideration  of 
the  more  important  of  these  derangements  in  detail;  taking  first,  those  in 
which  the  more  prominent  symptoms  are  connected  with  the  respiratory 
organs;  next  with  the  circulatory;  third  the  digestive,  and  lastly  the  or- 
gans of  excretion.  The  principal  derangements  of  which.  I  shall  speak, 
connected  more  prominently  with  the  respiratory  organs,  are  spasmodic 
asthma,  laryngismus  stridulus  or  spasmodic  croup,  aphonia  and  exoph- 
thalmic goitre.  Those  in  which  the  prominent  symptoms  are  manifest 
through  the  circulatory  system  will  be  grouped  under  the  heads  of  angina 
pectoris,  cardiac  irritability  and  palpitations,  fatty  degenerations  in  the 
heart  and  vessels,  aneurisms,  and  emboli.  Those  affecting  the  digestive 
organs  I  shall  group  under  the  heads  of  indigestion  or  dyspepsia,  gas- 
tralgia,  constipation  and  intestinal  parasites.  Those  affecting  the  excre- 
tory organs  more  particularly,  will  include  diabetes  mellitus  and  insipidus, 
eneuresis,  lithiasis,  urinary  and  biliary  calculi,  and  defective  eliminations 
from  the  skin.  In  connection  with  the  excretory  organs,  I  shall  also 
allude  to  those  rare  developments  of  oysts,  embracing  echinococci  in  the 
liver  and  kidneys  ;  also  a  brief  consideration  of  the  special  toxtemic  con- 
ditions of  the  blood  usually  included  under  the  terms  septicsemia  and 
pyaemia. 


LECTUEE  LXXXV. 

Spasmodic  Asthma  and  Laryngismus  Stridulus— Their  Causes,  Symptoms,  Diagnosis,  Prognosis 
and  Treatment. 

GENTLEMEN:  In  the  ordinary  field  of  general  practice  cases  are  not 
infrequently  met  with  of  a  purely  spasmodic  or  functional  character, 
affecting  the  respiratory  passages,  more  particularly  the  larynx  and  the 
smaller  bronchial  tubes.  They  do  not  constitute  distinct  diseases  in  the 
proper  sense  of  the  word,  but  rather  symptoms  of  some  preceding  patho- 
logical condition,  on  which  the  existence  of  the  paroxysms  of  contraction 
in  the  larynx  and  bronchial  tubes  depend.  They  are  manifest  almost  in- 
variably in  paroxysms  of  temporary  duration.  When  affecting  the  bron- 
chial tubes  and  giving  rise  to  much  dyspnoea,  or  asthmatic  breathing,  they 
are  more  frequently  mot  with  in  adult  life.  A  similar  condition  affecting 
the  larynx  is  much  more  frequent  in  children,  although  it  may  occur  dur- 
ing any  period  of  life.  During  the  paroxysms  the  chief  symptoms,  when 
affecting  the  bronchial  tubes  and  taking  the  ordinary  name  of  asthma  or 


816  SPASMODIC    ASTHMA. 

spasmodic   asthma,   consist  of  very  decided   constriction    or   difficulty  of 
breathing,  causing  a  sense  of  suffocation,  and  great  oppression  or  tightness 
in  the  chest,  accompanied  by  more  or  less  wheezing  or  dry  hissing,  sibilant 
and  sonorous  rales,  which  are  heard  throughout  the  whole  chest,  both  ante- 
riorly   and   posteriorly.     At  the   same   time  that  the  patient  experiences 
these  difficulties,  the  oppression  and  laboring  for  breath,  accompanied  by 
wheezing,  dry  rales,  the  face  becomes  more  or  less  suffused  with  redness, 
sometimes  more  of  a  leaden  or  purplish  hue;  the  patient  assumes  the  up- 
right  position,  leaning  a  little  forward,  endeavoring  to  rest  the  elbows 
upon  the  knees,  so  as  to  form  a  point  of  support  to  aid  the  extraordinary 
motions  of  the  chest.     The  expiratory  acts  are  almost  as  difficult  as  the  in- 
spiratory, and  nearly  of  the  same  length.    If  the  paroxysm  continues  more 
than  a  few  minutes  the  patient  feels  an  extreme  sense  of  weariness,  the 
skin  becomes  relaxed  and  bathed  with  perspiration;   the  pulse  soft,  weak, 
and  a   little   accelerated  in    frequency;  a  sense  of  oppression,  almost  of 
drowsiness,  comes  over  the  patient,  and  yet  he  has  entire  inability  to  sleep, 
causing  an  extreme  sense  of  weariness  and  exhaustion.     These  paroxysms 
continue  a  variable  period  of  time,  from  not  more  than  fifteen  or  twenty 
minutes    to   six  or   eight   hours.     They   much  more  frequently  manifest 
themselves  during  the  night,  usually  after  the  patient  has  fallen  asleep. 
He  is  started  up  from  his  sleep  by  a  sense  of  suffocation   and  oppressior, 
and  usually  throws  the  windows  and  doors  open  for  fresh  air,  and  gener- 
ally insists  on  keeping  the  upright  position  or  inclining  forward  as  I  have 
already  mentioned.     Commencing  in   this  way,  usually  in   the  early  part 
of  the  night,  after  the  first  half  hour  or  hour  of  sleep,  it  will  usually  con- 
tinue till  near  morning;   in    most  cases,  from  three  to  four  o'clock  in  the 
morning,  the  difficulty  of  breathing  will  gradually  diminish,  air  will  enter 
more  freely  to  the  air  cells,  and  the  patient  will  soon  obtain  a  sense  of  re- 
lief from  the  suffocation,  and  in  half  an   hour  more  reclines  at  an  angle 
of  fortv-five   degrees,   having  the    head   still   moderately  high,  and   falls 
asleep.     The  patient  usually  perspires  freely,  and  often  sleeps  four  or  five 
hours,  if  left  undisturbed,  and   wakes  up   feeling  weary,  but  with  entire 
freedom  of  breathing;  the  rales   are   gone   from   the   chest,  the   pulse  is 
natural  in  frequency,  and  nearly  so  in  force,  and  no  symptom  or  physical 
sign  remains  to  explain  the  apparent  obstruction  and  great  dyspnoea  that 
had  characterized  the  paroxysm.     These  latter  may  recur  every  night,  or 
they  may  occur  only  at  entirely  irregular  intervals,  depending  upon  certain 
other   derangements  which  precede   them.     They  do  not,  like  bronchitis, 
or  the  dyspnoea  from   inflammatory   affections   of  the   respiratory  organs, 
occur  more  frequently  in  cold  seasons   of  the   year.     But  this  spasmodic 
variety  of  disease  may  recur  at  any  and  all  seasons  of  the  year.     It  is  re- 
garded as  of  more  frequent  occurrence  in  males  than  in  females.     As  I 
have  already  remarked,  it  is  a  symptomatic  affection,  and  may  be  caused 
by  derangements   either   connected    with   the   digestive  organs,  which  is 
perhaps  more  common  than   any  other,  or   from   some  peculiar   suscepti- 
bility, or  genuine  idiosyncrasy  of  the  nerves  connected  with  the  air  pas- 
sages.    The  most   common  cases  of  all.   are  those  which  are  directly  de- 
pendent on  primary  derangements  of  the  function  of  the  stomach.     Di- 
gestion being  imperfect,  the  patient  retiring  to  bed  with  more  or  less  un- 
digested food,  and  deficient  gastric  secretion,  the  stomach  soon  becomes 
more    or   less  distended   with   gases,  and  their  action   with  other  morbid 
products  in  the  stomach  produces  an  impre:  s'on  upon  the  gastric  branches 
of  the  pneumogastric  nerve,  which  is  reflected  through  the  connections  of 
that  nerve  upon  those    supplying   the  delicate   muscular   fibers   entering 
into  the  coats  of  the   bronchioles  and  smaller  bronchial  tubes,  inducing  a 


CAUSES.  817 

genuine  spasmodic  contraction  of  these  fibers,  and  a  narrowing  of  the 
tubes,  which  is  the  immediate  cause  of  the  paroxysms  of  dyspnoea.  Af- 
ter the  derangement  of  the  stomach  is  relieved  by  the  discharge  of  the 
gases  and  other  materials  so  as  to  remove  the  exciting  cause,  the  asthmatic 
paroxysms  speedily  subside.  But  if  no  measures  are  taken  for  prevent- 
ing a  renewal  of  the  gastric  disorder,  the  dyspnoea  will  also  recur  in  par- 
oxysms more  or  less  frequent.  Almost  any  marked  derangement  in  the 
digestive  organs  is  capable  of  inducing  reflex  irritation  that  will  bring 
temporary  paroxysms  of  dyspnoea  or  asthmatic  breathing.  There  are 
some  persons,  however,  who  possess  a  peculiar  idiosyncrasy  in  the  sensi- 
bility of  the  nerves  connected  with  the  respiratory  organs,  bv  which  they 
are  made  liable  to  an  attack  of  spasmodic  asthma  whenever  certain  sub- 
stances diffused  in  the  atmosphere  are  allowed  to  enter  the  air  passages 
by  inhalation.  Certain  powders,  with  these  persons,  will  immediately  de- 
velop a  temporary  paroxysm  of  this  disease.  Powdered  ipecac  and  the 
odor  or  pollen  of  certain  flowers  and  plants,  have  been  known  invariably 
to  induce  paroxysms  of  the  disease  in  persons  thus  predisposed.  It  is  un- 
doubtedly true,  that  aside  from  actual  idiosyncrasy  in  this  respect,  there 
are  some  cases  in  which  ordinary  causes  have  produced  that  degree  of 
morbid  sensitiveness  in  the  bronchial  nerves  that  renders  the  patient 
liable  to  be  thrown  into  paroxysms  of  spasmodic  dyspnoea  on  the  slightest 
provocation.  A  slight  morbid  sensibility  in  any  portion  of  the  anterior 
lobes  of  the  brain  extending  back  far  enough  to  involve  the  origin  of  the 
pneumogastric  nerves  may  render  the  individual  very  sensitive  to  moder- 
ate impressions,  or  what  is  popularly  styled  exceedingly  nervous  or  easily 
excited.  A  few  instances  of  that  class  I  have  known  to  be  subject  to 
paroxysms  of  great  difficulty  of  breathing,  almost  uniformly  from  any 
sudden  emotion,  or  strong  mental  impression.  Almost  any  variety  of  sud- 
den and  decided  mental  excitement  would  be  sufficient  to  brina:  on  par- 
oxysms of  difficulty  of  breathing,  resembling  in  all  respects  spasmodic 
asthma,  and  usually  lasting  from  five  minutes  to  an  hour.  I  have  partic- 
ularly in  my  mind  at  the  present  time  a  woman,  aged  about  twenty-three 
years,  who  for  the  last  three  years  has  been  affected  with  this  form  of  dif- 
ficulty, coupled  with  a  simultaneous  spasmodic  affection  of  the  larynx. 
And  so  sensitive  has  she  become  that  great  care  is  required  to  avoid  the 
moderate  mental  disturbances  which  may  occur  in  almost  any  intercourse 
in  society,  lest  a  paroxysm  should  be  induced.  And  they  become  so  fre- 
quent as  to  render  the  patient's  life  exceedingly  troublesome,  and  the 
mind  habitually  despondent.  Yet  the  closest  scrutiny  could  not  detect 
any  organic  or  structural  changes,  nor  inflammatory  affections  either  in 
the  larynx,  or  any  part  of  the  bronchial  ramifications.  When  a  similar 
paroxysmal  constriction  takes  place  in  the  larynx  as  I  have  described  as 
occurring  in  the  bronchial  tubes,  which  often  happens  in  children,  it  con- 
stitutes laryngismus  stridulus  or  sjoasmodic  croup.  And  it  may  arise 
from  any  and  all  the  causes  I  have  alluded  to,  as  producing  the  asthmatic 
difficulties.  There  being  a  predisposition  consisting  of  undue  sensitive- 
ness of  the  nerves  of  the  larynx,  any  slight  irritating  influence,  whether 
the  inhalation  of  impure  air,  irritating  vapors,  or  being  exposed  to  chilly 
night  air  will  be  sufficient  to  provoke  an  attack.  Perhaps  the  most  fre- 
quent causes  are  the  sudden  impression  of  cold  and  damp  air,  or  even 
allowing  the  feet  to  get  unusually  cold,  and  temporary  derangements  of 
the  digestive  organs,  especially  the  formation  of  gases  in  the  stomach  at 
night.  An  attack  is  most  liable  to  supervene  after  the  first  hour  or  two 
of  sleep,  when  the  patient  awakes  suddenly  with  a  sense  of  suffocation, 
and  such  a  contraction  of  the  muscular  structures  connected  with  the 
53 


818  LARYNGISMUS   STRIDULUS. 

larynx  and  vocal  cords,  as  to  produce  great  difficulty  of  inspiration  and 
inclination  to  cough,  with  loud,  ringing,  stridulous  sounds,  as  though  the 
patient  had  suddenly  developed  the  most  dangerous  form  of  croup  or 
laryngitis.  The  paroxysm  thus  developed  will  usually  last  from  one  to 
three  or  four  hours,  when  it  subsides,  leaving  the  patient  almost  entirely 
free  from  any  conscious  difficulty,  either  in  the  breathing,  or  in  the  tend' 
erscy  to  cough.  This,  like  the  asthma,  may  be  renewed  each  night  for 
several  nights  in  succession,  or  it  may  come  only  in  individual  paroxysms 
at  irregular  and  sometimes  long  intervals.  Both  this  affection,  so  com- 
mon among  children,  and  the  spasmodic  asthma,  are  distinguished  from 
the  difficulty  of  breathing  which  we  have  already  described  in  connection 
with  inflammation  of  the  larynx  and  bronchial  tubes,  by  the  fact  that  the 
active  symptoms  are  all  purely  paroxysmal,  in  the  interval  there  remain- 
ing no  physical  signs  even  of  congestion  of  the  mucous  membrane  in 
those  passages.  This  of  course  is  not  the  case  in  either  laryngitis  or 
bronchitis;  while  there  will  be  paroxysms  of  difficulty  of  breathing  in  the 
"latter  instances,  in  the  intermission  between  the  paroxysms  the  patient 
still  has  some  degree  of  difficulty  and  the  physical  signs  of  congestion 
still  remain  as  constant  phenomena  till  the  disease  is  removed.  Another 
marked  distinction,  is,  that  in  the  inflammatory  affections  of  the  larnyx 
and  bronchial  tubes  the  temperature  of  the  patient  is  increased,  consti- 
tuting more  or  less  febrile  movement,  the  pulse  is  accelerated,  while  in 
the  spasmodic  affection  there  is  no  increase  of  temperature,  more  fre- 
quently rather  a  diminution,  and  the  pulse  has  none  of  the  short,  quick, 
febrile  quality,  that  belongs  to  the  inflammatory  affections  I  have  named. 
As  these  spasmodic  affections  seldom  if  ever  prove  fatal,  there  are  no  an- 
atomical changes  known  to  be  characteristic  of  their  existence. 

Treatment. — As  you  will  have  inferred  already,  from  the  fact  that  the 
spasmodic  affections  I  have  described  are  symptomatic,  always  arising 
from  some  prior  pathological  condition  found  in  other  organs,  the  respira- 
tory trouble  being  only  from  reflex  influence,  the  great  and  leading  ob- 
jects of  treatment  are:  first,  to  hasten  the  relief  of  the  patient  from  the 
existing  paroxysm,  when  called  during  its  existence,  while  the  second, 
and  more  important  object  is  to  ascertain  the  pathological  conditions  from 
which  the  troublesome  paroxysms  originate,  and  adopt  such  measures  as 
may  be  indicated  for  their  removal.  For  accomplishing  the  first  object,  it 
is  sufficient  to  bring  the  patient  quickly  under  the  influence  of  almost  any 
reliable  antispasmodic  and  slightly  anodyne  remedy.  The  cautious  in- 
halation of  an  angesthetic,  like  chloroform  or  ether,  still  better  the  nitrite 
-of  amyl  or  the  vapor  of  the  oil  of  eucalyptus,  will  in  many  cases  speedily 
relieve  the  existing  paroxysm.  So  will  the  internal  administration  of  a 
■combination  of  almost  any  mild  anodyne  with  an  expectorant.  A  com- 
bination of  the  camphorated  tincture  of  opium  with  the  compound  syrup 
of  squills,  to  which  may  be  added  a  certain  proportion  of  the  tincture  of 
lobelia  inflata,  constitutes,  perhaps,  one  of  the  most  efficient  that  can  be 
made  for  the  relief,  both  of  the  laryngeal  spasm  and  the  asthmatic  parox- 
ysms. K  prescription,  consisting  of  the  compound  syrup  of  squills  thirty 
c.  c.  (^i),  tincture  of  lobelia  fifteen  c.  c.  (|ss)  camphorated  tincture  of 
opium  forty-five  c.  c.  (^iss),  may  be  made,  of  which  four  cubic  centime- 
ters, or  one  fluid  drachm,  diluted  with  a  tablespoonful  of  water  may  be 
given  to  an  adult  at  once.  It  may  be  repeated  in  one  or  two  hours,  if  re- 
lief is  not  sooner  obtained.  The  same  combination,  only  reducing  the 
dose  so  as  to  adjust  it  to  the  age  of  the  patient,  may  be  given  to  children, 
particularly  for  the  relief  of  what  is  commonly  known  as  spasmodic  croup. 
Where  the  lobelia  might  be  objectionable  on  account  of  its  tendency  to 


TEEATMENT.  819 

excite  too  mucli  nausea  or  sedative  action,  an  equal  quantity  of  the  tinct- 
ure of  sanguinaria  may  be  substituted  in  its  place.  In  some  instances  I 
have  seen  very  speedy  relief  result  from  ariving  proper  doses  of  an  equal 
mixture  of  the  fluid  extract  of  grindelia  robusta,  and  camphorated  tincture 
of  opium.  Many  families  having  children  who  are  somewhat  predisposed 
and  consequently  are  frequently  attacked  with  this  variety  of  croup  or  spas- 
modic laryngeal  affection,  keep  constantly  on  hand  the  ordinary  syrup  of 
ipecac,  and  whenever  the  children  are  attacked,  sufficient  is  given  to  pro- 
duce nausea  or  slight  vomiting,  which  causes  relaxation  of  the  parts 
involved,  and  the  paroxysm  passes  off.  But  the  more  important  part  of 
the  treatment  in  all  such  cases  is  to  ascertain  as  accurately  as  possible  the 
derangements  which  precede  and  give  rise  to  the  phenomena  that  we 
have  been  discussing,  that  such  measures  may  be  adopted  as  vrill  remove 
them  and  thereby  prevent  the  recurrence  of  future  paroxysms.  Those 
cases  which  depend  upon  some  natural  idiosyncrasy  rendering  the  patient 
liable  to  attacks  either  of  laryngeal  or  bronchial  spasm,  from  inhalation 
of  certain  substances  in  the  atmosphere,  are  probably  incurable.  They 
are,  like  other  idiosyncrasies,  congenital  and  usually  continue  through  the 
whole  period  of  life.  Yet  in  some  instances  they  have  been  known  to 
gradually  diminish  after  the  middle  period  of  life,  and  finally  disappear. 
When  there  is  morbid  sensitiveness  of  the  nerves  of  the  air  passages, 
accompanied  by  a  general  nervous  temperament,  constituting  a  condition 
that  is  easily  impressible  from  almost  any  cause,  the  object  of  the 
physician  should  be  to  give  such  instructions  to  the  patient  or  his  parents 
and  guardians  as  will  enable  them  to  adopt  a  system  of  training  calcu- 
lated intelligently  to  change  this  morbidly  sensitive  constitutional  con- 
dition to  one  more  healthy,  and  thereby  do  away  with  the  unpleasant 
consequences  that  would  otherwise  annoy  the  patient  through  life. 
Among  the  measures  most  important  for  such  patients  is  the  wearing  of 
flannel  next  to  the  surface  during  all  the  cold,  damp  and  variable  seasons, 
which  in  the  northern  part  of  this  country  would  embrace  nearly  all  the 
year,  living  upon  plain,  easily  digestible  food,  and  a  regular  daily  practice 
of  moderate  out-door  exercise,  including  positive  exercise  of  the  chest  and 
arms,  thereby  cultivating  strength  and  efficiency  in  the  muscles  concerned 
in  carrying  on  the  involuntary  process  of  respiration.  In  some  cases 
during  the  last  two  or  three  years,  I  have  obtained  considerable  advantage 
by  causing  the  patient  to  inhale,  for  three  to  five  minutes  at  a  time,  the 
vapor  of  the  oil  of  eucalyptus  morning  and  evening.  This  vapor  appears 
to  exert  a  sedative  effect  upon  morbid  nervous  sensibility,  and  to  excite 
healthy  secretory  action  in  the  mucous  follicles  of  the  membrane  lining 
the  air  passages.  In  that  large  class  of  cases  of  spasmodic  bronchial 
affection  existing  in  connection  with,  and  sometimes  dependent  upon, 
derangements  of  digestion,  the  only  rules  that  can  be  laid  down  for  their 
management  is  to  adopt  such  measures  in  regard  to  diet,  exercise  and 
medicine  as  are  required  for  the  effectual  correction  of  the  digestive 
derangements,  including  regulation  of  the  bowels  and  the  promotion  of 
the  natural  secretions,  especially  from  the  skin  and  kidneys.  For  obser- 
vations show  that  a  large  proportion  of  the  cases  where,  from  gastric 
derangements,  the  air  tubes  are  frequently  constricted,  interfering  more  or 
less  with  the  uniformity  of  the  functions  of  the  lungs,  the  urine  is  very 
liable  to  become  impregnated  with  a  large  excess  of  the  phosphatic  and 
amnioniacal  salts.  In  such  cases,  the  urine  on  cooling  deposits  a  large 
amount  of  a  white  or  pinkish  white  color,  which  is  wholly  dissipated  by 
heat  or  nitric  acid.  All  these  derangements  affecting  digestion  and  the 
important  eliminations  from  the  kidneys  and  skin,  require  the  attention  of 


820  APHONIA. 

the  practitioner  if  he  would  succeed  in  permanently  restoring  the  patients 
to  reliable  health.  Among  other  things  it  often  becomes  necessary  to 
correct  the  patient's  mode  of  doing  business,  or  the  kind  of  work  in  which 
he  is  engaged.  For  many  of  this  class  will  be  found  either  so  occupied 
as  to  be  kept  an  inordinate  amount  of  time  in-doors,  very  frequently  in 
confined  air,  or  sleeping  in  close,  poorly  ventilated  and  warm  rooms  at 
night.  Sometimes  they  are  engaged  in  occupations  where  the  air  is 
impregnated  continuously  with  some  foreign  substance,  as  in  the  manu- 
facture of  tobacco,  and  various  other  manufacturing  processes  that  cause 
habitual  impregnation  of  the  air  which  the  workmen  are  obliged  to  inhale. 
Another  difficulty  occasionally  met  with  in  direct  connection  with  the 
respiratory  passages,  more  particularly  with  the  larynx,  is  that  of  aphonia 
or  loss  of  voice. 

Aphonia. — When  speaking  of  laryngitis  in  all  its  various  grades,  you 
will  remember  that  we  had  alterations  of  the  voice  in  every  degree,  from 
that  of  the  loud,  harsh  and  ringing,  to  entire  suppression  or  reduction  of 
the  voice  to  a  whisper,  accompanying  most  of  the  inflammatory  conditions 
of  that  part  of  the  respiratory  apparatus.  But,  aside  from  this,  there  are 
conditions  of  the  nervous  system  which  are  accompanied  by  entire 
aphonia  or  loss  of  voice.  This  is  not  of  very  frequent  occurrence,  and  is 
chiefly  met  with  in  females  of  a  highly  nervous  or  hysterical  tempera- 
ment. In  this  class  of  patients,  many  cases  have  been  observed  in  which 
from  sudden  mental  impressions  or  the  paroxysms  of  high  nervous  excite- 
ment, the  voice  has  been  suddenly  lost,  the  patient  being  entirely  unable 
to  articulate  a  sound  or  to  make  any  audible  sound  above  that  of  a 
whisper.  Such  cases  are  distinguished  from  inflammatory  affections  by 
the  entire  absence  of  soreness,  pain  or  any  of  the  phenomena  of  inflam- 
matory action,  and  when  examined  for  the  physical  signs  by  the  laryngo- 
scope, or  even  by  listening  over  the  larynx  with  the  ordinary  stethoscope, 
there  is  absence  of  all  the  signs  that  accompany  inflammatory  congestion 
or  exudation  in  the  membrane  lining  the  larynx,  or  covering  the  vocal 
cords.  In  most  such  instances,  a  careful  inspection  of  the  parts  with  the 
laryngoscope  shows  either  partial  or  complete  paralysis  of  the  functions 
of  the  vocal  cords.  In  some  instances,  the  loss  of  voice  is  felt  for  a  few 
minutes,  and  in  others  it  lasts  for  days  or  weeks.  Perhaps  the  most 
efficient  agent,  which  is  calculated  to  act  quickly  in  restoration  of  the  loss 
of  voice  from  paralysis  or  from  suspension  of  the  natural  action  of  the  parts, 
is  that  of  electricity  applied  by  faradisation,  or  any  other  method  by  which 
electric  or  electro-magnetic  currents  of  a  moderate  degree  of  intensity 
are  made  to  pass  through  the  parts  involved.  The  application  may  be 
continued  from  five  to  ten  minutes  at  a  time,  and  sometimes  results  in  at 
once  re-establishing  natural  action.  At  other  times  it  requires  an  appli- 
cation each  day  for  several  days.  If  the  patients  are  troubled  at  the  same 
time  with  other  nervous  phenomena,  the  use  of  such  nervous  sedatives, 
antispasmodics  and  tonics  as  may  be  indicated  to  improve  the  general 
condition  of  the  patient  will  also  assist  in  restoring  the  action  of  the  vocal 
cords.  If  such  patients  are  debilitated,  requiring  the  influence  of  tonics, 
perhaps  one  of  the  best  that  can  be  given  for  preventing  a  recurrence  of 
the  aphonia  after  the  voice  has  been  once  restored,  or  even  during  the 
process  of  the  restoration,  is  the  combination  of  moderate  doses  of  strych- 
nia, quinine  and  iron.  They  are  agents  that  may  be  very  conveniently  com- 
bined in  proper  proportion  in  doses  to  suit  the  age  of  the  patient,  in  gela- 
tine capsules,  and  administered  without  annoyance  to  the  patient.  Although 
not  usually  mentioned  bywriters  upon  practical  medicine,  there  is  a  class 
of  patients  which  you  are  liable  to  come   in  contact  with  who  are,  as  you 


SYMPTOMS.  821 

will  find,  very  much  alarmed  at  times  with  a  sense  of  difficulty  of  breath- 
iii<i^,  or  rather  a  sense  of   want  of  breath   and   weakness  across   the  chest. 
Usually,  in  the  paroxysms  they  present  a  pale  and  anxious  expression  of 
countenance,  ahnost  always  sitting  upright  in  the  bed  or  chair,  and  when 
you  approach  them  complaining  with  great  alarm  that  they  are  suffocating 
or   cannot   breathe;  and  yet,  aside  from  the   expression  of    countenance  1 
have  mentioned,  you  find  on  further  examination   that  the  pulse  and  tem- 
perature are  natural  and  no  rales  in  the  chest.     But  in   watching  them  for 
a  moment  or  two  ^''ou  will    observe   that   the    inspiratory  and  expiratory 
movements  are  performed   imperfectly  or  inefficiently,   perhaps  for  five  or 
six  respirations,  and  ending  in  a  deep,  sighing  inspiration    by   which  the 
patient   apparently   seeks    instinctively    to    compensate    himself   for    the 
defectiveness   of  the   respirations   that   occurred  between  these  sighings. 
The  mechanism  of  the  breathing  in  these  cases  is  not  that  of  asthma  or  of 
any   constriction    of   the   air   passages.     It  is    rather  impairment    of  the 
function  of  the  nerves  connected  with  respiration,  and  a  condition  of  the 
bronchial  tubes  similar  to  that  which  involves  the  vocal  cords  and  larynx 
in  aphonia.     It  is  a  direct,  though  temporarv,  impairment  of  the  function 
of  respiration,   the   respiratory   movements  being  so   defective   that  the 
patient    feels     a    sense    of    impending    suffocation,     or    as    though    the 
mechanisms  of  respiration   and  circulation   were   about   to   stop.     I  have 
met  with  such  cases  more  frequently  in    females  who  are  in  the    habit  of 
xising  freely  and  habitually  strong  tea  than  in  any  other  class  of  subjects; 
but  it   has  not  been  restricted  altogether  to  them.     I  have  met  with  the 
same   phenomena   in   adults   of   the  male  sex,  and  in   some   instance^  of 
females   who  are  not  addicted  to  the  use  of  any  inordinate  amount  of  tea 
or  coffee.     But  perhaps  a  large   proportion  of  all  I  have   seen  have  been 
subject  to   the  excessive  use  of  those  agents,  and   more   especially  of  the 
tea.     Among  the   more   common    cases  of  the  kind   are   women   who  are 
nursing.     Within  the  first  two  or  three   months   after   their  confinement, 
following  the  popular  notion  that   while  nursing  they  must   take  an  extra 
amount  of  drink,  and  that  tea   helps  to  form  milk,  they  acquire  the  habit 
of  taking  sometimes  from  six  to  twelve  ordinary  cups  of  strong  tea  in  the 
twenty-four  hours.     Occasionally  one  takes  less,  but  substitutes  in  place 
of  it  beer,  ale  or  porter.     These   patients   almost   invariably    lose   their 
appetite  for  food   and   consequently  eat  but  little,  depending  altogether 
upon  their  drink;  the  result  of  which  is  that  the  theine  of  the  tea  being  a 
direct  nervous  excitant,  increases  the  inherent  susceptibility  of  the  nerve 
structures  and  in  process  of  time  develops  an  extraordinar}^  impressibility 
or  excitability  of  the  nerves  that  are  more  particularly  connected  with  the 
heart  and  respiratory  organs.     The  use  of  the  beer  and   ale  modifies  the 
eflfect  but   little,  while  it  aids  in   destroying  the   appetite   for  wholesome 
food,  and  the  patient  becomes  more  or  less  impoverished  in  the  nutritive 
elements   of  the    blood  and  subject  almost  every  night  and   sometimes 
during  the  day  to  those  distressing  feelings  of  oppression  and  inability 
to  breathe,   occasionally  accompanied  by  irregular   action  of  the  heart, 
I  have  many  times  been  called  in  the  night  to  patients  of  this  elass,  under 
the  positive  assurance  that  they  were   m  danger   of  dying,    and  when   I 
arrived,  found  them  sitting  in  bed,  as  I  have  described,  pale,  anxious,  skin 
bathed  in  perspiration,  but  cool,  and  not  a  shadow  of  physical  evidence  of 
obstruction  in   any  part    of  the  air  passages,  and   the  heart  perfectly  free 
from  evidence  of  any  structural  or  valvular  change;  the  whole  difficulty 
being  dependent  upon   the  impairment  of  nerve  function  in   carrying  on 
the   mechanical   process    of     breathing.     For    immediate    relief  to    such 
patients,  I  have   found  no   remedy  more   efficient  than  a  combination  of 


822  CARDIAC    IRRITABILITY. 

digitalis,  Scutellaria  and  valerian  in  such  proportions  that  with  each  dose 
of  four  cubic  centimeters  (fl.  3i)  the  patient  would  get  two  cubic  centi- 
meters (fl.  3ss)  of  the  fluid  extract  of  valerian,  one  cubic  centimeter 
(min.  xv)  of  the  tincture  of  digitalis,  and  the  same  quantity  of  the  fluid 
extract  of  Scutellaria.  This  dose  may  be  given  disguised  in  a  little 
sweetened  water,  and  repeated  every  two  hours  until  the  patient  is 
relieved  from  immediate  distress.  And  the  same  given  morning,  noon 
and  night  for  a  week  or  two  after  the  immediate  paroxysm  has  passed 
away  will  contribute  much  to  prevent  its  recurrence.  But  the  great 
reliance  for  the  cure  of  such  derangements  is  in  the  removal  of  the  causes 
that  have  led  to  them,  viz.,  the  discontinuance  of  all  excess  in  the  use  of 
tea  and  coflee,  restricting  the  use  of  these  agents  to  one  cup  of  moderate 
strength  at  a  meal-time,  requiring  patients',  if  they  really  need  more 
drink,  to  take  milk  or  water,  and  the  entire  disuse  of  all  fermented  or 
distilled  drinks.  At  the  same  time  require  them  to  moderately  exercise 
in  the  open  air  every  day,  either  by  riding  or  short  walks,  as  their  strength 
will  allow,  and  to  take  plain,  easily  digestible  food  at  the  regular  meal- 
times. Obedience  to  these  requirements  will  serve  to  restore  almost 
every  one  of  them  in  a  few  weeks  to  a  fair  appetite,  ability  to  sleep  well, 
or  in  other  words,  a  reasonable  degree  of  health.  Yet,  I  have  seen  many 
of  these  cases  that  had  not  been  well  understood,  and  in  consequence  had 
suffered  for  a  longer  period  of  time,  and  some  cases  of  nursing  women  who 
actually  took  the  child  from  the  breast  at  an  unreasonably  early  period, 
under  the  impression  that  there  was  no  chance  of  recovery  without  doing 
so.  .Next  to  the  nursing  women,  the  parties  most  frequently  afi"ected 
with  this  kind  of  functional  difficulty  are  servant  girls  who  are  employed 
in-doors,  and  especially  in  the  kitchen.  Taking  but  little  outside  air  and 
contracting  the  habit  of  using  an  inordinate  amount  of  tea,  large  numbers 
of  them  sufi"er  more  or  less  from  the  kind  of  derangement  that  I  have 
indicated,  coupled  with  a  tendency  almost  constantly,  to  constipation  of 
the  bowels,  impairment  of  appetite,  impairment  of  digestion,  till  some  of 
them  become  disabled  from  the  prosecution  of  their  work.  And  yet  it 
only  requires  diligence  in  ascertaining  their  habits  to  arrive,  at  a  proper 
appreciation  of  the  causes  and  remove  them,  when  health  may  soon  be 
restored. 


LECTURE  LXXXVI. 

Functional  Derangements  of  the  Central  Organs  of  Circulation— Cardiac  Irritability. 

GENTLEMEN:  Closely  allied  to  the  class  of  cases  to  which  I  was 
directing  your  attention  at  the  close  of  the  preceding  lecture  is  an- 
other, embracing  a  less  number  of  patients,  bat  still  not  very  rare.  I 
allude  to  what  I  shall  denominate  simple  cardiac  irritability  from  nervous 
derangement  or  perversion  of  nervous  function.  The  cases  to  which  I 
now  allude  will  be  best  understood  by  a  brief  enumeration  of  the  more 
prominent  symptoms.  They  are  met  with  much  more  frequently  from 
the  period  of  puberty  to  twenty-five  or  thirty  years  of  age.  It  is  only 
seldom  that  I  have  met  with  cases  beyond  the  latter  period  of  life.  In 
most  instances  the  patients  have  been  spare  in  flesh,  slightly  anaemic  in 
their    appearance,   presenting   wnat    would    be    denominated  a    nervous 


SYMPTOMS.  823 

temperament,  and  very  j^enerally  sedentary  in  their  habits,  or  following 
some  occupation  that  keeps  them  most  of  the  time  in-doors.  The  prom- 
inent symptom  which  caases  this  class  of  patients  to  seek  the  advice  of 
the  physician,  is  rapid  beating-  of  the  heart.  When  fully  characterized,  it 
is  not  ordinary  palpitation  of  the  heart,  such  as  comes  frequently  a  few- 
moments  at  a  time  and  subsides,  but  it  is  a  continuous  rapid  beating. 
In  some  of  these  cases  I  have  found  it  difficult  to  count  the  beats  of 
the  heart  from  its  rapidity.  The  systolic  action  was  short,  quick  and  re- 
peated so  rapidly,  that  no  distinction  between  the  first  and  second 
sounds  could  be  recognized.  Of  course  the  pulse  has  the  same  degree  of 
rapidity,  and  is  almost  always  soft,  easily  compressed  or  weak.  The 
respirations  are  habitually  accelerated,  but  not  in  comparison  to  the 
degree  of  acceleration  of  the  pulse.  There  is  often  a  continual  feeling  of 
oppression,  especially  behind  the  lower  part  of  the  sternum,  which 
prompts  the  patient  every  now  and  then  to  take  a  deep  inspiration  or 
sigh.  There  is  no  febrile  movement,  no  physical  sign  of  pericarditis  or 
endocarditis.  Some  of  these  cases  where  the  cardiac  irritability  or 
extreme  rapidity  of  action  has  continued  from  one  to  three  weeks,  render- 
ing it  difficult  for  the  patient  to  sleep  at  night,  it  has  resulted  in  much 
general  debility,  as  well  as  a  constant  feeling  of  anxiety  and  oppression. 
A  majority  of  this  class  of  cases,  however,  do  not  have  the  periods  of 
cardiac  excitement  continue  so  long,  but  they  will  recur  in  paroxysms. 
Ji^rom  slight  undue  mental  excitement  and  slight  exertion  it  will  return 
upon  them  with  full  development  of  its  rapidity  and  continue  perhaps  one 
or  two  hours,  then  gradually  subside,'  leaving  them  again  comparatively 
free  till  some  slight  cause  produces  its  return.  They  may  be  subject  to 
these  paroxysms  two  or  three  times  in  the  twenty-four  hours,  but  in  some 
instances  it  comes  the  same  time  once  every  day,  for  several  days  and 
nights  in  succession.  Close  examination  of  such  of  these  patients  as  have 
come  under  my  own  care  has  revealed  the  fact  that  they  have  either 
suffered  themselves  to  be  kept  too  continuously  in-doors,  with  almost  con- 
stant mental  application,  or  that  they  have  been  subject  to  some  special 
disturbing  influence  of  a  depressing  character  operating  upon  the  nervous 
system  through  the  mental  emotions  and  affections.  Sometimes  grief 
from  loss  of  friends  has  produced  it.  In  some  instances  it  has  resulted 
from  severe  disappointment  or  the  sudden  breaking  off  of  attachments, 
and  in  a  very  few  instances  I  have  found  it  in  connection  with  cases  of 
long-continued  and  excessive  self-abuse.  All  these  cases  of  course  are 
to  be  distinguished  or  differentiated,  both  from  structural  disease  of  the 
heart  and  inflammatory  affections  of  that  organ  by  careful  attention  to 
the  physical  signs.  In  some  instances,  where  the  heart  at  the  time  of 
the  physician's  visit  is  beating  with  the  rapidity  I  have  described,  he  may 
be  uncertain  as  to  whether  there  is  organic  change  in  the  valvular  struct- 
ure of  the  heart,  from  the  mere  fact  that  he  can  not  analyze  the  rhythm. 
In  all  such  instances  he  may  properly  leave  a  completion  of  his  diagnosis 
until  he  has  subjected  the  patient  to  some  suitable  remedy  for  steadying 
the  heart's  action,  till  the  paroxysm  has  passed  awaj'-,  and  he  has  oppor- 
tunity to  examine  the  patient  again  when  the  cardiac  systoles  are  nearer 
their  natural  frequency.  This  will  enable  him,  without  any  doubt  what- 
ever, to  perceive  that  there  are  no  murmurs  or  other  signs  indicating 
structural  change. 

Treatment. — The  treatment  of  this  class  of  cases,  like  the  other  symp- 
tomatic disturbances  to  which  I  have  been  calling  your  attention,  embraces 
two  objects;  the  one  to  relieve  more  dn-ectly  the  excessive  cardiac  action, 
and  the   other  to  remove  the  cause.     In  almost  all  cases  that  have  come 


824  ANGINA    PECTORIS. 

under  my  care  I  have  succeeded  in  accomplishing  the  first  object  by  the 
use  of  the  same  combination  of  the  fluid  extracts  of  valerian,  Scutellaria 
and  digitalis  that  I  gave  you  in  the  preceding  lecture.  By  giving  it  in 
moderate  but  frequently  repeated  doses,  the  digitalis  soon  controls  the 
cardiac  excitement,  while  the  other  ingredients  lessen  the  general  nervous- 
ness and  sustain  the  strength  of  the  patient.  Whenever  this  effect  is  in- 
duced, to  prevent  exaggerated  action  of  the  digitalis  the  intervals  between 
the  doses  must  be  greatly  lengthened,  aiming  only  to  perpetuate  sufficient 
influence  to  steady  and  strengthen  the  heart's  movements  without  unduly 
diminishing  their  frequency,  and  without  producing  constriction  of  the 
chest.  There  are  many  other  remedies  which  will  afford  relief  tem- 
porarily. Fluid  extracts  of  cactus  grandiflora  and  convallaria,  either 
alone  or  in  combination  with  other  mild  tonics  and  antispasmodics  will 
generally  produce  the  desired  effect.  When,  through  the  direct  inter- 
ference of  medicine,  the  patient  is  relieved  in  a  great  measure  from  the 
immediate  embarrassment  of  the  circulation,  the  next  important  object 
should  be  the  removal  of  the  causes  which  may  have  led  to  it.  And  as 
this  almost  invariably  involves  either  the  occupation  or  the  habits  of  the 
patient,  it  is  necessary  that  these  be  pointed  out  and  that  the  patient  be 
fully  and  explicitly  warned  of  the  necessity  of  changing  them  if  he  would 
make  any  permanent  recovery.  Mental  application  must  be  limited 
within  a  reasonable  length  of  time  each  day,  and  thereby  allow  a  reason- 
able time  for  out-door  exercise,  and  especially  exercise  of  the  chest  by  full- 
ness of  respiration  and  free  movements  of  the  arms.  All  those  habits  which 
would  impair  the  general  tone  of  the  nervous  system  must  be  omitted. 
The  sleeping  room  must  be  well  aired  or  ventilated,  and  of  sufficient 
capacity  to  supply  the  patient  with  fresh  air  during  the  whole  of  the 
night.  Complete  avoidance  of  such  nervous  excitants  as  tea  and  coffee, 
such  anaesthetics  as  alcoholic  liquors  and  tobacco,  must  be  practiced. 
The  patient  should  be  left  on  pure  air,  moderate  out-door  exercise,  a 
reasonable  limit  to  mental  applications,  and  there  will  usually  be  no 
difficulty  in  bringing  about  a  permanent  change,  with  sufficient  physical 
vigor  and  health  to  secure  relief  from  all  danger  of  future  attacks. 

ANGINA  PECTORIS. 

The  next  subject  to  which  I  will  direct  your  attention  is  usually  de- 
nominated angina  pectoris  and  sometimes  neuralgia  of  the  heart.  Tt 
generally  occurs  in  persons  past  the  middle  period  of  life,  and  perhaps 
more  frequently  in  men  than  in  women.  It  is  also  noticed  very  frequently 
among  those  who  are  leading  sedentary  lives,  following  occupations  that 
keep  them  much  in -doors,  and  a  large  proportion  of  them  are  addicted  to 
the  habitual  use  of  strong  tea  and  coffee.  The  symptoms  of  this  affection 
usually  supervene  suddenly,  though  sometimes  a  dull,  aching,  depressing 
pain  is  felt  in  the  cardiac  region,  gradually  increasing  through  several 
hours  before  the  paroxysms  become  fully  developed.  In  most  instances  the 
patient  begins  to  realize  a  pain  of  the  character  I  have  just  mentioned  to- 
gether with  a  feeling  of  weight  or  hard  pressure  as  of  a  heavy  body  upon  the 
left  side  of  the  chest,  and  in  from  a  few  minutes  to  an  hour  or  two,  increas- 
ing in  severity  until  the  patient  appears  extremely  distressed.  The  pain 
centers  in  the  cardiac  region  and  radiates  upward  to  the  shoulder  and 
sometimes  down  the  left  arm  and  not  infrequently  directly  backward 
between  the  left  scapula  and  the  spine.  The  intensity  of  the  suffering  is 
accompanied  by  a  sense  of  great  oppression,  causing  an  anxious  expression 
of  countenance,  face  generally  pale,  surface  of  the  body  cool,  and  not 
infrequently  bathed  in  perspiration,  extremities  cold,  pulse  soft,  weak  and 


PATHOLOGY.  825 

sometimes  quiclc,  but  more  generally  not  faster  than  natural  and  occasion- 
ally intermitting.  The  respirations  are  very  variable  on  account  of  thi 
intensity  of  the  distress  and  sense  of  oppression  in  the  chest,  and  the 
patient  every  few  minutes  takes  a  deep  sighing  inspiration  or  attempts  to 
do  so,  which  is  sometimes  defeated  by  the  severity  of  the  pain  which 
arrests  the  expansion  of  the  chest  before  its  completion.  The  location  of 
the  pain  centering  in  the  cardiac  region  and  sometimes  radiating  in  the  di- 
rections already  named,  the  entire  absence  of  febrile  phenomena,  the  sud- 
denness with  which  the  attack  supervenes,  with  the  extreme  anxiety  de- 
picted in  the  face,  soft,  irregular  pulse,  cold  surface  and  extremities,  are 
sufficient  to  characterize  this  form  of  disease  and  distinguish  it  from  the 
painful  affections  of  the  stomach  called  gastrodj-nia  and  sometimes  gastral- 
giaon  the  one  hand,  and  from  pleurodynia  or  pain  in  the  intercostal  spaces 
on  the  other.  The  paroxysms,  as  I  have  described  them,  continue  very 
variable  periods  of  time  in  different  cases  and  in  different  attacks  on  the 
same  patient.  In  the  majority  of  instances  the  suffering  begins  to  abate 
in  about  one  hour,  and  frequently  diminishes  so  rapidly  that  the  patient 
is  comfortable,  though  feeling  extremely  weak,  at  the  end  of  another  hour. 
There  are  some  cases  where  it  will  be  shorter,  lasting  not  more  than  ten 
to  fifteen  minutes.  There  have  been  others  in  which  it  has  continued 
with  much  severity  for  twelve,  or  even  eighteen  hours;  and  there  are 
instances  on  recoi'd,  although  they  are  few  in  number,  in  which  a  severe 
and  protracted  paroxysm  has  terminated  in  the  death  of  the  patient. 
Patients  who  are  subject  to  attacks  of  this  disease  suffer  from  them  at 
very  variable  periods  of  time.  In  some  cases  they  recur  with  some 
degree  of  severity  almost  every  day  or  more  than  once  in  the  day.  But 
in  the  great  majority  of  cases  they  recur  only  at  intervals  of  from  one  to 
three  or  four  weeks,  unless  in  such  cases  as  are  liable  to  their  recurrence 
at  any  time  from  particular  motions  or  exercise.  In  some  cases  paroxysms 
are  brought  on  at  any  time  by  attempts  at  active  walking,  going  up  stairs 
or  any  active  muscular  action. 

Pathology. — There  can  be  little  doubt  but  that  the  seat  of  this  affec- 
tion is  in  the  heart  itself,  or  in  the  cardiac  nerves;  yet  there  are  no 
uniform  structural  changes  that  can  be  detected  by  post  mortem  examina- 
tions that  appear  to  be  specially  characteristic  of  this  form  of  disease  or 
to  be  the  special  cause  of  the  paroxysms  of  severe  suffering.  In  some 
instances  the  coronary  arteries  have  been  found  ossified,  in  others  there 
"have  been  indications  of  gouty  deposits  and  concretions  in  the  coats  of 
the  arteries,  instead  of  ordinary  ossification.  These  have  been  patients 
•who  are  either  hereditarily  or  otherwise  disposed  to  attacks  of  gout,  and 
are  suffering  from  the  gouty  diathesis.  In  perhaps  a  larger  number  of 
cases  the  only  change  that  has  been  found  after  death  is  more  or  less  fatty 
degeneration  of  the  muscular  structure  of  the  heart,  causing  diminution 
of  its  muscular  force,  and  consequently  impairment  of  its  ability  to  circu- 
late the  blood.  One  writer  has  claimed  that  the  disease  consists  in  a 
spasm,  or  more  or  less  tonic  contraction  of  the  coronary  arterioles.  That 
some  influence  of  the  kind  may  be  exerted  over  the  arterioles  through  a 
morbid  condition  of  the  vaso-motor  nerves  supplying  them,  is  very 
probable  during  the  paroxysms  of  this  affection;  but  there  is  no  proof 
that  such  is  uniformly  the  case.  There  have  been  a  large  number  of 
examinations,  some  of  them  very  minute  and  reliable,  of  patients  who 
have  been  subject  to  severe  paroxysms  of  angina  pectoris  for  years,  and 
yet  no  structural  lesions  have  been  observed  after  death.  And  in  those 
cases  where  the  changes  I  hava  enumerated  have  been  found  after  death, 
thi  history  of  each  individual  patient  renders  it  evident  that  the  changes. 


826  ANGIIN^A    PECTOKIS. 

such  as  ossification  of  the  coronary  arteries,  gouty  deposits  and  fatty 
degeneration  are  rather  coincidents,  resulting  from  causes  altogether  in- 
dependent of  the  angina  pectoris,  and  that  they  are  simply  coincident 
pathological  conditions,  instead  of  causes  of  that  disease.  From  such 
cases  as  have  come  under  my  own  observation,  I  am  led  to  think  that  the 
immediate  paroxysms  of  angina  pectoris  are  caused  by  a  morbid  condition 
of  the  nerves  supplying  the  vessels  of  the  heart,  and  leading  primarily  to 
contraction  of  those  vessels,  lessening  the  supply  of  blood  to  the  muscular 
structure,  and  inducing  both  pain  and  impairment  of  the  force  of  the 
heart's  action,  and  consequently  developing  the  extreme  anxiety,  pain 
and  depression  that  the  patient  endures.  That  ossification  of  the 
arteries,  gouty  changes,  fatty  and  atheromatous  deposits  or  any  similar 
structural  changes,  by  interfering  with  the  natural  action  of  the  muscular 
structure  as  well  as  with  the  sensibility  of  the  nerves,  may  predispose  to 
the  occurrence  of  angina  pectoris,  there  can  be  no  doubt;  but  their  rela- 
tions to  the  disease  are  those  of  predisposing  influences  rather  than  patho- 
logical changes  constituting  a  necessary  part  of  the  disease. 

Causes. — I  have  been  led  by  clinical  observation  to  the  conclusion 
that  the  liberal  use  of  tea,  cofi'ee,  tobacco,  and  perhaps  in  a  less  degree 
alcoholic  drinks,  has  a  tendency  more  or  less  to  favor  the  occurrence  of 
angina  pectoris  in  persons  beyond  the  middle  period  of  life,  and  especially 
as  they  approach  what  is  called  old  age,  or  the  period  between  fifty  and 
sixty  years;  also  sedentary  habits,  confinement  in-doors,  particularly  if  at 
the  same  time  they  are  pursuing  persistent  and  laborious  mental  occupa- 
tion. It  is  probable  that  all  these  causes  operate,  not  in  directly  inducing 
the  painful  affection  called  angina  pectoris,  but  by  interfering  with  the 
functions  of  respiration  and  digestion,  and  ultimately  impairing  the 
nutritive  processes  more  or  less,  they  lead  to  those  structural  changes  I 
have  already  enumerated,  especially  such  as  fatty  degenerations,  impair- 
ment of  the  muscular  force  of  the  heart  and  perversion  of  nerve  sensi- 
bilitv.  These  cause  the  patients  to  experience  that  weakness  of  cardiac 
action  which  renders  them  liable  to  attacks  of  pain  on  the  supervention 
of  any  exciting  cause,  as  undue  exertion  or  imperfect  digestion.  And  in 
many  cases,  after  they  have  suffered  a  few  attacks,  they  become  liable  to 
have  them  supervene,  even  without  any  special  exciting  cause. 

Prognosis. — The  prognosis  in  any  given  case  of  angina  pectoris  must 
depend  almost  entirely  upon  the  question  whether  any  portion  of  the 
cardiac  structures  have  undergone  anatomical  changes  of  a  fixed  or  per- 
manent character.  If  the  cavities  of  the  heart  are  enlarged  by  dilatation, 
if  the  arteries  have  become  more  or  less  ossified,  if  gouty,  fatty  or  athe- 
romatous changes  have  taken  place  in  the  muscular  structure  of  the  heart, 
as  these  are  changes  not  usually  capable  of  being  removed,  there  is  every 
reasonable  probability  that  the  paroxysms  of  angina  will  continue  to  recur 
on  the  occurrence  of  the  slightest  exciting  cause  during  the  remainder  of 
the  patient's  life.  But  if  on  close  examination,  aided  by  careful  physical 
exploration  of  the  chest,  no  structural  changes  can  be  detected  and  the 
systolic  action  of  the  heart  between  the  paroxysms,  when  the  patient  is  at 
ease,  have  the  natural  degree  of  force  and  steadiness  indicating  that  there 
is  at  least  no  decided  weakness  of  the  muscular  structure  from  fatty 
degeneration,  there  is  strong  probability  that  the  case  may  be  conducted 
to  a  favorable  termination,  or  in  other  words,  that  the  patient  may  per- 
manently recover. 

Treattnent. — As  has  been  clearly  indicated,  the  statements  I  have 
already  made  regarding  the  classes  of  patients  subject  to  these  attacks, 
and    the    influence    of   certain   habits   and  pathological   changes  in   per- 


TKEATMENT.  827 

petuating  them,  lead  directly  to  the  inference  that  the  painful  paroxysms 
which  constitute  the  atfection  we  are  considering-  ara  symptomatic,  i.  e., 
not  founded  necessarily  upon  any  fixed  morbid  conditions  of  the  heart  or 
structural  changes.  The  treatment  which  demands  the  careful  considera- 
tion of  the  physician  is  to  be  viewed  in  two  relations:  first,  in  relation  to 
the  means  most  efficient  for  the  speedy  relief  of  the  patient  during  the 
paroxysms;  second,  the  removal  of  the  causes,  when  possible,  including 
all  habits  and  circumstances  which  would  favor  a  return  of  the  paroxysms. 
The  one  has  for  its  object  temporary  relief,  the  other  permanently  secur- 
ing the  patient  exemption  from  a  repetition  of  the  paroxysms  of  suffering. 
At  the  present  period  of  time,  it  is  quite  common  to  relieve  the  yjatient 
when  the  physician  is  called  in  the  midst  of  a  paroxysm,  by  immediate 
resort  to  the  liypodermic  injection  of  morphia.  There  is  no  doubt  but  so 
far  as  securing  the  temporary  relief  is  concerned  the  hypodermic  injection 
constitutes  one  of  the  most  speedy  methods.  It  is  subject,  however,  to 
two  serious  objections.  The  first  is  the  danger  which  is  involved, 
especially  in  such  cases  as  are  accompanied  by  structural  changes  in  the 
heart,  of  a  character  that  greatly  weakens  or  impairs  its  systolic  action. 
AVhen  the  muscular  force  of  the  heart  is  much  impaired,  especially  by 
fatty  degeneration,  the  sudden  induction  of  the  narcotizing  effect  of 
morphia  is  liable  to  be  followed  by  fatal  stupor.  Especially  is  this  true 
if  the  patient  is  unduly  sensitive  to  the  effects  of  opiates,  or  if  the  point 
of  the  syringe  pisses  in  such  a  direction  that  it  enters  some  small  blood 
vessel,  and  consequently  places  the  remedy  at  once  in  the  blood  and 
develops  its  effects  with  extreme  rapidity.  There  is  some  risk  that  it 
may  speedily  suspend  the  sensibility  and  action  of  the  cardiac  nerves, 
and  lead  to  immediate  aeath.  At  least  two  cases  of  death  under  such 
circumstances  have  coino  within  the  circle  of  my  own  observation.  This 
danger  should  certainly  make  you  very  cautious  about  the  quantity  of 
morphine  introduced  in  tliis  sudden  manner.  If  it  is  resorted  to  at  all,  it 
is  much  better  that  the  dose  be  too  small  for  full  relief,  necessitating  its 
repetition  in  half  an  hour  or  hour,  rather  than  to  risk  the  sudden  develop- 
ment of  the  effects  of  a  full  dose  at  once,  with  perhaps  an  imperfect 
knowledge  of  the  ability  of  the  heart  to  carry  on  the  circulation.  And  in 
addition  to  this,  many  patients  who  have  no  danger  from  structural  dis- 
ease of  the  heart,  nevertheless  are  uniformly  susceptible  to  secondary 
nausea  and  severe  sickness  for  many  hours  whenever  morphine  or  prep- 
arations of  opium  are  introduced  sufficient  to  produce  even  a  moderate 
anodyne  effect,  requiring  sometimes  one  or  two  days  for  the  stomach  to 
regain  its  ability  to  retain  nourishment.  The  patient  is  thereby  caused 
more  suffering  in  the  aggregate  than  he  would  have  endured  during  the 
brief  period  of  the  duration  of  the  paroxysm  if  left  alone.  The  second 
danger  arising  from  the  use  of  hypodermic  injections  of  morphine  consists 
in  its  tendency  to  speedily  create  the  necessity  for  its  repetition  at  shorter 
intervals.  For,  in  almost  all  cases,  while  the  direct  effects  of  the  mor- 
phine may  relieve  the  patient  at  once,  its  frequent  repetition  so  impairs 
the  tone  of  the  nervous  system  as  to  greatly  increase  that  feeling  of  ex- 
haustion which  alarms  the  patient,  and  causes  him  to  become  clamorous 
for  its  repetition  on  every  threatened  recurrence  of  the  paroxysm.  And 
hence  it  requires  but  a  few  months  for  the  patient  to  become  thoroughly 
habituated  to  the  effects  of  the  morphine  and  unwilling  to  be  without 
it  even  for  a  day.  It  has  the  effect  of  leaving  him  with  a  sense  of  de- 
pression, goneness  and  weakness  that  makes  him  ex3eedingly  uneasy 
until  the  anodyne  effects  of  the  remedy  are  renewed.  That  I  am  not 
giving  you  useless  caution,  is  certain  from  the  fact  that  I  have  seen  cases 


828  ANGINA    PECTOKIS. 

tn  wh'ch  the  resort  to  hypodermic  injections  in  this  and  similar  nervous 
affections  has  led  to  the  most  serious  disturbances  on  account  of  the  de- 
velopment of  a  strong  opium  habit.  In  one  of  these  cases  it  was  actually- 
carried  to  such  an  extent  that  the  patient  insisted  on  having  one  hypo- 
dermic injection  in  the  morning  and  one  in  the  evening  every  day,  and 
it  vpas  not  discontinued  until  mental  derangement  finaliy  ensued,  and 
it  became  necessary  to  remove  the  patient  to  an  asylum  for  the  insane. 
Therefore,  if  other  remedies  are  a  few  minutes  less  speedy  in  their  effects 
and  less  perfect  in  the  direct  relief  they  afford,  it  is  better  to  use  them 
and  in  the  end,  much  to  the  advantage  of  the  patient  rather  than  to  resort 
so  readily  to  the  rapid  introduction  of  morphine.  As  the  gouty  diathesis 
is  not  an  infrequent  accompaniment  and  in  fact  a  predisposing  cause  of 
paroxysms  of  this  disease,  in  such  cases  there  is  perhaps  no  remedy  that 
can  be  administered  by  the  mouth,  that  will  afford  more  speedy  relief 
than  a  combination  of  the  acetated  tincture  of  opium  and  the  wine  of 
colchicum  root,  equal  parts,  of  which  ten  to  twenty  minims  may  be  given 
in  a  little  sweetened  water,  and  repeated  every  thirty  minutes  till  the 
patient  is  relieved.  But  if  instead  of  the  gouty  diathesis  with  which  you 
have  to  deal,  the  patient  is  one  of  thosB  who,  from  much  confinement  in- 
doors or  the  habitual  use  of  fermented  drinks,  has  accumulated  a  large 
amount  of  fatty  tissue  with  some  degree  of  fatty  impairment  of  the  heart, 
one  of  the  combinations  most  likely  to  relieve  him  from  the  distress 
of  the  paroxysm,  is  that  of  the  tincture  of  digitalis,  one  part,  and  what 
is  veiy  generally  known  as  Hoffman's  anodyne,  two  parts,  of  which 
from  twenty  to  thirty  minims  may  be  given  and  repeated  every  half  hour 
till  the  patient  is  relieved.  Quite  a  variety  of  antispasmodic,  slightly 
stimulant  and  anaesthetic  remedies,  may  be  used  for  the  relief  of  the 
paroxysms  according  to  the  circumstances  and  the  convenience  of  the 
physician  and  his  patient.  In  addition  to  the  internal  remedies,  it  will 
generally  help  to  afford  relief  if  a  strong  mustard  sinapism  is  applied 
to  the  space  between  the  left  scapula  and  the  spinal  column,  and  another 
directly  opposite  on  the  left  side  of  the  chest,  allowing  them  to  remain 
until  the  skin  is  red,  but  not  till  blisters  are  actually  raised,  then  remov- 
ing them  and  substituting  in  their  place  cloths  wrung  out  of  water  as 
warm  as  can  be  comfortably  borne.  But  in  many  instances  when  the 
physician  is  called  to  these  patients,  the  time  M'hich  elapses  before  his 
arrival  will  be  such  that  the  paroxysm  has  already  disappeared  and  he 
fi.ids  his  patient  comparatively  comfortable.  The  question  then  is  how 
best  to  accomplish  the  second  object  o."  the  treatment,  that  is,  to  prevent  a 
recurrence  of  the  paroxysms  in  the  future.  It  is  entirely  obvious  to  your 
own  mir)d,  from  what  I  have  said  of  the  patients  themselves  and  the 
variety  of  causes  to  which  they  may  have  been  subjected,  that  no  one 
remedy  or  combination  of  remedies  can  be  recommended  for  this  purpose. 
Here  the  great  object  to  be  accomplished  is  to  ascertain  whatever  errors 
exist  in  the  modes  of  life,  habits  of  eating,  drinking,  exercise  and  dress, 
that  would  have  a  tendency  to  predispose  to,  and  provoke  these  attacks; 
and  to  correct  all  such  habits  whatever  they  may  be,  and  thereby  remove 
the  ordinary  causes  of  the  disease.  If  the  patients  are  debilitated,  the 
bowels  inactive  and  the  digestion  enfeebled,  it  is  highly  proper  to  recom- 
mend such  course  of  treatment  as  is  calculated  to  obviate  these  several 
coincident  conditions.  Whatever  will  improve  the  general  tone  of  health 
and  render  the  processes  and  functions  of  the  human  body  more  natural, 
healthful  and  vigorous,  will  strengthen  and  tend  to  prot'ect  the  patient 
from  a  recurrence  of  the  paroxysms  of  this  dreaded  affection.  It  is  par- 
ticularly desirable  to  have  the  patient  avoid  the  too  free  use  of  strong  tea 


EXOPHTHALMIC    GOITRE.  829 

and  coffee,  and  to  rigidly  abstain  from  all  alcoholic  beverages,  either  fer- 
mented or  distilled,  and  to  adopt  such  regular,  moderate  and  daily  out- 
door exercise  by  riding  or  moderate  walking,  as  may  be  best  suited  to 
sustain  the  strength  of  the  patient,  promote  the  oxygenation  and  decar- 
bonization  of  his  blood,  and  to  sustain  the  functions  of  digestion  and  assimi- 
lation. At  the  same  time  it  is  quite  necessary  to  give  immediate  attention 
also  to  the  mental  habits  of  the  patient.  All  excessive  mental  application, 
either  in  studying,  writing  or  any  other  process  must  be  avoided.  The 
occupation  of  the  mind,  like  that  of  the  body,  should  be  sufficient  to  en- 
gage the  attention,  relieve  the  monotony  of  idleness,  give  the  content  that 
is  derived  from  doing  a  little  something  every  day,  and  yet  there  should 
be  a  careful  avoidance  of  intensity  of  mental  application  or  the  entering 
upon  such  business  as  will  bring  anxiety  of  mind  in  regard  to  results. 


LECTUEE    LXXXVII. 


Exophthalmic  Goitre— Fatty  Degeneration  of  the  Heart-  Aneurism, 

GENTIjEMEN:  The  assemblage  of  symptoms  which  has  given  origin 
to  the  name,  exophthalmic  goitre  are  mot  with  not  very  frequently  in 
ordinary  practice,  but  they  are  sufficiently  characteristic  to  merit  separate 
consideration.  As  the  words  exophthahnic  goitre  would  seem  to  imply,  the 
three  prominent  symptoms  characterizing  all  the  cases  belonging  to  this 
group,  are  enlargement  of  the  thyroid  gland^  prominence  of  the  eyeballs, 
and  extraordinary  or  unusual  action  of  the  heart  and  the  larger  blood 
vessels,  embracing  particularly  the  aorta,  subclavian  and  carotid  arteries. 
It  is  most  frequently  met  with  in  females,  though  not  exclusively  so. 
Much  the  larger  number  of  cases  occur  between  fifteen  and  thirty  years  of 
age;  in  most  instances  the  symptoms  are  developed  slowly,  and  generally 
the  first  to  attract  the  attention  of  the  patient  is  an  unusual  excitability  of 
the  heart.  This  causes  throbbing  or  unusual  pulsative  action  of  the  heart, 
extending  to  the  vessels  of  the  neck,  in  a  less  degree  to  the  head,  often  pre- 
venting the  patient  for  a  time,  if  lying  down  at  night,  from  going  to  sleep, 
and  accompanied  by  more  or  less  feeling  of  choking  or  tightness  around 
the  neck  and  upper  portion  of  the  chest;  soon  it  is  observed  that  the 
thyroid  gland  is  decidedly  larger  than  natural,  giving  the  usual  promi- 
nence to  that  part  of  the  neck.  This  enlargement  of  the  gland  differs 
from  that  of  ordinary  goitre  in  being  softer,  more  compressible,  and  being- 
accompanied  by  a  direct,  plain,  pulsation  in  the  vessels  of  the  gland. 
Usually  in  two  or  three  months  after  the  beginning  of  the  cardiac  ex- 
citability and  the  vessels  of  the  neck  become  troublesome,  it  begins  to  be 
observed  that  the  eyeballs  are  more  prominent,  or  project  forward  more 
than  natural.  Generally  there  is  at  this  time  also  more  or  less  pain  in  the 
frontal  region  of  the  head,  though  not  always;  in  some  cases  there  is  diz- 
ziness, sometimes  ringing  or  noises  in  the  head  and  ears  and  a  disagree- 
able pulsation  in  the  carotid  and  temporal  arteries.  When  these  patients 
lay  the  head  down  at  night  they  are  constantly  annoyed  by  the  un- 
usual pulsation  and  deterred  from  sleep.  In  young  females,  there  is  fre- 
quently an  additional  complication  during  the  progress  of  the  disease  in 
the  suppression   of  the  menses.      This   does   not   always    occur,   but   in 


830  EXOPHTHALMIC    GOITRE. 

several  instances  coinirifr  under  my  observation,  they  have  become  en- 
tirely suppressed  during  the  progress  of  the  disease,  adding  much  to  the 
anxiety  of  the  patients  and  their  friends,  and  sometimes  leading  to  altera- 
tions in  the  blood,  indicated  by  the  old  name  chlorosis.  If  no  measures 
are  taken  to  interfere  with  the  disease,  the  eyeballs  become  remarkably 
prominent,  giving  a  peculiar  expression  to  the  face,  the  thyroid  becomes 
so  large  as  to  make  a  decided  tumor  upon  each  side  of  the  neck,  and  in 
some  cases  extending  across  from  one  lobe  to  the  other,  and  the  vessels 
entering  into  it  so  much  enlarged  and  pulsating,  that  it  gives  them  many 
of  the  qualities  of  a  large  anastomosing  aneurism.  The  vessels  are  capable 
of  being  emptied  to  a  considerable  degree,  and  the  swelling  reduced  in 
size  by  steady  pressure;  but  they  fill  again  with  a  plain  pulsating  motion 
of  the  blood,  and  fully  distend  the  tumor  as  soon  as  the  pressure  is  re- 
moved. It  is  in  this  way  that  you  can  distinguish  these  enlargements 
of  the  thyroid  from  ordinary  simple  goitrous  tumors  or  hypertrophy  of 
the  th^T-ruid  gland.  The  increased  size  of  the  thyroid,  and  consequent 
greater  feeling  of  embarrassment  about  the  neck,  is  accompanied  by  a 
corresponding  increase  in  the  excitability  of  the  heart,  with  a  sense  of 
fullness  or  vertigo  in  the  head,  which  sooner  or  later  so  interferes  with  the 
movements  of  the  patient  as  to  cause  almost  entire  confinement  to  the 
house,  but  seldom  to  the  bed.  There  is  usually  no  febrile  heat  accom- 
panying any  part  of  the  progress  of  these  cases,  unless  from  the  acci- 
dental supervention  of  local  imflamtnatory  action,  not  constituting  a  part 
of  the  disease  proper.  Physical  examination  by  percussion  usually  elicits 
only  negative  results,  there  being  no  increased  dullness  over  any  part  of 
the  chest.  Aascultation,  however,  pretty  uniformly  reveals  a  blowing  or 
bellows  murmur,  both  over  the  heart  and  over  the  course  of  the  aorta  up 
to  the  subclavian  and  carotid  arteries,  and  frequently  it  is  quite  as  loud 
and  distinct  over  the  vessels  last  named  at  the  lower  part  of  the  neck  as 
over  the  heart  itself.  The  bellows  murmur  heard  in  these  cases  is  free 
from  roughness  and  harshness.  It  has  none  of  the  rough,  harsh  quality  be- 
longing to  the  bellows  murmer  caused  by  valvular  disease,  and  particularly 
by  the  indurated  condition  of  the  mitral  valve  so  frequently  resulting 
Irom  acute  rheumatic  attacks.  ]f  the  disease  continues  for  a  long  period 
of  time,  the  over-excitement  of  the  heart  leads  in  many  cases  to  dilatation 
of  its  cavities  with  thinning  of  their  walls.  The  disease  has  no  definite  tend- 
ency to  a  self-limited  duration,  although  in  a  few  instances  of  the  milder 
grade,  spontaneous  recoveries  have  taken  place;  yet  the  great  majority 
of  cases  are  liable  to  persist  through  an  indefinite  period  of  time,  and  in  a 
considerable  proportion  of  them  to  develop  such  structural  changes  as  to 
finally  induce  a  fatal  result. 

Causes. — The  causes  which  give  rise  to  this  form  of  disease  are  so  obscure 
as  to  have  hitherto  eluded  any  certain  identification. 

Pathological  Changes.—  In  such  cases  as  have  terminated  fatally,  the 
heart  and  larger  vessels  have  presented  no  uniformity  in  their  morbid 
conditions.  When  the  disease  has  existed  for  a  number  of  years  before 
the  fatal  result,  the  cavities  of  the  heart  have  been  found  much  dilated, 
the  coats  of  the  aorta  affected  by  atheromatous  degeneration,  and  the  ves- 
sels of  the  thyroid  greatly  enlarged,  as  well  as  those  in  the  posterior  part 
of  the  orbit  of  the  eye.  Some  observers  have  detected  changes  of  a  mor- 
bid character  in  the  cervical  gang.ia  of  the  sympathetic  nerve.  The  the- 
ory that  the  disease  has  its  origin  in  a  morbid  condition  of  the  vaso-motor 
nerves,  or  that  portion  of  the  nervous  system  ramifying  in  the  coats  of  the 
vessels  of  the  heart  and  of  the  large  arteries  in  the  chest  and  neck,  influ- 
encing their  functions  in  such  a  way  as  to   favor  dilatation  of  the  vessels 


TKEATMENT.  831 

and  a  yielding  to  the  pressure  of  blood  in  them,  coincidently  with  an  in- 
crease of  the  excitabilit}',  is  as  plausible  as  any  that  has  yet  been  proposed. 
But  what  particular  influences  are  operating  in  most  cases  to  induce  such 
a  change  in  the  nerves,  and  consequent  calibre  of  the  vessels,  is  not  appar- 
ent; clinical  study  having  detected  no  uniformity  in  the  influences  that 
are  traced  as  operating  upon  different  patients  sufficient  to  explain  such 
results. 

Treatment. — The  treatment  in  these  oases,  when  commenced  early, 
and  pursued  with  a  degree  of  patience  and  judiciousness  will  often  re- 
sult in  recovery  of  the  patient.  But  it  requires  a  considerable  length  of  time 
and  judicious  adjustment  of  remedial  agents,  in  connection  with  the  hy- 
gienic management  of  the  patient,  to  afford  any  chance  of  so  favorable 
a  result.  The  primary  object  in  the  treatment  consists  in  such  a  reo-ula- 
tion  of  the  heart's  action,  as  to  lessen  the  morbid  excitability  of  the  ves- 
sels and  reduce  the  flow  of  blood  through  them  more  nearly  to  the  natural 
standard  of  quantity  and  frequency;  in  other  words  to  bring  to  bear  upon 
the  heart  and  larger  vessels  such  a  sedative  influence  as  will  hold  the 
cardiac  and  vascular  excitability  in  check  steadily  through  a  considerable 
period  of  time.  My  own  experience  has  led  me  to  place  more  reliance 
upon  a  combination,  or  at  least,  coincident  use  of  digitalis,  Scutellaria  and 
ergot,  for  the  accomplishment  of  this  purpose,  than  upon  any  other  reme- 
dies. Several  cases  that  have  come  under  my  care  within  the  last  few 
years  have  been  greatly  benefited  by  these  agents,  given  in  such  doses 
and  with  such  degrees  of  frequency  as  to  develop  the  slowing  influence  of 
the  digitalis  upon  the  circulation,  together  with  the  tonic  or  contracting 
effect  of  the  ergot  upon  the  vascular  system.  If  the  bowels  are  inactive,: 
suitable  remedies  should  be  prescribed  for  their  regulation.  If  the  kid- 
neys fail  to  secrete  the  usual  amount  of  urine,  diuretics  should  be  added. 
Attention  should  be  give  n  to  the  skin,  and  if  inclined  to  be  dry  or  defi- 
cient in  eliminations,  it  should  be  subjected  two  or  three  times  in  the  week 
to  a  warm  bath,  followed  by  frictions  of  flannel  and  the  constant  wear- 
ing of  flannels  next  to  the  skin  to  protect  the  surface  from  sudden  atmos- 
pheric changes,  and  keep  the  eliminations  more  uniform.  The  diet  should 
be  so  regulated  as  to  afford  the  patient  sufficient  plain,  easily  digestible 
food  for  a  good  degree  of  nutrition,  and  yet,  all  stimulating,  indigestible 
materials  should  be  carefully  excluded.  The  regulation  of  exercise  is  also 
a  matter  of  much  importance.  It  is  desirable  that  patients  laboring  under 
this  affection  should  have  invigorating  outside  air,  but  it  is  better  that 
they  obtain  this  by  riding  or  by  frequent  short  walks,  than  by  any  more 
protracted  and  severe  exertion.  Indeed,  the  latter  should  be  carefully 
avoided.  The  patients  should  be  encouraged  to  take  much  rest,  and  exer- 
cise but  a  short  period  of  time  continuously,  either  in-doorsor  out,  and  to 
so  regulate  their  business  and  movements  as  to  favor  quietude  of  the  cir- 
culation, and  as  much  freedom  from  excitement  as  possible.  If  the  men- 
strual flow  has  either  become  scanty  and  pale,  or  interrupted  altogether, 
this  should  not  be  entirely  neglected  in  adjusting  the  treatment  of  the 
patient-.  In  one  instance  recently  under  my  care,  in  which  the  menses 
were  suppressed,  the  patient  appeared  to  derive  much  benefit  from  taking 
in  addition  to  the  digitalis,  Scutellaria  and  ergot,  a  pill  composed  of  thir- 
teen centigrammes  (gr.  ii)  of  gum  guaiac,  six  centigrammes  (gr.  i)  of  sul- 
phate of  iron,  three  centigrammes  (gr.  -^)  of  pulverized  aloes,  and  two  cen- 
tigrammes (gr.  -J)  of  blue  mass,  of  which  one  pill  was  taken  after  each 
meal  time.  The  guaiac  was  given  to  encourage  a  return  of  the  menstrual 
flow  and  to  act  as  a  general  organic  tonic.  Another  remedy,  however, 
which  is  perhaps  more  generally  recommended  and  used  than  any  I  have 


832  PATTY    DEGENERATION    OF    HEART. 

named,  is  the  application  of  electricity,  or  electro-magnetism.  I  have  cer- 
tainly seen  a  number  of  patients  greatly  benefited,  and  two  who  appar- 
ently recovered,  chiefly  through  the  persistent  use  of  electro-magnetism. 
The  mode  of  application  was  to  place  the  positive  pole  of  a  battery  to  the 
nape  of  the  neck, or  immediately  below  the  occipital  region,  and  the  other  at 
different  points  from  the  lower  part  of  the  neck  to  the  ensiform  cartilage^ 
in  making  the  currents  gentle,  simply  sufficient  for  the  patient  to  feel 
their  influence,  and  avoiding  all  shocks  or  severe  disturbance,  and  con- 
tinuing the  electric  influence  from  ten  to  fifteen  minutes  each  day. 
Sometimes  the  mode  of  application  was  varied,  the  patient  taking  one  pole 
in  each  hand,  and  allowing  the  current  to  pass  in  the  usual  way  from  one 
hand,  through  the  trunk  of  the  body  to  the  other.  More  frequently,  how- 
ever, when  extending  the  application  a  distance  from  the  back  of  the 
neck  and  the  region  of  the  sternum,  I  have  kept  one  pole  below  the  occi- 
put in  the  upper  part  of  the  neck  and  placed  tlie  other  at  the  bottom  of 
one  of  the  feet;  and  in  a  few  instances  I  have  varied  the  use  of  the  elec- 
tricity in  such  a  way  as  to  charge  the  patient's  system  with  the  electric 
fluid  by  insulating  her  upon  an  insulating  stool.  To  make  these  or  any 
other  remedies  effectual  in  the  treatment  of  this  form  of  disease,  each 
patient  must  exercise  patience  and  perseverance,  both  in  the  application 
of  the  remedies  and  in  the  general  hygienic  management,  as  I  have  al- 
ready indicated. 

,  Fatty  Degeneration  of  the  Heart. — I  shall  detain  you  only  for  a  few 
words  in  regard  to  fatty  degeneration  of  the  heart.  It  is  a  condition 
which  usually  results  from  the  slow  and  long  continued  defective  oxygena- 
tion and  decarbonization  of  the  blood.  When  once  fairly  established  it 
creates  that  weakness  of  cardiac  action  which  greatly  embarrasses  the 
patient  whenever  attempting  to  take  active  exercise.  Most  patients  sub- 
ject to  this  condition  of  the  heart,  whenever  quiet,  either  in  the  recumbent 
position  or  in  the  sitting  posture,  enough  inclined  to  be  at  ease,  are  hardly 
conscious  of  the  existence  of  any  embarrassment.  But  they  have  no 
power  of  endurance.  A  very  moderate  attempt  at  exercise,  as  inordinary 
walking,  particularly  ascending  hills  or  going  up-stairs,  causes  extreme 
rapidity  of  the  circulatory  movements,  accompanied  by  a  sense  of  oppres- 
sion, or  weakness  across  the  chest,  and  such  a  degree  of  mental  anxiety 
as  usually  induces  the  patient  speedily  to  seek  a  position  of  rest.  A  soft, 
weak,  slightly  accelerated  pulse,  diminution  of  the  impulse  of  the  heart  in 
the  cardiac  region,  shortness  of  the  systolic  action,  and  the  inability  to 
exercise,  constitute  the  symptoms  most  characteristic  of  this  form  of 
trouble.  The  best  mode  for  its  management  consists  in  inducing  the  pa- 
tient to  so  regulate  his  diet  as  to  avoid  all  indigestible  articles,  and  yet 
secure  a  sufficient  supply'  of  food  to  afford  a  fair  degree  of  nutrition;  to 
take  food  at  such  times  in  the  day  that  digestion  is  always  completed  be- 
fore the  time  for  sleep  at  night,  and  to  avoid  all  severe  physical  exertion. 
Yet  the  patient  should  obtain,  either  by  riding,  or  very  short  and  quiet 
walks,  more  or  less  of  out-door  exercise  daily.  Patients  laboring  under 
this  condition  of  the  heart,  when  not  subject  to  paroxysms  of  angina  pec- 
toris, or  any  other  special  complication,  are  nevertheless  easily  tired,  and 
readily  exhibit  a  relaxed  condition  of  the  skin,  with  perspiration  sufficient 
to  keep  the  surface  damp,  and  sometimes  even  to  dampen  the  underclothes, 
and  of  course  whenever  exposed  to  currents  of  air  feeling  at  once  chilly, 
and  morbidly  sensitive  to  atmospheric  changes.  They  not  only  become 
weary  from  trifling  exertion,  and  short  of  breath,  but  they  are  subject  to 
a  great  sense  of  weakness  across  the  chest,  and  anxiety,  as  though  stop- 
page of  the  heart's  action  was  immediately  pending.     This  impression  is 


TREATMENT.  833 

added  to  by  the  occurrence,  with  many  of  the  patients,  of  irregularity  in 
the  movements  of  the  heart,  consisting  of  two,  three  or  four  systolic  beats 
or  contractions  in  quick  succession,  then  stopping  perhaps  long  enough  to 
omit  one  beat,  and  resuming  anew,  with  a  short  and  distinct  interval; 
then  a  variation  to  the  irregular,  rapid,  systolic  movement,  and  then  a  re- 
turn as  before  to  a  slower,  and  sometimes  intermitting  condition.  Tiie 
heart  and  the  pulse  thus  become  weak,  variable,  and  sometimes  intermit- 
ting. 

Treatment. — The  treatment  of  this  class  of  cases  consists  mainly  in  the 
proper  regulation  of  the  patient's  exercise,  diet,  habits,  mental  and  physical, 
in  such  manner  as  to  avoid,  as  far  as  possible,  undue  excitement,  and  too 
great  an  amount  either  of  mental  application  or  of  mental  worry  and 
fatigue.  The  anatomical  changes  resulting  from  fatty  degeneration  are 
in  most  cases  a  slow  atrophy  or  thinning  of  the  walls  of  the  heart,  with 
corresponding  enlargement  or  dilatation  of  the  ventricles.  It  is  this  kind 
of  disease  of  the  heart  that  renders  patients  most  liable  to  sudden  death. 
For  as  the  muscular  structure  becomes  more  and  more  degenerated,  and 
consequently  has  less  and  less  contractile  power,  with  some  degree  of  dil- 
atation of  the  ventricles,  it  arrives  at  a  stage  of  weakness,  when  at  the 
moment  of  some  moderate  degree  of  exertion,  as  in  rising  from  bed  or  in 
taking  up  some  moderate  weight  and  carrying  it  a  few  steps,  the  heart 
cavities  fill  with  blood,  their  walls  fail  to  contract,  the  heart  stops  in  dia- 
stole, and  the  patient  dies  instantly,  exhibiting  paleness  of  features,  or  an 
almost  bloodless  condition  of  countenance  and  conscious  only  of  a  reeling 
in  the  head  and  dimness  of  vision  as  they  sink  to  the  floor.  As  the  heart 
first  ceases  to  act  these  cases  have  been  called  death  by  syncope.  As  I 
have  just  said,  the  leading  objects  in  the  treatment  of  these  cases  are  to 
regulate  properly  the  patient's  habits,  mental  and  physical,  and  to  admin- 
ister such  remedies  as  will  increase  the  force  and  lessen  the  frequency  of 
the  cardiac  action  and  arrest  further  molecular  degeneration.  Digitalis,  cac- 
tus and  convallaria  are  perhaps  the  three  remedies  on  which  we  can  rely 
more  than  on  any  others  to  increase  the  force,  lessen  the  frequency  and 
thereby  render  more  efficient  the  circulation  of  the  blood.  The  doses  of 
these  remedies  must  be  apportioned  to  the  age  and  condition  of  the  pa- 
tient, in  beginning  with  moderate  doses,  and  gradually  increasing  until 
the  pulse  becomes  slower  and  more  full,  then  recede  a  trifle,  aiming  to 
continue  the  influence  without  causing  it  to  become  exaggerated.  In  cases 
accompanied  by  much  general  deposit  of  fat  throughout  the  system,  I  have 
thought  that  the  patients  derived  positive  benefit  by  taking  irom  three  to 
six  decigrams  (gr.  v  to  x)  of  the  chlorate  of  potassium  in  dilute  solution 
with  mucilage  of  gum  arable  and  water  after  each  meal.  The  increase  of 
the  chlorine  salt  in  the  blood,  when  thus  administered,  I  have  reason  to 
think  is  capable  of  increasing  the  amount  of  oxygen  taken  up  from  the  air 
cells  of  the  lungs,  and  consequently  of  increasing  the  oxygenation  and  de- 
carbonization  of  the  blood,  and  in  the  same  proportion  checking  the  prog- 
ress of  the  tissue  degeneration.  Consequently,  when  the  stomach  and 
bowels  will  tolerate  moderate  doses  of  the  chlorate,  administered  in  this 
manner  for  a  considerable  period  of  time,  it  is  capable  of  doing  much  good. 
If  the  appetite  is  poor,  adding  a  few  drops  of  hydrochloric  acid  to  each 
dose  of  the  solution  of  chlorate  of  potassium  will  frequently  improve  the 
appetite  and  render  the  digestion  of  food  more  active  and  complete. 

Aneurisms. — Aneurisms  are  usually  classed  with  surgical  diseases,  and 
treated  of  fully  in  surgical  works;  and  yet  the  management  of  aneurisms 
located  upon  the  heart  or  aorta  are  usually  entirely  beyond  remedy  by 
surgical   means,  and  are  consequently  left  generally  for  the  management 

53 


834  ANEUEISMS. 

or  palliation  of  the  ordinary  medical  attendant.  You  will,  therefore,  some- 
times be  required  to  take  charge  of,  and  endeavor  to  counteract  the  prog- 
ress of  this  class  of  aifections.  For  a  full  discussion  of  aneurisms  of  the 
heart  and  aorta,  I  must  refer  you  to  surgical  works,  and  will  only  detain 
you  for  the  purpose  of  suggesting  a  few  simple  rules  in  regard  to  the  best 
modes  for  their  management.  When  fully  formed,  there  is  but  little  hope 
of  cure.  A  true  aneurismal  tumor  or  dilatation  of  any  portion  of  the  walls 
of  the  heart,  of  the  coats  of  the  aorta  or  larger  blood  vessels  connected 
with  it,  neither  admits  of  being  treated  by  surgical  operation  on  the  one 
hand,  nor,  on  the  other  hand,  are  there  known  any  means  or  agencies  of  a 
medicinal  character  capable  of  contracting  these  dilated  pouches  or  an- 
eurismal sacs,  and  restoring  them  to  their  natural  condition.  If  you  coag- 
ulate the  blood  in  them  by  astringent  injections  or  otherwise,  you  incur 
the  great  risk  of  having  portions  of  the  coagulum  carried  as  emboli  into 
the  vessels  of  the  brain  or  lungs  and  producing  speedy  death.  There  is 
also  risk  of  ulceration  at  the  point  of  puncture,  and  fatal  hemorrhage.  Yet 
judicious  management  of  such  cases  may  greatly  increase  the  strength  oi 
the  patient,  retard  the  natural  increase  in  size  of  the  aneurism,  and  con- 
sequently materially  prolong  the  life  of  the  patient.  To  accomplish  these' 
results  all  patients  afflicted  with  aneurism  of  the  heart  or  great  vessels  in 
the  chest  should  be  instructed  to  avoid  all  active  exercise,  sudden  exertion. 
or  active  manual  labor,  and  yet  they  should  be  encouraged  to  take  a  mod- 
erate amount  of  quiet  out-door  exercise  either  by  riding  or  moderate  walk- 
ing every  day.  To  render  life  useful,  occupy  the  attention,  and  thereby 
relieve  them  from  misanthropy  and  continual  dread,  they  may  be  en- 
couraged to  engage  every  day  m  some  light  occupation,  or  attending  tc 
any  business  that  can  be  done  by  riding,  and  yet  the  mind  should  not  be 
over-tasked  or  rendered  anxious  on  account  of  pecuniary  results.  The 
clothing  should  be  strictly  adjusted  for  comfort  to  the  seasons  of  the  year 
and  climate,  attention  should  be  given  to  all  the  various  functions,  with  a 
view  to  keeping  the  digestive  organs  in  as  perfect  order  as  possible,  and 
the  Secretions  and  eliminations  at  their  natural  standard  of  activity.  In 
addition  to  this,  the  direct  treatment  on  account  of  the  aneurism  should 
consist  in  the  administration  of  such  remedies  as  will  lessen  the  force  and 
frequency  of  the  current  of  blood,  filling  the  aneurismal  tumor,  as  far  as  it 
can  be  done,  without  seriously  debilitating  the  patient.  For  this  purpose 
the  use  of  the  well-known  arterial  sedatives  judiciously  adjusted,  consti- 
tute our  greatest  reliance.  In  former  generations,  copious  bleeding  was 
resorted  to  with  the  idea  of  lessening  the  fullness  of  the  vessels  and  con- 
sequently encouraging  contraction  or  lessening  of  the  aneurismal  sac. 
This,  however,  is  productive  of  no  benefit  except  in  some  rare  cases,  where 
the  general  condition  of  the  patient  is  one  of  actual  plethora.  In  such  a 
case  the  abstraction  of  just  enough  blood,  once  or  twice  in  the  year,  to  re- 
move any  excess  or  positive  plethoric  condition  might  be  desirable.  Few 
patients,  however,  laboring  under  aneurismal  disease,  possess  any  such 
plethoric  condition.  But  the  doses  of  digitalis,  veratrum  viride,  aconite, 
gelseminum  and  perhaps  cotivallaria,  can  usually  be  so  adjusted  as  to  suit 
almost  all  classes  of  patients,  and  keep  sufficient  sedative  influence  upon 
the  heart,  to  greatly  promote  the  comfort  of  the  patient  ajid  prolong 
his  life.  When  the  habits  or  temperament  of  the  patient  has  been  such  as 
to  encourage  fatty  or  atheromatous  degeneration  of  the  walls  of  the  vessels, 
three  decigrams  (gr.  v)  of  the  iodide,  or  six  decigrams  (gr.  x)  of  the 
chlorate  of  potassium,  given  after  each  meal  time,  in  a  wine  glass  full  of 
sweetened  water  or  of  mucilage,  will,  in  some  cases  at  least,  do  much  good. 


DERANGEMENTS   OF   DIGESTION.  835 


LECTUEE    LXXXVIII. 

Functional  Derangements  of  the  Stomach  and  Organs  of  Digestion— Their  N'ature  and  Treatment. 

GENTLEMEN:  The  words  dyspepsia,  indig'estion  and  constipation, 
thoug'h  in  very  common  use  to  indicate  a  class  of  functional  disorders 
of  the  stomach  and  alimentary  canal,  nevertheless  indicate  no  one  special 
patholo^^ical  condition.  They  are  derived  from  the  prominent  symptoms 
rather  than  from  any  particular  relation  to  the  morbid  conditions  on 
which  these  symptoms  may  depend.  As  you  perceived  while  listening  to 
the  discussion  of  the  subject  of  gastritis  in  its  various  grades,  indiges- 
tion was  one  of  the  more  prominent  symptoms  accompanying  one  of  the 
forms,  or  grades  of  that  disease.  And  as  we  have  already  discussed  fully 
that  subject,  including  gastric  hyperemia,  and  hypertesthesia,  vve  have 
now  only  to  consider  that  large  and  almost  constantly  recurring  class 
of  cases,  in  which  the  prominent  symptoms  are  imperfect  digestion  of 
food,  arising  from  conditions  independent  of  local  inflammatory  action. 
Leaving  out  of  view  all  grades  of  the  latter,  we  may  still  have  perhaps 
three  distinct  and  recognizable  conditions  of  the  stomach,  more  par- 
ticularly of  the  structures  entering  into  the  composition  of  the  mucous 
membrane,  which,  though  giving  rise  to  the  common  symptoms  of  im- 
perfect digestion  of  food,  accompanied  by  more  or  less  distress  to  the 
patient,  are  essentially  different  in  their  nature,  and  require  different 
methods  of  treatment.  Proper  nerve  sensibility,  the  normal  amount  and 
quality  of  the  gastric  juice,  and  the  proper  muscular  motion  of  the 
stomach,  are  the  three  essential  requisites  for  the  performance  of  healthy 
digestion.  It  follows  then,  that  a  failure  of  either  of  these  three  would 
be  likely  to  derange  the  process,  and  lead  to  imperfect  results,  sufficient 
to  inconvenience  or  distress  the  patient.  A  close  examination  of  patients 
will  enable  you  to  distinguish  cases  depending  upon  each  of  these  three 
derangements  separately,  but  perhaps  more  frequently  cases,  that  depend 
upon  the  coincidence  of  two  of  them  at  the  same  time.  The  coincidence 
of  defective  secretion  of  gastric  juice  with  insufficient  peristaltic  motion 
constitutes  the  most  common  condition  of  ordinary  indigestion,  especially 
in  patients  of  sedentary  habits,  or  who  are  much  confined  by  their  occu- 
pations, in-doors.  The  alterations  of  nerve  sensibility,  as  a  source  of  de- 
rangement of  digestion,  is  of  less  frequent  occurrence,  and  yet,  there  are 
some  cases  depending  upon  this  cause,  and  if  not  recognized,  they  are 
very  liable  to  be  protracted  in  duration  and  exceedingly  troublesome,  both 
to  the  physician  and  patient.  The  alterations  of  nerve  sensibility  maybe 
either  reflex,  as  when  derived  directly  from  morbid  conditions  in  the 
nervous  centers  from  which  the  nerves  concerned  in  the  functions  of  the 
stomach  are  derived,  or  in  the  gastric  nerves  alone.  You  are  aware  that 
in  addition  to  a  supply  of  nervous  filaments  from  the  vaso-motor,  or 
ganglionic  system,  an  important  supply  comes  also  through  branches 
of  the  pneumogastric,  connecting  the  mucous  membrane  of  the  stomach 
directly  with  the  brain,  and  constituting  the  medium  through  which  im- 
pressions may  be  transmitted  from  the  cerebral  centers  to  the  stomach,  or 
the  reverse.  That  conditions  of  the  brain,  as  to  excitability,  or  the  activ- 
ity of  mental  processes,  are  capable  of  radiating  an  influence  through 
the  pneumogastric  nerves  upon  the  secretory  structures  of  the  stomach 
sufficient  to  produce  marked   alterations  in  the  secretions,  both  in  regard 


836  DERANGEMENTS  OF    DIGESTION. 

to  their  quantity  and  quality,  is  easily  illustrated  by  investigating  the 
effects  of  strong  mental  emotions,  passions,  or  even  of  intense  and  con- 
tinuous intellectual  activity,  soon  after  takiiig  food.  Nothing  has  been 
more  fully  determined  than  that  these  conditions  are  extremely  liable  to 
arrest  the  digestion  of  food,  lead  to  its  fermentation,  and  all  the  phenom- 
ena of  a  severe  paroxysm  of  indigestion.  It  is  on  this  account  that  per- 
sons engaged  in  intellectual  pursuits,  including  those  who  are  engaged  as 
accountants  and  book-keepers,  who  are  in  the  habit  of  resorting  to  their 
work  immediately  after  their  meals,  are  so  very  liable,  in  a  few  years  and 
sometimes  in  a  few  months,  to  become  habitually  troubled  with  indiges- 
tion. But  there  is  another  and  different  condition  of  the  gastric  nerves 
which  interferes  with  digestion,  namely,  a  true  hypereesthesia  of  the 
nerve  filaments,  rendering  the  membrane  so  sensitive  that  food,  when 
taken,  will  not  be  retained,  but  rejected  almost  as  soon  as  it  is  swallowed. 
There  is  no  appearance  of  gastric  inflammation,  nor  any  quickening  of  the 
pulse,  tenderness  over  the  epigastrium,  nor  any  of  the  symptoms  thac 
usually  indicate  inflammatory  conditions,  not  even  a  reddened  conditiou 
of  the  tip,  or  edge  of  the  tongue;  but  in  the  absence  of  all  these,  a 
degree  of  morbid  sensitiveness,  the  prompt  rejection  of  food  within  a  very 
few  minutes  after  it  is  received  into  the  stomach  with  hardly  a  conscious- 
ness of  nausea,  and  usually,  in  the  same  condition  in  which  it  was  origi- 
nally taken,  without  having  undergone  either  digestion  or  fermentation. 
Such  cases  are  not  of  frequent  occurrence,  and  yet  I  have  met  with  a  con- 
siderable number  of  them  during  my  clinical  experience.  Such  patients 
take  food  with  apparent  ease,  but  hardly  have  time  to  more  than  tarn 
away  from  the  table  before  they  eject  it  in  the  same  condition  in  which  it 
had  been  swallowed;  and  they  sometimes  feel  a  decided  disposition  to 
turn  back  and  eat  as  much  more.  If  they  do,  it  is  usually  ejected  in  the 
same  manner.  Such  persons,  by  taking  a  very  small  quantity,  will  some- 
times retain  it,  and  it  is  probable  that  they  rarely  reject  all  the  food  they 
take  at  any  one  time,  because  few  of  them  really  become  emaciated.  I 
have  seen  some  instances  where  the  patients  would  thus  promptly  reject  a 
large  part  of  the  food  after  almost  every  meal  for  months,  and  yet  lose 
but  little  flesh,  and  exhibit  but  little  indication  of  anaemia.  I  need  not  re- 
mind you  that  the  vomiting  so  frequently  observed  during  the  early 
months  of  pregnancy,  is  reflex  in  its  character  from  irritability  in  the 
nerves  of  the  uterus  being  transmitted  to  the  nervous  centers,  and  from 
there  reflected  upon  the  stomach.  And  in  many  of  the  acute  diseases, 
particularly  inflammations  involving  the  nervous  centers,  unusual  vomit- 
ings are  among  the  first  symptoms  to  attract  attention. 

The  best  mode  of  managing  reflex  cases  of  indigestion,  is  to  carefully 
ascertain  the  habits  and  influences  affecting  the  patient's  daily  life,  with  a 
view  of  ascertaining  if  possible  the  causes  and  circumstances  which  have 
induced  the  morbid  sensibility  of  the  gastric  nerves.  If  there  is  any  focus 
of  irritation  in  other  viscera  that  reflects  a  disturbing  influence  upon  the 
base  of  the  brain,  or  origin  of  the  pneumogastric  nerves,  and  through 
them  upon  the  stomach,  so  far  as  possible  the  primary  seat  of  irritation 
must  be  relieved  before  permanent  relief  of  the  gastric  symptoms  can  be 
expected.  If  the  source  of  morbid  sensitiveness  is  in  the  brain  itself, 
whether  derived  from  intense  mental  application,  or  indulgence  of  the 
emotions  and  passions,  particularly  during  the  first  stage  of  digestion  or 
soon  after  eating,  or  any  other  cause  capable  of  producing  undue  deter- 
mination of  blood  to  the  brain — these  conditions  must  be  ferreted  out  and 
corrected,  as  a  necessary  part  of  the  treatment,  if  relief  of  any  perma- 
nent character    is  to  be  obtained.     It  is  a  good  rule  for  every  person  to 


TREATMENT.  837 

avoid  engaging  in  intense  mental  work  for  the  first  half  hour  after  taking 
an  ordinary  meal,  and  if  possible  to  spend  that  time  either  out  of  doors 
or  where  they  have  a  full  access  to  fresh  pure  air.  It  is  well  known 
from  physiological  experiments,  that  oxygen  is  taken  up  from  the  air  cells 
of  the  lungs  very  much  more  rapidly  during  the  first  hour  after  taking  an 
ordinary  meal,  while  digestion  is  going  on  actively,  than  at  any  other 
];eriod  of  time.  This  would  indicate  that  the  patient  during  such  time,  or 
the  early  part  of  digestion,  should  have  the  freest  access  to  pure  air,  and 
that  the  process  of  breathing  should  be  untrammeled,  accompanied  by 
light  physical  exercise  or  mental  diversion. 

There  is  no  doubt  but  the  observance  of  this  simple  rule  in  regard  to 
leaving  the  mind  habitually  in  a  state  of  ease,  with  a  full,  free  access  of 
air  during  the  first  half  or  three  quarters  of  an  hour  after  taking  an  ordi- 
nary meal,  would  prevent  a  very  large  amount  of  imperfect  digestion  of 
food,  and  save  a  great  many  individuals  from  becoming  confirmed 
invalids  through  imperfect  digestive  processes.  When  this  rule  has 
been  habitually  violated  and  patients  are  sulfering  from  indigestion 
in  consequence,  it  is  in  vain  to  endeavor  to  cure  them  by  drugs  or 
do  anything  more  than  simply  to  palliate  some  of  the  more  promi-- 
i.ent  symptoms  from  time  to  time,  unless  the  rule  is  enjoined,  and 
it  is  literally  complied  with.  In  regard  to  medicine  for  the  class  of 
cases  dependent  upon  pure  morbid  excitability  of  the  nervous  structures, 
it  is  desirable  to  select  and  use  some  agent  calculated  to  produce  as  direct 
a  soothing  or  sedative  effect  upon  the  sensibility  of  the  nerves  involved, 
ai  is  possible.  The  best  time  to  make  an  impression  is  immediately  before 
taking  food.  In  some  instances  I  have  obtained  very  prompt  and  entire 
relief  by  giving,  just  before  the  patient  sits  down  to  take  his  meals,  six 
decigrammes  (gr.  x)  of  bromide  of  potassium  with  the  same  number  of 
minims  of  the  fluid  extract  of  hyoscyamus  in  a  tablespoonful,  or  four  cubic 
centimeters  of  water.  The  bromide  and  hyoscyamus  in  many  such  cases 
when  taken  just  before  taking  food,  coming  in  contact  with  the  sentient 
nerves  of  the  mucous  membrane,  produce  their  full  sedative  efl:'ect,  lessen- 
ing the  nervous  excitability,  and  by  absorption  and  diffusion  extend  some 
of  the  same  soothing  or  calming  influence  over  the  whole  central  portion 
of  the  nervous  system.  If,  as  sometimes  happens  in  these  cases,  there  is 
some  tendency  to  fermentation,  causing  the  formntion  of  gases  and  eructa- 
tions, the  addition  of  small  doses  of  carbolic  acid  to  the  bromide  and  hy- 
oscyamus will  increase  the  efficacy  by  acting  as  an  antiseptic.  It  is  also 
moderately  sedative  to  nerve  excitability  and  therefore  makes  a  valuable 
addition  to  the  other  two  ingredierits.  In  the  same  class  of  cases  moder- 
ate doses  of  hydrocyanic  acid,  taken  in  mucilage  of  gum  arable,  have  also 
frequently  succeeded  in  removing  the  undue  sensitiveness  and  causing 
the  food  to  be  retained  and  assimilated.  As  I  have  said  before,  the 
larger  number  of  cases  of  ordinary  indigestion,  as  they  are  met  with  in 
]  r.ictice,  depend  upon  the  coincidence  of  defective  secretion  of  gastric 
juice  with  impaired  peristaltic  motion,  not  only  of  the  stomach,  but 
of  the  whole  alimentary  canal,  and  causing  the  indigestion  to  be  associated 
with  more  or  less  habitual  constipation.  This  condition  isof  very  frequent 
occurrence  in  modern  society  among  all  classes  who  are  not  engaged  freely 
and  abundantly  in  physical  exercise  out-doors,  but  more  especially  common 
among  the  female  sex,  who  in  addition  to  being  much  in-doors  and  neglect- 
ing active  ordinary  exercise  on  foot  in  the  open  air,  also  by  their  modes 
of  dress  confine  the  chest  in  such  a  way  as  to  limit  the  habitual  expansion 
ot  the  lungs,  and  the  consequent  consumption  of  oxygen  and  the  elimina- 
tion of  carbonic  acid  gas.     By  the  coincidence  of  in-door  life,  little  phys- 


838  DEKANGEME^'T    OF    DIGESTION. 

ical  exertion,  and  daily  restricting  the  function  of  respiration  so  as  to 
make  the  amount  of  oxygen  consumed  and  carbonic  acid  eliminated  a  few 
cubic  inches  below  the  normal  standard,  the  blood  is  caused  to  circulate 
through  the  whole  arterial  system,  holding  in  solution  an  excess  of  certain 
effete  constituents,  especially  carbonic  acid  gas,  which  is  a  direct  sedative 
to  nerve  sensibility,  and  a  deficient  supply  of  oxygen  as  an  excitant  both 
of  nerve  sensibility  and  muscular  contractility.  The  inevitable  result  of 
such  a  condition,  continued  for  any  considerable  time,  is  the  impairment 
of  the  tone  of  the  whole  muscular  system,  voluntary  and  involuntary,  in- 
cluding such  as  constitute  the  muscular  coat  of  the  stomach  and  intestines 
equally  with  those  of  voluntary  motion,  and  of  the  susceptibility  of  the 
whole  nervous  system,  both  central  and  peripheral.  One  of  the  conse- 
quences is  an  impairment  of  the  involuntary  muscular  movements,  includ- 
ing, particularly,  those  of  the  alimentary  canal  throughout  its  whole  course. 
Persons  of  this  class  consequently'  seldom  arrive  at  the  middle  period  of 
adult  life  before  they  have  developed  both  habitual  constipation,  and  im- 
perfect digestion  of  food.  The  tbod,  though  tai<en  with  a  moderate  ap- 
petite, is  found  to  lay  simply  like  a  load,  or  dead  weight,  in  the  epigas- 
trium after  eating.  Sometimes  this  is  so  marked  as  to  be  described  as 
feeling  like  pieces  of  lead  in  the  stomach.  This  dull,  heavy  feeling  is  ac- 
companied by  more  or  less  general  feeling  of  fullness  and  depression,  and 
not  infrequently,  mental  despondency.  In  many  cases  it  is  not  felt  per- 
ceptibly until  about  half  an  hour  after  eating.  Then  it  gradually  increases, 
the  load  and  sense  of  fullness  become  more  and  more  uncomfortable,  un- 
til in  from  one  to  two  hours  there  is  added  the  liberation  of  gases;  and 
what  was  previously  a  simple  feeling  of  heaviness,  now  becomes  a  very  dis- 
tressed feeling  of  distension  in  the  epigastrium  until  the  gases  begin  to  be 
belched  up,  generally  in  large  quantities.  After  belching  up  quantities  of 
gas,  in  most  instances  tasteless  and  odorless  but  sometimes  having  more 
of  a  nauseous  and  offensive  quality,  the  feeling  of  uneasiness  passes  off, 
and  the  patient  becomes  comparatively  comfortable  till  about  the  same 
hour  after  the  next  meal.  And  thus  he  passes  day  after  day,  month  after 
month,  suffering  about  the  same  length  of  time  after  almost  every  m  al 
that  is  taken.  Perhaps,  in  a  m;ijority  of  cases,  the  symptoms  are  simply 
those  I  have  described,  accompanied  by  constipation.  But  there;  are 
some  in  which  there  is  not  only  a  fermentation  which  results  in  the  libera- 
tion of  large  quantities  of  gas,  but  more  or  less  of  acid  also.  And  then 
you  meet  with  eructations  of  a  sour  or  acrid  character.  If  so,  there  is  usu- 
ally added  at  the  same  time  more  or  less  of,  burning  sensation,  or  what 
is  popularly  called  heartburn,  and  sometimes  gastralgia. 

In  these  cases  there  is  usually  a  light  degree  of  actual  hypertemia,  or 
approach  to  an  inflammatory  condition  of  the  mucous  membrane,  but  so 
slight  that  it  passes  off  as  soon  as  the  stomach  becomes  again  empty.  It 
is  a  very  common  practice  to  supply  this  class  of  patients  with  palliatives, 
including  every  variety  of  antacids,  antiseptics,  and  sometimes  stimulants, 
with  a  view  of  either  preventing  the  formation  of  gases,  which  are  sup- 
posed to  be  the  chief  cause  of  the  patient's  misery,  or  facilitating  their  ex- 
pulsion when  they  have  been  formed.  At  the  same  time  the  constipa- 
tion of  the  bowels  is  also  very  apt  to  be  regarded  as  the  evider.ce  of 
biliousness,  and  every  few  days  the  intestines  are  emptied  by  an  active 
dose  of  ])hysic;  but  just  as  often  they  lapse  back  into  the  same  inactive 
condition  as  they  were  in  before  the  physic  was  taken,  when  another  dose  is 
resorted  to.  Hence  such  patients  follow  up  the  routine  of  taking  all  the 
varieties  of  pepsin,  charcoal,  alkalies  and  carminatives,  interspersed  with 
active  physic,  every  two   or  three  days,  for  months   and  sometimes   years. 


TREATMENT.  839 

Such  management,  however,  has  no  otlier  result  than  that  of  simply  palli- 
atino-  symptoms,  but  dues  nothing'  toward  removing  tlie  ])atliological 
conditions  from  which  the  patient  suffers,  or  the  causes  which  have  led  to 
them.  No  beginner  in  the  practice  of  medicine  can  take  a  better  direc- 
tion for  ingratiating  himself  into  the  favor  of  a  large  number  in  the  com- 
munity, and  laying  the  foundation  for  a  popular  practice,  than  b\  a  care- 
ful study  of  this  class  of  cases  of  ordinary  indigestion  and  constipation, 
with  a  view  of  understanding  clearly  their  causes  and  the  pathological 
conditions  they  involve,  that  he  may,  whenever  he  comes  in  contact  with  a 
case,  be  able  to  put  the  patient  upon  such  a  course  of  correct  habits  of 
life,  and  such  aid  from  well-directed  remedial  agents,  as  will  give  him  a 
more  permanent  and  satisfactory  restoration.  Such  cases  are  curable 
with  only  a  moderate  use  of  medicine,  provided  the  patients  will  adopt 
proper  habits  of  life  and  avoid  the  causes  which  have  produced  them. 
Nearly  all  of  this  class  of  cases  depend  entirely  on  the  two  pathological 
conditions  I  have  mentioned,  namely,  defective  muscular  or  peristaltic 
motion  of  the  stomach  and  bowels  and  the  coincident  deficiency  in  the 
secretion,  both  of  the  gastric  juice  and  of  the  ordinary  mucous  from  the 
follicles  of  the  intestines.  And  the  causes  which  have  led  to  it,  are  in  a 
very  large  majority  of  the  cases,  the  coincidence  of  deficient  out-door  ex- 
ercise, and  either  habits  of  dress  or  occupations  that  help  to  limit,  or  em- 
barrass the  free  exercise  of  respiration,  and  thereby  lessen  the  oxygena- 
tion and  decarbonization  of  the  blood.  If  to  deficient  exercise,  and  in- 
efficient breathing,  there  is  added  constant  mental  application,  it  will 
hasten  the  development  of  evil  consequences.  The  rational  treatment  of 
such  cases  is  so  plain  that  I  hardly  need  take  time  to  mention  it  in  detail. 
It  involves  the  correction  of  erroneous  habit-,  as  essential  to  its  per- 
manency. It  is  not  difficult  to  temporarily  relieve  such  patients,  but  for 
permanent  relief,  the  causes  which  contribute  to  the  development  of  the 
morbid  conditions  must  be  absolutely  avoided.  Consequently,  exercise 
to  a  moderate  extent  in  the  open  air  at  some  part  of  every  day,  the  ex- 
ercise of  the  chest  in  such  a  way,  daily,  as  to  promote  absolute  full,  free, 
efficient  respiration,  sleeping  in  well-ventilated  rooms,  the  use  of  plain 
diet,  the  avoidance  of  all  anaesthetics,  like  alcoholic  drinks,  and  much  bet- 
ter, if  it  include  also  avoidance  of  tobacco,  are  absolutely  essential  parts 
of  the  treatment  of  all  cases  where  any  permanent  results  are  expected. 
There  are  not  many  patients  but  who,  if  the  necessity  for  this  part  of  the 
treatment  is  pointed  out  clearly,  will  sooner  or  later  yield  obedience  to 
the  requirements,  although  they  may,  if  engaged  in  particular  lines  of 
business,  protest  at  first  that  they  have  no  time  to  do  it.  But  there  is  no 
proper' business  in  the  world,  and  should  be  none  engaged  in  by  individ- 
uals anywhere,  that  does  not  leave,  if  time  is  properly  economized,  op- 
portunities every  twenty-four  hours  for  taking  the  exercises  which  are 
needed  for  the  class  of  patients  under  consideration. 

If  there  are  any  exceptions  to  this  rule,  they  are  to  be  found  among  the 
poorer  mechanics  and  artisans,  whose  work  is  habitually  within  doors  in 
some  confined  position,  and  who  must  extend  their  hours  to  the  utmost 
limit,  to  keep  the  poor  family  from  suffering  for  the  necessaries  of  life.  But 
then  they  are  rarely  required  to  be  at  their  labor  earlier  than  seven  in  the 
morning,  and  usually  at  home  as  early  as  six  in  the  evening,  thus  affording 
time  both  before  commencing  in  the  morning  and  still  greater  time  in  the 
evening  before  going  to  bed,  to  counteract  much  of  the  evil  effects  of  the 
day's  confinement  by  judicious  exercise,  in  such  manner  as  may  be  pointed 
out  to  them.  I  wish  you  not  to  forget  that  the  exercise  which  is  most  valu- 
able and  most  needed  for  promoting  elimination  of  waste  material,  more  effi- 


840  DERANGEMENTS    OF    DIGESTION. 

cient  oxygenation  of  the  blood,  its  diffusion  through  the  whole  vascular  sys- 
tem, and  consequently  the  establishment  of  its  influence  over  the  functions 
of  the  body,  does  not  consist  mainly  in  mere  walking,  but  involves,  neces- 
sarily, daily  exercise  of  the  arms  and  muscles  of  the  chest  sufficient  to  keep 
the  muscles  concerned  in  ordinary  respiratory  movements  in  a  vigorous  and 
healthy  condition.  Having  dwelt  thus  emphatically  upon  the  portion  of  the 
treatment  which  relates  to  the  hygienic  management  of  the  patient,  which 
is  really  the  most  important  of  all,  it  only  remains  to  study  those  remedial 
agents  best  adapted  to  such  cases,  and  select  such  as  will  possess  two  dis- 
tinct properties;  one  a  tonic  of  such  character  as  is  calculated  to  increase  the 
efficiency  of  the  nervous  and  muscular  actions  concerned  in  the  movements 
of  the  stomach  and  intestines,  and  with  these  just  sufficient  laxative  to  pro- 
mote a  single  natural  movement  of  the  bowels  once  a  day,  without  ever 
acting  as  a  cathartic.  If  you  can  select  from  your  materia  medica  any 
combination  of  agents  that  will  present  to  the  organic  nervous  system  a 
tonic  such  as  is  calculated  to  increase  the  innervation  and  nerve  sensibil- 
ity, you  will  thereby  increase  the  muscular  contractility  and  movements, 
and  with  this  such  a  laxative  for  a  time  during  the  early  part  of  the  treat- 
ment as  will  simply  suffice  to  prompt  a  single  movement  of  the  bowels 
each  day,  you  will  in  one  week  be  able  to  so  far  correct  the  faulty  action 
of  the  digestive  organs  as  to  have  well-nigh  established  exemption  from 
the  prominent  symptoms  of  indigestion  which  had  previously  tormented 
the  patient.  My  remarks  now  in  reference  to  remedies,  as  you  will 
notice,  include  those  most  efficient  and  desirable  for  the  removal  of  habit- 
ual constipation,  as  well  as  indigestion. 

For  a  long  period  of  years,  I  have  been  in  the  habit  of  prescribing  for 
this  class  of  patients  a  combination  of  the  extract  of  hyoscyamus,  sulphate 
of  iron,  aloes  and  nux  vomica  or  strychnia,  usually  in  the  form  of  a  pill. 
In  prescribing  for  an  adult,  a  pill  containing  six  centigrammes  (gr.  i) 
each  of  the  extract  of  hyoscyamus  and  sulphate  of  iron,  and  two  centi- 
grammes (gr.  -g-)  each  of  pulverized  aloes  and  extract  of  nux  vomica  may 
be  given  before  each  meal,  and  if  the  patient  is  laboring  under  a  very 
decided  degree  of  constipation,  another  at  bed  time.  x\ndif,  as  sometimes 
happens  in  these  cases,  there  is  a  yellowish  coat  upon  the  tongue,  the 
urine  a  little  redder  than  natural,  and  when  cool,  throwing  down  a  whitish 
phosphatic  or  ammoniacal  sediment,  it  will  be  profitable  to  add  two  cen- 
tigrammes (gr.  -J)  of  blue  mass  to  each  of  these  pills.  In  many  instances, 
giving  these  pills  as  I  have  indicated,  there  will  be  no  direct  effect  in 
moving  the  bowels  during  the  first  two  days.  But  if  the  patient  does 
not  resort  to  other  physic  by  the  third  day,  there  will  almost  invariably 
occur  an  evacuation,  which  with  a  majority  of  patients  will  be  costive, 
requiring  some  effort  as  usual  to  void  it,  especially  at  the  beginning  of 
the  evacuation.  Continuing  the  same  number  of  pills,  the  bowels  will 
move  again  the  next  day,  but  a  little  easier.  The  day  following  most 
■patients  will  have  two  evacuations,  showing  the  influence  of  a  laxative. 
My  rule  is,  to  give  definite  instructions  that  so  soon  as  the  effects  develop 
more  than  one  easy  natural  movement  a  day,  one  pill  is  to  be  omitted, 
usually  the  one  before  dinner,  allowing  the  patient  to  continue  the  one 
before  breakfast,  at  tea  time,  and  bed  time.  With  many  this  will  be 
found  not  merely  to  perpetuate  one  single  movement  a  day,  but  after  a 
few  days  to  make  the  bowels  a  little  more  loose,  and  another  pill  can  be 
dropped,  leaving  only  one  morning  and  evening;  and  still  later  another 
may  be  omitted,  leaving  but  one  to  be  taken  every  night.  The  great 
majority  of  such  patients,  by  the  end  of  the  third  week  from  the  time  they 
commence,  will  have  an  entirely  regular,  healthy  condition  of  the  aliment- 


TREATMENT.  841 

ary  canal,  with  little  or  no  trouble  from  indigestion  while  using  onlj  one 
pill  each  day.  It  is  better  that  they  continue  this  for  a  considerable 
time,  but  ultimately  they  can  diminish  this  to  one  every  second  evenino-, 
and  finally  to  once  in  three  days.  Then  they  can  drop  it  entirely  for  a 
week  or  more  at  a  time.  After  this  it  will  be  sufficient  to  follow  the  rule 
to  take  one  pill  at  bed  time  whenever  there  has  been  no  evacuation  dur- 
ing- the  preceding-  twenty-four  hours. 

An  additional  item  of  much  importance,  is,  that  the  patient  maintain  a 
strictly  regular  habit  of  going  to  stool  at  some  given  hour  each  day. 
Usually  the  best  times  to  go  are  immediately  after  breakfast  in  the  morn- 
ing, or  immediately  before  going  to  bed.  A  majority  of  patients  will 
succeed  best  by  going  immediately  after  each  morning  meal.  Proper  at- 
tention to  the  hygienic  measures  I  have  indicated,  combined  with  treat- 
ment by  medicine  on  the  principle  I  have  clearly  laid  down,  will  succeed 
in  ninety-nine  cases  out  of  a  hundred  in  relieving  this  class  of  patients  both 
of  indigestion  and  liabitual  constipation.  But  there  are  at  least  a  score 
of  remedies  and  combinations  that  may  be  made  from  the  tonics,  espe- 
cially of  the  class  of  nerve  tonics,  and  such  mild  laxative  remedies  as  are 
familiar  to  every  student  of  the  materia  medica,  besides  those  entering 
into  the  pill  I  have  indicated.  In  those  cases  of  indigestion  presenting 
in  addition  to  the  mere  load  in  the  stomach  and.  distension  from  the  gen- 
eration of  gases,  there  is  manifest  during  the  process  of  digestion  some 
sourness  or  acidity  rising  from  the  stomach,  indicating  acid  fermentation, 
I  have  derived  much  greater  benefit  by  giving  patients  a  teaspoonful,  or 
four  cubic  centimeters,  of  a  combination  I  have  often  mentioned  durino- 
this  course  of  lectures,  as  the  carbolic  acid  mixture.  It  contains  carbolic 
acid,  tincture  ofgelsemium,  and  camphorated  tincture  of  opium  in  proper 
proportions,  with  a  little  glycerine  and  water.*  Four  cubic  cen- 
timeters, (fl.  3i)  or  a  teaspoonful  of  this  mixture  in  a  tablespoon- 
ful  of  water  taken  immediately  before  the  patient  commences  to  eat,  at 
each  meal  time,  will  have  an  important  influence  in  correcting  the  process 
of  fermentation,  and  greatly  lessen  the  inconvenience  that  the  patient  suf- 
fers during  the  stomach  digestion.  Of  course  it  will  do  nothing  toward 
removing  constipation  and  maintaining  the  natural  muscular  action  of  the 
stomach  and  bowels.  To  accomplish  this,  where  I  use  the  carbolic  acid 
mixture  before  each  meal,  I  direct  at  the  same  time  a  pill  consisting  of 
six  centigrammes  (gr.  i)  each  of  the  extract  of  hyoscyamus,  sulphate  of 
iron,  aloes  and  blue  mass,  with  two  centigrammes  (gr.  ^)  of  extract  of 
nux  vomica,  and  allow  this  pill  to  be  taken  when  the  patient  retires  to  bed 
at  night.  By  this  increase  of  the  amount  of  aloes  and  blue  mass  to  each 
of  the  pills  previously  mentioned,  I  have  aimed  to  make  them  active 
enough  for  one  pill  taken  at  night  to  prompt  the  necessary  movement  of 
the  bowels  the  next  morning. 

During  the  last  ten  years  I  have  relieved,  more  satisfactorily  and  fully, 
a  majority  of  cases  of  ordinary  indigestion  coupled  with  constipation  of 
the  bowels,  by  this  process  of  giving  the  carbolic  acid  mixture  immediate- 
ly before  taking  food,  and  a  tonic  and  laxative  pill  at  bed  time,  than  by 
any  other  means.  But  by  no  means,  gentlemen,  get  the  idea  that  either 
this  or" any  of  the  formula  I  have  given  you  are  essential  in  the  treatment 
of  such  cases.  On  the  contrary,  any  combination  you  may  make  that  does 
not  contain  a  positively  irritating  material,  and  that  will  on  the  other 
hand  act  as  a  genuine  tonic  to  the  nervous  and  muscular  structures 
entering   into   the    alimentary  canal,  and   will    also   gently  promote    the 

*  See  page  138. 


842  DERANGEMENTS    OF    DIGESTION. 

secretions  of  the  gastric  and  intestinal  glandular  structures,  with  the 
proper  regulation  of  the  patient's  habits  and  modes  of  life,  will  afford  re- 
lief in  almost  all  this  numerous  class  of  cases.  After  alluding  to  these 
general  principles  in  regard  to  the  treatment  of  the  different  forms  of  in- 
digestion and  constipation,  I  need  not  take  up  more  time,  but  leave  each 
one  to  his  individual  judgment  and  tact,  in  selecting  the  special  remedies 
to  fulfill  the  indications  I  have  endeavored  to  point  out.  There  are, 
perhaps,  two  painful  conditions  of  the  stomach,  that  are  liable  to  occur 
more  or  less  in  connection  with  all  grades  of  indigestion,  about  which 
a  word  or  two  should  be  said.  I  allude  to  gastrodynia,  or  pain  in 
the  stomach,  and  cardialgia,  or  burning  in  the  stomach,  but  more 
popularly  styled  heart  hum.  The  latter  is  almost  always  dependent 
upon  either  the  generation  of  acid  in  the  stomach,  or  a  certain  degree 
of  inflammatory  action.  When  the  latter,  it  is  best  treated,  as  I 
have  already  pointed  out  to  you  when  speaking  of  the  forms  of 
gastritis.  When  dependent  upon  acid,  the  remedies  that  may  relieve 
temporarily  are  the  antacids,  alkalies,  alkaline  earths  or  substances  capa- 
ble of  neutralizing  an  acid.  Bicarbonate  of  soda,  calcined  magnesia, 
carbonate  of  magnesia  used  by  themselves,  or  in  solution  and  associated 
with  some  carminative,  as  cardamom,  anise,  or  mint  water,  will  usually,  if 
given  in  moderately  liberal  doses,  speedily  neutralize  the  excess  of  acid 
and  after  giving  rise  to  the  formation  and  eructation  of  gases,  relieve  the 
distress  of  the  patient.  Of  course  this  refers  only  to  the  paroxysms.  If 
associated,  as  it  generally  is,  with  one  of  the  forms  of  indigestion  that  I 
have  already  alluded  to,  permanent  relief,  or  the  prevention  of  the  re- 
currence of  such  paroxysms  will  depend  upon  the  removal  of  the  patho- 
logical condition  involved  in  the  case. 

Gastrodynia  is  a  term  applied,  not  to  the  ordinary  sensat^'on  of  un- 
easiness, load  or  burning  in  the  stomach,  but  a  distressing  pain  in  the 
epigastrium,  and  often  radiating  upward  behind  the  sternum,  reaching 
as  high  as  the  lower  part  of  the  neck,  and  not  unfrequently  involving 
the  sensation  as  if  there  was  a  great  weight  or  pressure  upon  the  whole 
anterior  part  of  the  chest,  with  an  extraordinary  intensity  of  pain  directly 
in  the  epigastrium,  yet  at  times  also  radiating  backward,  and  becoming 
almost  as  intense  in  the  central  part  of  the  dorsal  portion  of  the  spine  as 
in  the  epigastric  region  itself.  Most  of  such  attacks  are  accompanied  by, 
if  not  directly  dependent  upon,  a  rapid  generation  of  gases,  and  disten- 
sion of  the  stomach.  In  some  rare  instances  the  stomach,  at  least  for  the 
time  being,  seems  to  lose  the  tone  of  its  muscular  coat,  and  yields  to  the 
enormous  distension,  till  finally,  through  some  irritant  influence  the  muscu- 
lar ctoat  is  stimulated  to  contract,  causing  vomiting  and  throwing  off  of 
large  quantities  of  accumulated  material,  to  the  speedy  relief  of  the 
patient.  I  have  frequently  met  with  cases  in  which  patients  only  mode- 
rately troubled  with  habitual  indigestion  and  constipation,  would  be  sub- 
iect  occasionally,  through  some  cause  difficult  to  trace,  to  failure  in  the  di- 
gestion of  their  supper.  Taking  their  evening  meal  at  the  usual  time, 
they  would  pass  the  evening,  especially  the  early  part  of  it,  without  any 
more  than  moderate  sensations  of  heaviness,  and  oppression  near  the  lower 
end  of  the  sternum,  and  retire,  perhaps,  exhibiting  nothing  serious.  Fall- 
ing asleep,  in  less  than  an  hour,  they  wake  up  with  extreme  gastric  dis- 
tress, and  with  all  the  severity  and  character  of  the  symptoms  I  have  just 
previously  described.  Continuing  in  this  condition,  unless  relieved  by 
some  remedies,  for  two  or  three  hours,  it  ends  in  belching  large  quantities 
of  gas,  and  sometimes  vomiting  the  greater  part  of  their  evening  meal  in 
a  sour  and  undigested  condition.     Immediately  after  this  the  pain  begins 


INTESTINAL    PAKASITES.  843 

to  abate,  and  very  soon  they  are  so  far  relieved  as  to  fall  asleep.  Getting 
two  or  three  hours  of  sleej),  they  rise  in  the  morning  feeling  weary,  more 
or  less  depressed  mentally,  but  usually  able  to  take  a  light  breakfast. 
Going  out  in  the  open  air  soon  after,  they  recover  their  usual  spirits  and 
buoyancy  and  frequently  go  weeks  and  months  before  another  attack  oc- 
curs. Some  of  these  attacks  of  gastrodynia  are  almost  as  distressing  as 
those  of  genuine  angina  pectoris  and  are  of  the  same  general  character, 
only  the  pain  is  epigastric  and  generally  associated  with  more  or  less 
gaseous  eructations,  while  in  angina  pectoris  the  pain  is  more  in  the  chest, 
radiating  to  the  left  arm  and  shoulder,  and  accompanied  by  irregularity 
of  the  heart's  action.  In  these  cases  of  gastrodynia,  where  it  is  evident 
that  the  patient's  last  meal  is  not  digested  and  removed  from  the  stomach, 
but  is  still  Iving  there  in  a  fermenting  condition,  having  much  to  do  in 
causing  the  suffering,  the  most  speedy  means  of  relief  is  the  administra- 
tion of  a  mild  emetic,  of  which,  perhaps,  ipecacuanha  is  preferable  to 
anv  other.  Enough  should  be  given  to  make  sure  of  a  speedy  and  free 
vomiting,  aideiby  a  liberal  drink  of  warm  water.  By  filling  the  stomach 
with  warm  water  directly  after  a  moderately  full  dose  of  ipecac,  vomiting 
is  quickly  provoked.  If  there  is  a  little  slowness  in  the  subsidence  of 
the  pain  after  the  stomach  has  been  freely  evacuated,  any  mild  anodyne 
and  antiseptic,  more  particulady  a  teaspoonful  of  the  carbolic  acid  mix- 
ture, will  usually  be  sufficient  to  arrest  the  further  progress  of  pain  and 
speedily  induce  a  state  of  sleep.  Of  course  after  this  the  main  object 
must  be  to  correct  the  faulty  condition  of  the  digestive  organs  which 
have  rendered  such  attacks  possible. 


LECTUEE    LXXXi:^ 


Intestinal  Parasites— Their  Varieties,  Symptoms  and  Treatment. 

GENTLEMEN:  The  study  of  helminthology  is  one  of  sufficient  interest 
to  justify  you  in  giving  it  much  careful  attention  during  the  earlier 
years  of  practice,  when  time  may  be  afforded  for  further  special  studies, 
beyond  what  the  more  crowded  hours  of  the  lecture  room  would 
justify.  Those  parasites  which  have  been  found  in  the  human  body 
have  been  usually  classed  as  entozoa.  Thirty  or  more  different  varieties 
have  been  recognized  as  occasionally  found  in  some  part  of  the  human 
system.  The  principal  ones  may  be  divided  into  three  classes:  the  cestoid 
or  ribbon-like  worms,  frematoid  or  fluted  worms  and  the  nematoid  or 
round  worms.  To  the  first  class,  or  cestoid  worms,  belong  the  different 
varieties  of  tsenia;  as  the  taenia  solium,  tsenia  lata,  taenia  echinococcus, 
several  varieties  of  cysticercus,  and  the  bothriocephalus  latus.  The 
frematoid  worms  are  usually  flattened  and  somewhat  fluted,  corrugated 
and  soft,  and  are  found  mostly  in  the  interior  and  parenchyma  of  organs. 
The  class  of  nematoid  worms  embrace  the  more  common  varieties  as  the 
ascarides,  which  chiefly  inhabit  the  rectum;  the  ascaris-lumbricoides  or 
common  round  worms,  which  more  generally  occupy  the  small  intestines 
and  sometimes  the  stomach;  the  tricliocephalus,  oxyuris  vermicularis  an<l 
trichina  spiralis.  It  is  not  my  purpose  at  the  present  time  to  occupy 
your  attention  with  any  of  the  more  rare  varieties  of  worms  or  those  which 


844  INTESTINAL   WOEMS. 

are  found  in  the  interior  of  solid  organs  and  cysts.     Echinococci  in  cysts 
of  the  liver  and  other  parts,  cysticerci  found  in  the   eye  and  some   other 
places  are  so  rare  as  to  constitute  curiosities  in  medicine  rather  than  items 
of  ordinary  interest  to  the  practitioner.      But  I  shall  occupy  your  time  at 
the  present  hour,  simply  in  a  brief  consideration  of  the  symptoms  and  the 
best  mode  of  treatment  applicable  to  the  removal   of  the  three  most  com- 
mon varieties  of  intestinal  worms,  namely,  ascarides  or  pin  worms,  as  they 
are  sometimes  called,  the  different  varieties  of  lumbricoides  and  the  tfenia 
or  tape  worm.     The  two  fi:st  varieties  are  found  more  frequently  in  the 
intestinal  canal  of  children  and  young  persons  than  in  adults.     While  the 
different  varieties  of  tape  worm  are  quite  as  often,  perhaps  more  frequently, 
found  in  adults  than  in  children.     Tlie  ascarides  are  a  small  worm,  flattened, 
a  little   tapering  toward   the   head,   and   usually  occupying    the    rectum 
and  lower  part  of  the  colon.     They  multiply  with  great  rapidity,  are  often 
discharged  with  each  evacuation  from  the  bowels  in  considerable  numbers, 
usually  sufficiently  alive  to  make  their  crawling  movements  with  consider- 
able facility;  and  when  they  are  allowed  to  accumulate,  they  not   infre- 
quently crawl  out  of  the  anus  in  the  intervals  between  the  intestinal  evac- 
uations.    The   general  symptoms  to  which  they  give  rise  are  some  tickling 
sensations  or  itching  in  the  rectum   and   anus,  together  with  some   degree 
of  increased  nervousness  or  general  excitability  on  the  part  of  the  patient. 
Their  movements,  not  infrequently,  apparently  cause  the  child  to  start 
suddenly  during  sleep  in  the   night,  making  him  restless   and  sometimes 
starting  up  as  in  a  fright.     It  is  generally  supposed  that  the  existence  of 
worms,  especially  of  this  variety,  cause  also  more  or  less  dryness  and  itch- 
inor  in  the  nostrils,  thereby  inducing  the  child  to  rub  his  nose  frequently. 
But  rubbing  the  nose  and  dryness  of  the  nostrils  may  arise  from  so  many 
different  causes  quite  as  readily   as  from  the  influence  of  worms,  that  they 
are  of  little  or  no   value,  as  aids  in  diagnosis.     In   fact  the   only  certain 
diagnostic  sign  is  the  finding  worms  as  they  are  discharged  with  the  fasces 
from  time  to  time,  or  as  they  make  their  exit  after  crawling  from  the  lower 
opening  of  the  bowels  between  the  evacuations.     When  they  are  allowed 
to  accumulate  for  a  considerable    time,  they   undoubtedly   are   capable  of 
exciting  sufficient  irritation  upon   the  nerves   of  the  rectum    to  induce  a 
reflex  influence  upon    the  nervous   centers   and    temporarily  establishing 
febrile  reactions,   by  which   children    become   subject  every  few  days  to 
temporary  paroxysms  of  fever  in  which  the  face  will  appear  flushed,  the 
skin  will  become  hot,  breathing  a  little  hurried,  nostrils  more  or  less  dry, 
the  nervous  system  disturbed,  indicated  by  startings  and  excitability;  and 
perhaps  in   three  or   four  hours  the  paroxysm  passes  off  and  the  patient 
will  be  up  and  apparently  as  well  as  ever.     In  other  instances,  however, 
the  worms  may  exist  lor  a   longer  period   of  time  without   inducing   any 
active,  febrile  paroxyms,  giving  rise  to  nothing  more   than   nervous   rest- 
lessness at  night,  and  more  or  less  itching  and  annoyance  in  the  rectum. 
As  I  have  already  remarked  this  variety  of  worm  is  found  discharged  in 
large  numbers  with  the  ordinary  evacuations  from  the  bowels,  or  they  may 
be  dislodged  also  freely  at  any  time  by  taking  almost  any  variety  of  physic 
that  will  produce  two  or  three   free   evacuations.     But   very   frequently, 
purging  will  entirely  fail  to  remove  all  the  worms  or  their  larvae,  and  con- 
sequently they    are  reproduced   in   considerable   numbers  within   one  or 
two  weeks,  even  if  evacuating  remedies    have   been    used  with   as   much 
freedom  as  is  for  the  comfort  of  the  patient.     Generally  the  exhibition  of 
vermifuges  or  special  remedies,  calculated  to  deaden  the  worms  and  cause 
them  to  pass  oft",  produce  less  effect  upon    this  variety   than   upon   others 
occupying  the  upper  or  middle  part  of  the  bowels.     Remedies  calculated 


TREATMENT.  845 

to  destroy  these  parasites,  given  by  the  stomach,  in  passing  through  the 
alimentary  canal  do  not  reach  the  worms  in  sufficient  strength  to  produce 
the  desired  effect. 

So  little  certainty  is  there  of  effectually  removing  ascarides  or  pin 
worms  by  the  exhibition  of  vermifuge  remedies  by  the  mouth,  that  for 
many  years  I  have  almof-t  ceased  to  use  that  class  of  remedies,  and  have 
very  satisfactorily  removed  this  variety  of  worms  by  means  of  enemas. 
The  use  of  a  solution  of  common  salt  in  water  in  proportion  of  eight  gram- 
mes (3ii)  of  the  chloride  of  sodium  or  common  salt  to  half  a  pint  of  water, 
and  this  quantity,  or  as  much  of  it  as  the  rectum  will  permit,  shouldbe  given 
as  an  enema,  endeavoring  to  have  the  patient  retain  it  for  ten  or  fifteon 
minutes.  By  using  enemas  of  salt  water,  the  saline  having  a  poisonous 
effect  upon  this  variety  of  worm,  you  not  only  destroy  those  that  are  al- 
ready mature,  but  if  the  rectum  is  pretty  well  filled,  it  reaches  almost  cer- 
tainly the  larvas  also,  and  by  destroying  both,  there  is  less  liability  for  the 
worm  to  be  reproduced  and  require  treatment  again  in  a  few  weeks  or 
months.  I  have  generally  used  the  salt  water  enema  twice  a  week  for 
aVjout  two  weeks  in  succession,  and  it  is  very  seldom  that  this  fails  in  en- 
tirely removing  the  further  development  of  these  parasites.  If  the  bowels 
are  inclined  to  be  constipated  it  may  be  well,  in  addition  to  the  use  of 
enemas,  to  give  the  patient  a  mild  laxative  once  a  day,  with  wliich  may 
be  combined  a  few  drops  of  oil  of  turpentine,  which  will  be  likely 
to  reach  and  destroy  any  of  the  worms  or  their  larvae,  that  may  be  too 
high  up  in  the  alimentary  canal  for  the  enema  to  reach.  Besides  salt  water 
as  an  injection,  there  are  many  other  things  that  may  be  used  in  the  same 
manner  that  would  prove  effectual  for  the  removal  of  this  variety  of  worms 
An  emulsion  made  by  rubbing  up  a  certain  amount  of  oil  of  turpentine  and 
castor  oil,  with  mucilage  and  water  sufficient  to  dilute  the  enema  will 
generally  prove  effectual,  although  it  is  less  convenient,  and  usually  not 
more  efficient  than  solutions  of  common  salt.  An  infusion  of  spigelia 
marylandica,  mixed  with  a  little  senna,  may  also  be  used  as  an  efficient  in- 
jection or  enema  for  the  destruction  of  the  worms  inhabiting  the  rectum. 
The  ascaris  lumbricoides,  or  long  round  worm,  frequently  found  occupy- 
ing some  portion  of  the  small  intestine  and  occasionally  the  stomach,  may 
exist  for  an  indefinite  period  of  time,  and  produce  so  little  inconvenience 
to  the  patient  or  positive  symptoms  by  which  their  existence  could  be 
suspected  that  the  patients  have  no  thought  of  anything  disturbing  their 
health.  And  not  infrequently,  the  first  thing  which  causes  them  to  think 
of  worms  is  the  discovery  of  a  specimen  mixed  or  incorporated  with  the 
fseces  that  have  been  discharged  as  ordinary  evacuations.  So  true  is  it 
that  in  many  cases  there  appear  no  symptoms  of  their  existence,  and 
many  persons  are  found  to  pass  large  specimens  every  now  and  then,  who 
are  not  conscious  of  suffering  any  symptoms  of  ill  health.  But  where  they 
multiply  in  the  intestines  until  a  considerable  number  have  accumulated, 
they  usually  produce  an  obscure  train  of  symptoms,  such  as  chilliness,  oc- 
casional paroxysms  of  fever,  not  having  any  regularity,  but  skipping  a  day 
or  two,  and  then  again  returning,  without  any  regularity  as  to  the  interval 
between  their  occurrence.  Sometimes  patients  afflicted  with  these  worms 
have  a  variable  appetite,  eating  at  some  meals  unusually  voracious,  and 
at  others  taking  but  little  or  none.  The  presence  of  the  worms  or  their 
effect  upon  the  nerves  connected  with  the  small  intestines,  has  been  sup- 
posed capable  of  exciting  reflex  disturbance  of  the  nervous  centers  suffi- 
cient to  provoke  paroxysms  of  general  convulsions.  During  a  somewhat 
protracted  period  of  practice  I  have  seen  but  very  few  instances  in  which 
there  was  any  satisfactory  evidence  that  intestinal  worms  were  the  cause 


846  PAKASITES. 

of  convulsions  or  more  than  very  evanescent  paroxysms  of  fever.  The 
bowels  are  usually  re^^ular  though  sometimes  they  are  inclitiea  lo  constipa- 
tion, at  other  times  to  diarrhoea.  The  same  rule  applies  to  the  symptoms, 
which  are  so  often  regarded  as  indicating  worms,  namely,  rubbing  or  itch- 
ing of  the  nose.  And  the  only  means  for  positive  diagnosis  or  determining 
whether  this  variety  of  worms  exists,  is  in  finding  some  of  them  in  the 
evacuations.  Occasionally  one  comes  up  in  the  oesophagus  from  the 
stomach,  and  is  cleared  out  of  the  throat.  I  met  a  patient  only  yesterday, 
who  had  discharged  a  worm,  apparently  from  its  rising  in  his  oesophagus, 
creating  the  sensation  as  if  encouraging  the  act  of  vomiting,  and  a  little 
effort  threw  out  a  worm  of  the  round  lumbricoid  variety  some  four  inches 
long. 

Treatment. — A  considerable  number  of  remedies  have  been  recommend- 
ed from  time  to  time  for  the  removal  of  this  variety  of  worm,  any  one 
of  which  will  succeed  in  most  instances,  if  it  be  given  properly,  and  fol- 
lowed at  the  proper  time  by  a  moderately  brisk  cathartic.  A  very  old 
and  favorite  remedy,  in  years  gone  by,  was  the  spigelia  marylandica. 
When  a  child  or  young  subject  was  found  to  be  affected  by  worms  of  the 
lumbricoid  variety,  the  common  practice  was  to  take  eight  or  ten  grammes 
(311)  of  the  spigelia  root,  with  an  equal  quantity  of  the  senna  leaves, 
to  which  was  added  sufficient  water,  boiling  hot,  to  make  200,  c.  c. 
(|vi)  of  the  infusion.  This  can  be  given  in  divided  doses,  suited  tc  the 
age  of  the  patient,  once  in  three  or  four  hours  until  it  produces  threo  or 
four  free  evacuations.  The  spigelia,  or  pink  root,  is  supposed  to  deaden 
the  worms,  while  the  senna,  acting  as  a  cathartic,  causes  their  discharge. 
Equally  effectual  is  it  to  give  eight  or  ten  minims  of  the  oil  of  turpentine 
on  a  little  sugar,  or  rubbed  up  with  gum  arable  and  sugar  in  the  form  of 
an  emulsion,  three  times  a  day  for  two  or  three  days,  and  follow  it  by  a 
moderately  iDrisk  cathartic.  Another  remedy  which  is  usually  efficient,  is 
santonine;  which  from  the  smallness  of  the  dose  is  more  convenient  of 
administration  to  children  than  either  turpentine  or  the  spigelia,  though 
the  latter  may  be  obtained  in  concentrated  form  by  giving  the  fluid  ex- 
tract. Santonine  for  children  from  three  to  five  years  of  age  may  be  given 
in  doses  of  from  one  to  three  grains  in  the  form  of  a  powder,  morning, 
noon  and  evening,  and  the  next  morning  followed  by  a  cathartic,  or  a 
dose  of  the  santonine  may  be  given  morning  and  noon,  and  the  third  to  be 
given  at  night,  may  be  mixed  with  a  sufficient  quantity  of  rhubarb, 
powdered  senna,  or  of  calomel,  to  produce  a  free  movement  of  the  bowels. 
But  the  existence  of  worms  in  the  bowels  is  much  less  frequent  than  is 
usually  supposed  by  the  greater  portion  of  the  community.  A  large 
portion  of  the  cases  of  disease  that  are  supposea  to  originate  from  worms 
are  cases  of  simple  irritation  of  the  mucous  membrane  of  the  alimentary 
canal,  or  some  morbidly  excitable  condition  of  the  nervous  system  when 
there  are  no  worms  of  any  variety  existing  in  the  alimentary  canal  or  any 
of  the  adjacent  viscera.  The  taenia,  or  tape  worm,  occurs  more  frequent- 
ly in  adults  than  in  children,  but  may  be  found  at  any  period  of  life.  It 
usually  occupies  the  small  intestines,  and  is  far  more  difficult  of  dis- 
lodo-ment,  or  removal,  than  either  of  the  varieties  that  we  have  just  been 
considering.  Like  the  two  other  varieties  of  worm,  their  existence  is  not 
productive  of  any  absolutely  characteristic  or  diagnostic  symptoms,  ex- 
cept the  discovery  of  a  portion  of  the  worm  in  the  discharges  from  the 
bowels.  Indeed,  a  large  majority  of  all  the  patients  I  have  met,  when 
annoyed  with  the  existence  of  tape  worm,  have  not  been  conscious  of  any 
particular  ill  health  or  even  of  s3anptoms  of  indigestion,  till  they  accident- 
ally discovered  sections  of  the  worm    in    the  evacuations.     Most  patients 


TAPE  WORMS.  847 

after  they  have  learned  that  the  worm  exists  in  the  alimentary  canal,  by 
witnessing  the  discharge  of  sections  of  flat  and  truncated  pieces  day 
alter  day,  become  annoyed  with  what  they  will  describe  as  various  un- 
pleasant sensations  derived  from  the  presence  of  the  worm.  They  will 
not  infrequently  speak  of  a  crawling,  creeping,  turning,  twisting  motion 
of  the  bowels;  sometimes  having  a  voracious  appetite,  and  at  other  times 
no!ie  at  all.  They  generally  become  very  nervous,  and  not  infrequently 
complain  of  choking  sensations  in  the  neck  like  parties  affected  with 
hysteria.  Most  of  these  sensations,  however,  are  evidently  the  result  of 
mental  education,  and  watching  for  some  sensation  in  the  abdomen,  aided 
by  the  imagination  of  the  patient,  as  to  what  would  be  the  eifects  of  the 
presence  of  the  worm,  more  than  what  was  actually  felt,  or  that  they  had 
any  knowledge  of,  prior  to  having  become  satisfied  that  the  worms  existed. 
And  yet,  it  is  probably  true  that  the  presence  of  this  variety  of  worm, 
especially  when  it  has  attained  considerable  size,  causes  many  obscure  and 
annoying  feelings  in  the  abdomen,  which  are  sometimes  reflectc-d  to  the 
central  portion  of  the  nervous  system,  giving  rise  to  temporary  periods  of 
excitement  or  feverishness,  disturbance  of  sleep  at  night,  associated  with 
a  disposition  to  perform  the  act  of  deglutition,  or  a  sense  of  choking 
in  the  neck.  These  worms  sometimes  attain  great  length,  being  broad, 
flat  and  jointed,  tapering  almost  to  a  point,  with  a  little  bulb  at  the  end 
constituting  the  head.  This  head  in  most  cases  is  armed  with  antennae,  or 
little  hooks,  projecting  from  either  side  of  the  enlargement.  The  worm 
grows  broader  and  keeps  a  distinctly  flattened  form  as  it  extends  in  length 
until  when  it  has  attained  a  pretty  full  size,  each  section  is  from  three  to 
six  lines  wide  and  about  the  same  injength.  These  pieces,  although 
detached  sections  of  the  worm,  are  most  of  them,  when  passed,  possessed 
of  sufficient  vitality  to  make  very  distinct  and  sometimes  regular  move- 
ments, such  as  contracting  and  extending  in  width,  and  crawling,  or  more 
or  less  of  a  progressive  motion.  But  the  difficulty  for  the  physician  is  not 
usually  in  the  diagnosis.  The  worm,  when  joints  of  it  are  presented,  is 
easily  recognized  and  its  general  habits  and  disposition  for  reproduction 
understood.  But  the  chief  point  of  interest,  both  for  the  physician  and 
patient,  is  the  best  mode  of  treatment,  or  the  one  most  certam  to  effect  its 
entire  removal.  For  this  purpose  quite  a  long  list  of  remedies  have  been 
used,  and  from  time  to  time,  each  in  its  turn  has  been  recommended  as 
efficient.  The  principal  difficulty  in  removing  this  variety  of  worm,  is 
in  getting  any  medicine  to  reach  it  in  sufficient  strength  to  act  as  a  poison 
or  to  so  deaden  the  worm  as  to  loosen  its  hold,  or  the  grasp  of  its  hooks, 
upon  the  folds  of  the  intestines.  Occupying  a  particular  portion  of  the 
alimentary  canal,  and  involved  more  or  less  in  the  fecal  contents  of  the 
intestines,  whatever  is  administered  by  the  mouth,  or  by  the  rectum,  be- 
comes so  diluted  by  its  intermixture  with  fecal  matters  or  removed  by 
absorption  before  it  has  reached  the  worm,  that  it  is  not  of  sufficient 
strength  to  produce  the  desired  effect  upon  the  parasite.  Consequently, 
if  we  would  obtain  the  greatest  degree  of  certainty  in  the  removal  of  the 
worm  by  any  particular  plan  of  treatment,  we  will  be  very  much  more 
likely  to  succeed  if  the  bowels  are  first  emptied  by  the  administration  of 
sufficient  laxatives,  and  the  patient  during  the  time  of  treatment  abstains 
either  from  all  nourishment,  or  from  all  solid  food,  taking  at  each  meal 
time,  only  just  such  limited  amounts  of  liquid  nourishment  as  will  pre- 
vent too  great  a  degree  of  exhaustion  from  the  abstinence.  After  empty- 
ing the  alimentary  canal,  and  taking  a  very  small  amount  of  liquid 
nourishment,  the  worm  becomes  exposed,  or  as  free  from  envelopment  by 
the  contents  of  the  bowels  as  is  possible.     Having  placed  the  patient  in  this 


848  TAPE    WOEMS. 

condition,  whatever  remedies  are  chosen  to  exert  a  toxiieraic  or  po'sonous 
influence  upon  the  worm  should  now  be  administered  in  sufficient  doses, 
and  repeated  as  often  as  the  nature  of  the  medicine  will  permit  with 
safety,  for  eighteen  or  twenty-four  hours,  during  which  its  full  eifect  on 
the  worms  may  be  developed.  This  should  be  followed  immediately  by  one 
pint  of  previously  prepared  infusion  or  mucilage  of  pumpkin  seeds,  drank 
at  once.  This  will  usually  cause,  in  five  or  six  hours,  one  or  more  free 
intestinal  evacuations,  carrying  with  them  the  entire  worm.  When  evac- 
uations do  not  follow  in  the  time  mentioned,  a  full  dose  of  physic  should  be 
given  to  hasten  the  desired  result.  During  the  time  occupied  by  the 
active  treatment,  the  patient  should  take  sparingly  of  liquid  nourishment 
only. 

This  plan  of  treatment,  when  judiciously  and  faithfully  executed, 
has  succeeded  in  expelling  the  entire  worm  in  three  cases  out  of 
four.  When  it  has  failed,  after  allowing  the  patients  a  few  days  to  re- 
cover from  the  debilitating  effects  of  two  or  three  days  of  fasting  andevac- 
uents,  I  repeat  the  same  plan  of  treatment,  and  almost  always  with  suc- 
cess. The  variety  of  the  worm  having  hook-shaped  antenuEe  are  the  most 
difficult  to  expel.  The  only  evidence  of  complete  success  is  the  finding 
of  the  head  of  the  worm,  which  you  distinguish  from  the  other  parts  by  its 
being  a  slight  bulb  or  enlargement  at  the  end  of  a  long  neck  that  had  ta- 
pered almost  to  a  point.  Among  those  specimens,  which  I  show  you  from 
the  college  museum,  are  some  in  which  the  head  is  readily  distinguished. 
Concerning  the  best  vermifuge  or  toxic  agents  to  afi"ect  the  different 
varieties  of  tape  worm  there  is  much  difference  of  opinion  expressed  by 
writers  and  practitioners.  I  have  succeeded  best  with  the  fluid  extract  of 
the  pomegranate  bark  and  the  etherial  extract  of  felix  mas  or  male  fern. 
T  give  the  first  in  doses  of  four  cubic  centimeters  (fl.  3i)  every  three  or 
four  hours  until  five  or  six  doses  have  been  taken;  and  the  second  in  half 
that  quantity  just  as  often,  following  them  with  the  mucilage  or  infusion 
of  pum]Dkin  seeds.  These  doses  are  for  adults,  and  each  dose  should  be 
given  diluted  with  a  little  sweetened  water.  In  many  cases  I  have  given 
the  pomegranate  and  male  fern  together,  and  occasionally  have  had  the 
worm  expelled  before  it  was  time  to  give  the  pumpkin  seed  tea.  Besides 
the  remedies  I  have  mentioned  you  will  find  recommended  in  your  books 
the  flowers  of  the  Brayera  anthelmintica  called  kousso;  the  rottlera  tincto- 
ria,  called  kameela;  carbolic  and  salicylic  acids,  and  large  doses  of  oil  of  tur- 
pentine or  petroleum.  Indeed,  there  are  a  great  variety  of  remedies  which 
have  occasionally  proved  successful  in  expelling  tape  worms.  The  first 
tape  worm  I  met  with  after  entering  upon  the  practice  of  medicine,  was 
expelled  while  the  patient,  a  young  woman,  was  taking  purgative  doses 
of  the  powdered  colchicum  root.  I  must  caution  you,  however,  against 
resorting  to  excessive  doses  of  drastic  cathartics  or  of  such  oils  as  are 
liable  to  induce  inflammation  of  the  mucous  membranes,  either  of  the  in- 
testines or  urinary  organs.  They  are  not  only  unnecessary,  but  lia,bie  to 
do  much  injury.  Several  cases  have  come  under  my  care,  in  which  oil  of 
turpentine  had  been  taken  in  from  four  to  sixteen  cubic  centimeters  (fl. 
3i  to  3iv)  at  a  dose,  resulting  in  tenesinas,  excessive  stranguary  and 
bloody  urine,  from  which  the  patients  did  not  recover  fully  for  several 
months,  and  yet  without  having  expelled  the  worm. 

With  a  proper  attention  to  the  preparation  of  the  patient  and  the  regu- 
lation of  the  diet,  milder  measures  will  be  found  not  only  safer,  but  uni- 
formly successful  in  relieving  the  patient  of  his  dreaded  parasite. 

As  all  this  class  of  p^iraaites  are  supposed  to  gain  access  to  the  aliment- 
ary canal  in  the  form  of  larvae  or  germs  contained  in  pork  and  other  varie- 


TRICHINA    SPIEALIS.  849 

ties  of  meat  that  has  been  taken  for  food,  it  suggests  a  prophylactic  at  once 
effectual,  and  within  the  reach  of  every  family.  It  is  simply  to  avoid  all 
use  of  raw  or  inadequately  cooked  meats.  And  this  leads  me  to  say  a  few 
words  about  the  trichina  spiralis. 

This  parasite  belongs  to  the  group  called  nematoid,  and  first  began  to 
attract  attention  in  the  decade  between  1820  and  1830.  It  is  found  most 
abundantly  in  the  muscular  structures  of  the  hog,  and,  in  a  less  degree 
however,  in  the  flesh  of  almost  all  domestic  animals.  It  gains  access  to 
the  human  system  in  the  meat  that  is  eaten,  and  is  capable  of  multiply- 
ing rapidly  and  permeating  from  the  intestines  into  nearly  all  the  mus- 
cular structures  of  the  body.  When  it  exists  only  in  small  numbers, 
either  in  man  or  animals,  it  appears  to  exert  very  little  influence  upon 
the  health.  But  when  meat  is  eaten  containing  large  numbers,  it  is  apt 
to  be  followed  first  by  all  the  symptoms  of  gastro-intestinal  inflammation, 
such  as  vomiting,  diarrhoea,  severe  griping  pains,  and  rapid  prostration. 
After  a  few  days  these  symptoms  abate,  but  are  soon  followed  by  severe 
pains  and  hyper^esthesia  in  one  set  of  muscles  after  another  until  the  pa- 
tient is  tortured  with  irregular  pains  and  great  soreness  in  almost  all  parts 
of  the  body  and  extremities,  under  which  he  may  reach  a  fatal  stage  of 
exhaustion  in  from  one  to  four  weeks,  or  may  slowly  recover,  A  large 
proportion  of  the  more  severe  attacks  have  terminated  fatally  in  opposi- 
tion to  any  form  of  treatment  thus  far  devised. 

Post  mortem  examinations  have  shown  that  the  trichinae  exist  in  large 
numbers  in  various  stages  of  development  in  most  of  the  voluntary 
muscles  of  the  body  and  extremities;  and  in  cases  which  have  terminated 
in  death  early,  they  are  still  found  in  the  intestines. 

Treatment. — After  the  trichinous  disease  has  become  fairly  developed, 
no  remedies  have  been  found  capable  of  exerting  a  satisfactorily  control- 
ling influence  over  its  progress. 

But  few  cases  have  come  directly  under  my  care,  and  consequently  my 
opportunities  for  clinical  observation  in  the  treatment  of  the  disease  have 
been  limited.  In  the  first  stage  while  the  prominent  symptoms  are  those 
of  gastro-intestinal  irritation,  the  following  mixture  has  afforded  more  re- 
lief than  anything  else  prescribed: 

;^     Acidi  Carbolici  0.500  grams  gr.  viii 

Glycerinae  30.000  c.  c.  3! 

Tincturse  Opii  Camphoratae  60.000  c.  c.  |ii 

AquEe  30.000  c.  c.  |i 

Mix.  To  adults  four  cubic  centimeters  (fl.  3i)  may  be  given  every  two 
or  three  hours  until  the  vomiting  and  diarrhoea  cease.  After  the  gastro- 
intestinal symptoms  abate,  if  the  symptoms  of  pain  and  soreness  in  the 
muscles  show  that  the  parasites  are  developing  in  the  muscular  structures, 
I  think  it  better  to  substitute  from  three  to  five  decigrams  (gr.  v  to  viii)  of 
salicylic  acid  in  the  place  of  the  carbolic,  leaving  the  other  ingredients  the 
same.  If  the  patient  survives  the  active  stage  and  convalescence  ap- 
proaches, little  else  than  rest  and  easily  digestible  food  is  required  for 
completing  the  recovery. 

Prophylaxis. — The  only  reliable  mode    of  absolutely  preventing  the 
occasional  occurrence  of  trichinosis  is  for  all  persons  to  avoid  eating  meat 
of  every  kind  which  has  not  been  cooked  or  heated  to  150°  F.,  which 
renders  it  perfectly  safe. 
54 


850  DIABETES. 


LECTURE  XC. 


Diabetes— Varieties,  Clinical  History,  Prognosis  and  Treatment. 

GENTLEMEN;  Among  the  more  important  disorders  connected  with 
the  functions  of  excretion,  which  have  not  been  already  passed  in 
review,  are  the  varieties  of  diabetes.  This  word  signifies  increased  flow 
of  urine,  and  clinically  we  meet  with  two  varieties  of  the  disease,  one 
called  diabetes  insipidus,  and  the  other  diabetes  mellitus.  The  prominent 
feature  of  the  former  is  excessive  flow  of  urine  without  material  alteration 
of  its  constituents,  while  the  latter,  diabetes  mellitus,  is  sometimes  called 
glucosuria,  from  the  fact  that  it  not  only  presents  a  very  great  increased 
flow  of  urine  in  a  given  length  of  time,  but  the  urine  contains  an  abnormal 
amount  of  sugar.  Both  these  forms  of  diabetes  are  met  with  more  fre- 
quently during  the  early  period  of  adult  life  than  either  in  childhood  or  old 
age,  although  cases  have  been  known  to  occur  at  all  periods  of  life,  even 
in  infancy.  Both  varieties  are  said  to  occur  much  more  frequently  in 
males  than  in  females. 

Diabetes  Insipidus. — The  causes  of  this  variety  are  very  obscure,  but 
facts  seem  to  show  that  in  a  large  proportion  of  cases  exposure  to  cold, 
damp  air,  particularly  living  in  damp  rooms,  with  but  little  access  of  sun- 
light, directly  favors  the  development  of  the  disease.  Drinking  cold  liq- 
uids when  the  body  is  warm  or  excited  from  severe  exercise  has  been  al- 
leged as  a  cause  in  some  cases,  injuries  afi'ecting  the  brain  or  spinal  cord, 
such  as  blows  upon  the  head,  shocks,  and  penetrating  wounds,  particularly 
when  afi^ecting  the  base  of  the  brain  or  portions  of  the  medulla  oblongata, 
have  been  followed  by  this  form  of  disease.  While  cases  are  on  record 
of  diabetes  insipidus  in  which  some  one  or  more  of  the  causes  enumerated 
would  appear  to  have  exerted  an  important  influence  in  their  development, 
there  are  others  in  which  it  is  difficult  to  trace  any  cause  adequate  for  the 
production  of  the  disease.  It  is  probable  that  hereditary  influence  exists 
in  some  instances. 

Symptoms. — Simple  or  insipid  diabetes  not  infrequently  commences 
abruptly,  but  in  some  instances  its  development  appears  to  be  slow  and 
insidious.  But  whether  abrupt  or  insidious,  as  soon  as  it  has  made  suf- 
ficient progress  to  present  a  noticeable  increase  in  the  amount  of  urine 
passed  in  the  twenty-four  hours  above  normal,  there  is  observed  greater 
paleness  of  features,  accompanied  generally  by  an  excited  expression  of 
countenance,  some  degree  of  mental  despondency,  frequently  obscure,  dull 
pains  in  the  loins,  occasionally  aching  in  the  lower  extremities,  althougii 
both  these  latter  symptoms  are  not  infrequently  absent.  The  patients 
also  tire  easily,  indeed,  feel  a  sense  of  weanness  a  large  part  of  the  time, 
even  when  not  undergoing  muscular  exercise.  But  the  most  prominent 
symptoms  are  the  excessive  quantity  of  urine  passed,  and  the  marked 
thirst  or  desire  for  drink.  The  latter,  or  desire  for  drink,  increases  at  an 
almost  uniform  ratio  with  the  increase  in  the  flow  of  urine.  After  the 
disease  has  progressed  for  a  few  weeks,  there  is  noticeable  diminution  of 
flesh,  or  emaciation,  the  skin  becomes  dry  and  rough,  the  mouth  habitually 
dry,  sometimes,  on  rising,  giddiness  or  dizziness  in  the  head,  startings  and 
restlessness  in  sleep  at  night,  and,  if  the  disease  continues  to  progress,  the 
patient  becomes  more  and  more  emaciated,  the  skin  dryer  and  more 
husky,  the  strength  wastes  till  in  some  instances  the  exhaustion  readies  a 


TREATMENT.  851 

fatal  degree  of  progress.  More  frequently  complications  spring  up  in  the 
latter  stages  of  the  disease,  either  in  the  form  of  diarrhoea,  involving  ex- 
cessive discharges  which  speedily  end  in  collapse  and  death,  or  in  the 
development  of  local  inflammation  in  the  serous  membranes,  such  as  the 
pleura  or  pericardium,  followed  by  copious  effusion,  and  sometimes  death. 
The  disease  is  very  persistent,  nor  is  it  amenable  with  certainty  to  any 
known  mode  of  treatment. 

Anatomical  Changes. — It  can  not  be  said  that  post  mortem  examinations 
have  revealed  any  structural  changes  which  may  be  regarded  as  charac- 
teristic or  peculiar  to  this  form  of  disease.  In  some  the  kidneys  have  been 
found  somewhat  atrophied,  in  others  they  are  enlarged  and  congested,  in 
still  other  cases  there  has  been  found  more  or  less  fatty  degeneration ; 
and  yet  there  are  rare  instances  in  which  no  morbid  changes  have  been 
found,  and  instead  of  structural  lesions  in  the  kidneys,  a  few  congested 
and  altered  appearances  have  been  found  in  the  ganglia  of  the  sympathetic 
nerve.  In  a  few  cases  morbid  appearances  have  been  seen  in  the  liver; 
but  as  I  have  already  remarked  most  of  these  changes  have  resulted  from 
the  influence  of  complications,  rather  than  as  a  legitimate  part  of  the  di- 
abetic affection.  The  essential  pathology  is  certainly  not  well  known. 
There  are  reasons  to  believe  that  the  most  constant  pathological  condition 
connected  with  the  disease  is  dilatation  of  the  capillary  vessels  of  the  kid- 
neys, under  some  faulty  influence  of  the  vaso-motor  nerves. 

Frognosis. — The  prognosis  in  this  variety  of  diabetes  must  always  be 
given  with  caution;  for  while  a  considerable  proportion  of  those  cases  that 
are  brought  under  treatment  early,  and  the  patients  are  in  the  middle 
period  of  life,  recover,  yet,  where  the  early  stage  has  been  neglected,  and 
in  some  instances  even  where  treatment  has  been  adopted  from  the  begin- 
ning of  the  disease,  the  morbid  action  continues  until  the  patient  becomes 
fatally  exhausted. 

Treatment. — One  of  the  important  items  in  the  management  of  all  cases 
of  diabetes  insipidus,  consists  in  a  close  examination  of  the  historv  of  the 
patient  with  a  view  of  ascertaining  as  far  as  practicable  the  causes  which  may 
have  had  an  influence  in  developing  the  disease,  and  to  prevent  their 
further  action.  The  hygienic  management  is  also  of  great  importance. 
The  patient  should  be  required  to  wear  warm  flannel  underclothes,  oc- 
cupy well  lighted  and  warm  rooms,  with  good  ventilation  and  ample  sup- 
ply of  pure  air.  He  should  take  just  so  much  exercise  in  the  open  air 
every  day  as  his  strength  will  allow;  limit  his  drinks  to  a  m(jderate  quan- 
tity of  milk  whey,  or  buttermilk,  and  the  class  of  mineral  waters  represented 
by  those  of  Waukesha  in  Wisconsin,  and  which  are  found  of  a  similar 
character  in  many  parts  of  this  country.  It  is  not  desirable  or  advan- 
tageous to  punish  the  patient  by  actual  deprivation  of  drinks,  but  the 
quantity  should  be  limited  as  much  as  the  patient  can  bear  without  too 
much  discomfort.  Man^^  of  the  cases  are  accompanied  by  a  rather  vora- 
cious appetite.  If  so,  some  degree  of  restriction  should  be  placed,  suffi- 
cient at  least  to  limit  the  quantity  to  the  capacity  of  the  stomach,  to  digest 
fully;  otherwise  the  patient's  condition  will  be  aggravated  by  indigestion 
and  the  fermentation  of  the  excessive  quantities  of  food  in  the  stomach. 
Such  gastric  disorders  disturb  still  more  the  nervous  centers,  and  radiate 
an  increasingly  disturbing  influence  upon  the  vaso-motor  nerves  and  there- 
by increase  the  diabetic  difficulty.  A  great  variety  of  remedies  have  been 
tried  in  this  form  of  diabetes,  but  very  few  of  them  have  been  found  ca- 
pable of  producing  permanent  benefit.  Nitrate  of  potassium,  iodide  of 
potassium,  and  the  carbonated  alkalies  have  been  given  sometimes  with 
apparent  advantage,  but  usually  without  exerting  any  material  influence. 


852  DIABETES    MELLITTJS. 

Almost  every  variety  of  astringent,  vegetable  and  otherwise,  such  as  tan- 
nin, gallic  acid,  alum  and  preparations  of  iron,  have  been  given  with  a  view 
of  exerting  a  tonic  or  astringent  influence  upon  the  capillary  vessels  of  the 
kidneys,  and  thereby  lessen  the  flow  of  urine.  So  far  as  my  own  observa- 
tions go  I  have  seen  but  little  benefit  from  the  use  of  any  of  these  reme- 
dies. Within  the  last  few  years  some  cases  of  a  very  well-marked  char- 
acter have  been  under  my  care,  in  which  the  patients  derived  decided  ad- 
vantage from  the  use  of  a  reliable  preparation  of  ergot,  either  in  the  form 
of  ergotin  or  the  fluid  extract.  Two  of  the  cases  to  which  I  allude  were 
placed  upon  the  use  of  ergot  and  glycerine  combined,  two  parts  of  the 
glycerine  and  one  of  the  fluid  extract  of  ergot,  of  which  the  patient,  who 
had  arrived  at  adult  life,  was  given,  at  first,  two  cubic  centimeters  (fl.  3ss), 
but  which  was  gradually  increased  to  four  (fl.  3i)  at  a  dose,  four  times  in 
the  twenty-four  hours.  Each  dose  of  the  medicine  was  given  largely 
diluted  with  water.  Two  or  three  times  during  the  treatment  of  these 
cases  sufficient  doses  of  pilocarpine  were  given  to  produce  the  character- 
istic flow  of  saliva  and  diaphoresis.  In  one  of  them  moderate  doses  of 
codeine  were  given  every  night,  partly  for  procuring  rest,  and  partly  for  its 
eff"ect  in  lessening  the  urinary  secretion.  Under  the  same  treatment,  con- 
tinued in  the  one  case  three  months,  and  in  the  other  two,  recovery  took 
place,  each  for  a  considerable  length  of  time  continuing  without  a  relapse. 
After  several  months  both  patients  passed  beyond  my  observation,  conse- 
quently I  have  not  learned  whether  subsequent  relapses  took  place  or  not. 
In  two  other  cases  similar  measures  produced  amelioration  of  the  symptoms, 
and  rendered  the  patients  very  much  more  comfortable  for  a  long  period  of 
time,  and  yet,  ultimately,  failed  to  control  the  disease.  Where  the  skin  is 
very  dry,  as  is  true  in  most  of  the  cases,  a  warm  bath  twice  a  week  followed 
by  light,  rapid  frictions  of  flannel  over  the  whole  surface,  is  well  calculated 
to  aid  in  ameliorating  the  condition  of  the  patient.  In  some  cases,  also, 
the  moderate  influence  daily  of  electricity  or  galvanism,  applied  with  the 
positive  pole  upon  the  back  of  the  neck  or  below  the  occiput,  and  the 
negative  alternately  over  the  loins  and  over  the  epigastrium,  has  been  found 
to  aid  in  diminishing  the  prominent  symptoms  of  the  disease. 

Diabetes  .Mellitus.—Fidrhai^^  more  frequent  than  the  insipid  variety,  and 
decidedly  of  greater  importance  because  more  persistently  tending  to  the 
destruction  of  the  patient,  is  that  form  of  diabetes  in  which  the  increased 
flow  of  urine  is  accompanied  by  constant,  or  nearly  constant,  excess  of 
glycogen,  or  sugar.  There  are  two  classes  of  patients  subject  to  attacks 
of  this  variety  of  diabetes:  The  one  class  are  naturally  of  spare  form  and 
rather  nervous  temperament;  the  other,  decidedly  obese  from  an  excess  of 
fatty  nutrition.  So  far  as  my  own  observation  has  gone,  nearly  all  the 
cases  of  the  latter  variety  have  been  females.  I  have  seen  but  two  in- 
stances in  which  diabetes  mellitus  existed  in  males  presenting  a  decided, 
predominance  of  fatty  nutrition  or  obesity;  while  three  or  four  times  that 
number  of  females  are  still  fresh  in  my  recollection.  But  whatever  maybe 
the  temperament  of  the  patient,  this  form  of  diabetes  almost  always  com- 
mences slowly  and  very  obscurely.  The  first  symptoms  which  usually  at- 
tract the  attention  of  the  patient,  or  his  friends,  are  an  unusual  feeling  of 
weariness  and  consequent  indisposition  to  exertion,  together  with  an  in- 
ordinate desire  for  drink,  and  in  some  cases,  also,  an  unusual  appetite  for 
food.  And  though  taking  with  a  relish,  perhaps  an  excess  of  both  food  and 
drinks,  yet  he  finds  his  strength  from  day  to  day  diminishing,  with  in- 
creased weariness,  aching  in  the  limbs,  and  sometimes  in  the  loins. 
In  a  few  weeks  after  the  symptoms  are  first  observable,  there  will  usually 
be  more   or  less  derangement  of  digestion,  the  patient  by  his  appetite 


SYMPTOMS.  853 

being  induced  to  take  more  food  than  there  is  gastric  juice  to  impregnate 
or  prevent  from  fermenting,  the  period  of  digestion  becomes  disturbed  by  the 
formation  of  gaseous  eructations,  in  some  cases  tasteless,  in  others  stron<>-ly 
acid.  The  bowels  are  apt  also  at  this  period  to  be  more  or  less  constipated. 
These  symptoms  almost  always  induce  patients  to  think  that  they  are 
either  bilious  or  dyspeptic,  and  consequently  they  resort  to  remedies  of 
their  own,  choosing  usually  some  form  of  physic,  but  which  does  not  af- 
ford them  any  of  the  relief  they  had  anticipated.  Usually  in  from  one  to 
three  months  from  the  first  beginning  of  symptoms  they  will  have  reached 
a  degree  of  weakness,  thirst,  unusual  appetite,  loss  of  flesh,  dryness  and 
liuskiness  of  the  skin,  dryness  of  the  mouth,  which  impresses  upon  them 
the  conviction  that  it  is  time  to  seek  medical  aid.  It  is  in  this  condition 
that  a  large  majority  will  first  present  themselves  to  their  physician.  When 
th-'y  come  to  you  under  such  circumstances,  you  will  find  them  with  a  pulse 
soft,  weak,  easily  compressed,  but  little  or  not  at  all  increased  in  frequen- 
cy; extremities  rather  cold  and  having  a  congested  look,  from  the  slowness 
of  the  circulation  in  the  cutaneous  capillaries;  the  voice  rather  weak,  lips 
looking  dry,  and  countenance  often  pinched,  from  more  or  less  shrinking 
or  emaciation.  They  will  complain  of  weakness,  despondency,  some  de- 
gree of  indigestion,  having  constipation  the  greater  part  of  the  time,  but 
occasionally  alternated  with  short  turns  of  diarrhoea  or  looseness  of  the 
bowels.  Many  also  present  a  slight  dry  cough  and  a  very  dry  corrugated 
and  husky  feeling  of  the  skin. 

Such  symptoms  should  always  cause  you  to  suspect  the  existence  of 
diabetes.  In  order  to  render  the  examination  of  the  patient  complete,  it 
is  not  only  necessary  to  ascertain  from  him  that  he  is  making  a  larger 
quantity  of  urine  than  natural  every  day,  as  well  as  drinking  more  largely, 
but  a  specimien  of  the  urine  should  be  obtained  for  direct  analytical  ex- 
amination. If  a  specimen  of  urine  is  subjected  to  proper  tests,  it  will  be 
found  of  high  specific  gravity,  usually  varying  from  1020  to  1040,  a  lit- 
tle paler  in  color  than  natural,  having  a  very  slightly  turbid  appearance, 
although  in  many  cases  it  remains  as  clear  as  spring  water.  The  most 
common  test,  or  that  which  is  sufficient  for  clinical  purposes,  is  known 
as  Trommer's  test,  or  the  modification  of  it  proposed  by  Fehling.  This 
test  consists  essentially  in  first  placing  in  a  test  tube  equal  quantities 
of  a  solution  of  sulphate  of  copper  and  of  caustic  potassae,  then  adding- a 
few  drojDS  of  the  suspected  urine  and  heating  it  over  a  spirit  lamp  until 
it  boils.  The  reaction  between  the  liquor  potassge  and  the  copper  are 
such  if  sugar  is  present  as  to  cause  a  precipitate  of  the  insoluble  sub- 
oxide of  copper  of  an  orange  or  brick  red  color.  Fehling's  test  consists 
in  a  ready  formed  solution  containing  a  proper  proportion  of  the  copper 
and  potassae;  and  by  placing  a  small  quantity  of  this  in  a  test  tube,  and 
adding  directly  to  it  a  few  drops  of  the  suspected  urine,  and  then  bring- 
ing it  to  a  boiling  heat  over  the  spirit  lamp  the  copper  is  reduced  and  the 
characteristic  orange  red  precipitate  is  formed  in  the  solution.  This  is  a 
very  convenient  test  because  it  can  be  quickly  applied,  but  the  liquor  is 
liable  to  change  after  long  standing,  and  consequently  should  be  pre- 
pared fresh  at  short  intervals  of  time.  The  amount  of  sugar  in  the  urine 
will  be  indicated  by  the  quantity  of  precipitate  formed.  To  judge  of 
the  quantity  of  the  sugar  excreted  it  is  necessary  to  take  into  account 
both  the  ratio  of  precijiitate  that  is  formed  in  a  given  quantity  of  urine 
in  the  test  glass,  and  the  actual  absolute  quantity  of  urine  passed  in  the 
twenty-four  hours.  And  as  many  patients  with  diabetes  mellitu'5,  after 
the  disease  is  well  established,  pass  from  one  to  three  or  four  gallons  of 
urine  in  the  twenty-four  hours,  it  can  be  readily  seen  by  the  indications 


854  DIABETES    MELLITUS. 

of  sugar  in  the  test  tube,  that  the  quantity  passed  in  the  amount  of  watr^r 
named  would  be  sufficient  to  require  the  appropriation  of  nearly  all  the 
food  the  patient  could  take  instead  of  allowing  any  to  remain  for  the 
proper  nutrition  of  the  tissues  of  the  body.  It  is  in  consequence  of  this 
drain  that  most  diabetic  patients  rapidly  emaciate  until  their  tissues  are 
as  attenuated  as  in  the  advanced  stage  of  the  slow  wasting  form  of  tuber- 
cular phthisis.  When  the  extreme  stage  of  exhaustion  has  been  reached 
there  are  some  instances  in  which  the  feet  and  ankles  become  swollen  or 
oedematous,  but  more  frequently  they  become  blue,  cold,  shrunken  and 
sometimes  are  attacked  with  gangrene.  More  generally,  however,  before 
such  results  are  reached  the  frequent  turns  of  diarrhoea,  and  the  imper- 
fect nutrition  of  the  mucous  membrane  of  the  alimentary  canal  lead  to 
collapse  and  death  from  pure  inanition.  But  a  large  proportion  of  the 
cases  of  diabetes  mellitus  are  also  complicated  with  tuberculosis,  and  as 
they  reach  the  extreme  degree  of  exhaustion,  the  tubercular  deposit  in 
the  lungs  begins  to  develop  active  characteristic  clianges,  and  cause  ex- 
pectoration and  all  the  phenomena  of  consumption,  thereby  hastening  the 
final  termination  of  the  case. 

The  clinical  history  I  have  now  given  you  applies  more  especially  to 
that  class  of  diabetic  patients  who  are  not  obese  or  subject  to  excessive 
fatty  nutrition.  In  this  latter  class  of  cases  there  are  usually  certain  im- 
portant modifications  in  the  progress  of  the  disease.  There  is  the  same 
thirst,  the  same  excessive  flow  of  urine  usually  with  quite  as  large  a  pro- 
portion of  saccharine  matter  in  the  urine  when  voided,  but  these  cases 
differ  chiefly  in  the  fact  that  their  tissues  emaciate  but  slowly,  retaining  a 
decided  fullness  from  fatty  deposit  and  a  look  of  oliesity  to  a  very  late 
stage  of  the  diseise.  As  they  arrive  at  an  advanced  period  in  its  prog- 
ress there  is  almost  always  the  occurrence  of  a  most  troublesome  and 
sometimes  remakable  development  of  boils,  abscesses  and  carbuncles  that 
may  make  their  appearance  in  any  part  of  the  cutaneous  surface  and  some- 
times occupy  almost  the  entire  surface  of  the  body.  Two  or  three  years 
since,  one  of  the  most  striking  cases  of  this  class  came  under  my  observa- 
tion in  the  west  division  of  the  city.  It  was  a  woman  about  forty-five 
years  of  age,  who  had  during  the  earlier  part  of  life  enjoyed  apparently  good 
health  and  was  the  mother  of  a  large  family  of  children.  She  had  acquired 
a  strongly  marked  fatty  accumulation,  sufficient  to  give  her  a  weight 
of  nearly  two  hundred  pounds.  She  was  attacked  with  diabetes  mellitus, 
and  as  far  as  I  could  learn  it  had  come  on  in  the  usual  way,  insidiously, 
and  had  been  continuing  at  least  six  or  seven  months  at  the  time  I  was 
called  in  consultation  in  the  case.  She  presented  the  most  striking  pict- 
ure of  a  human  being  covered  with  boils,  abscesses  and  carbuncles  (the 
latter  varying  in  size  from  half  an  inch  to  three  inches  in  diameter),  that 
I  have  ever  seen  since  I  have  been  engaged  in  the  practice  of  medicine. 
These  larger  carbuncles  were  distributed  over  the  whole  posterior  part  of 
the  body,  from  the  neck  down  to  the  gluteal  regions,  while  the  anterior 
part  of  the  trunk  and  more  or  less  of  the  extremities  were  covered  with 
hard,  prominent,  slowly  suppurating  boils,  with  half  a  dozen  or  more  cellular 
abscesses  in  different  parts  of  the  body.  This  poor  woman  lingered  two 
months  more  in  great  misery  from  these  sores  when  she  was  relieved  by  ar- 
riving at  the  fatal  stage  of  exhaustion.  Throughout  the  whole  course  of  the 
disease  the  urine  was  strongly  impregnated  with  saccharine  matter,  and  the 
quantity  voided  was  usually  from  three  to  six  quarts  in  the  twenty-four 
hours.  I  have  seen  no  cases  of  this  class  recover.  Two  that  I  have  had 
under  treatment, temporarily  convalesced,  and  remained  apparently  nearly 
free  from  any  excess  in  the  quantity  of  urine  or  appearance  of  saccharine 


PATHOLOGY.  855 

matter  for  several  weeks  at  a  time,  when  both  would  return,  but  under 
treatment  would  again  be  checked,  and  one  of  them,  after  its  being  kept 
in  abeyance  a  considerable  time,  finally  took  on  persistent  or  contin- 
uous symptoms,  and  terminated  fatally;  the  other  is  still  under  treatment 
and  has  presented  well-marked  diabetic  quantities  of  urine  with  sugar  in 
it,  accompanied  by  the  same  degree  of  thirst  and  moderate  dryness  of  the 
skin  for  thiee  or  four  weeks  at  a  time  and  then  disappearing  under  a 
certain  amount  of  treatment,  and  remaining  absent  from  two  to  four 
months  at  a  time.  Although  this  patient  has  lost  from  her  previ- 
ously full,  fatty  habit,  at  least  thirty  or  forty  pounds  in  weight,  she 
is  still  by  no  means  emaciated,  but  would  give  to  any  observer  the  idea 
of  a  moderate  degree  of  obesity.  What  will  be  the  ultimate  result  re- 
mains to  be  seen. 

Pathological  Changes. — The  same  remark  may  be  made  in  regard 
to  the  anatomical  changes  found  after  death  from  diabetes  mellitus  as 
was  made  in  reference  to  that  of  diabetes  insipidus.  In  more  than  half 
of  all  the  cases  the  patients  are  found  to  have  more  or  less  of  tubercular 
deposit,  sometimes  in  an  entirely  crude,  primary  condition,  disseminated 
through  the  various  structures,  particularly  in  the  lungs,  but  in  some  cases 
in  the  liver,  spleen  and  kidneys,  and  at  other  times  more  advanced.  Yet  in 
many  other  cases  no  traces  of  tuberculosis  can  be  found  after  death.  Con- 
sequently it  must  be  admitted  that  although  there  is  some  evident  affinity 
or  close  relationship  between  diabetes  mellitus  and  tuberculosis,  they  are 
not  necessarily  associated,  or  the  one  dependent  upon  the  other,  but  that 
they  frequently  exist  as  coincident  aifections.  The  kidneys  are  found  on 
post  mortem  examination  in  many  instances  moderately  enlarged,  softened 
or  flabby  in  texture,  in  some  instances  paler  than  natural,  in  others  hav- 
ing the  appearance  of  congestion  or  hypergemia.  But  there  are  no  con- 
stant anatomical  changes  observable  in  these  nor  any  other  organs  in  the 
body.  The  liver  in  some  cases  presents  a  congested  and  enlaro-ed  condi- 
tion; in  other  instances,  if  there  is  any  change,  it  is  contracted  and  appar- 
ently less  vascular  than  natural.  Examination  of  the  ganglia  of  the  sym- 
pathetic and  vaso-motor  systems  of  nerves  has  revealed,  in  some  instances, 
a  congested  or  apparently  inflammatory  condition  of  the  ganglia,  especial- 
ly those  along  the  trunks  of  that  part  of  the  nerves  contained  in  the  thorax 
and  abdomen.  Quite  as  often,  perhaps,  some  obscure  indications  of  disease 
have  been  observed  in  the  medulla  and  base  of  the  brain.  It  is  a  well- 
known  fact  that  wounds  inflicted,  especially  penetrating  wounds,  into  the 
floor  of  the  fourth  ventricle,  and  in  some  portion  of  the  base  of  the  brain 
and  medulla,  sometimes  produce  all  the  phenomena  of  diabetes  mellitus, 
increasing  the  flow  of  urine,  and  producing  a  copious  amount  of  saccharine 
matter  in  it.  Injuries  of  the  brain  from  concussion  and  injuries  to  the 
spinal  cord,  have  not  infrequently  resulted  in  the  production  of  diabetes, 
or  at  least  saccharine  urine.  It  is  quite  evident  from  the  absence  of  any 
uniform  morbid  condition  of  the  kidneys,  that  we  must  look  elsewhere 
than  in  these  organs  for  the  essential  pathology  of  the  disease.  And  since 
it  has  been  well  ascertained  that  the  starchy  and  other  carbonaceous  con- 
stituents of  the  food  are  converted  into  glucose  or  sugar,  in  the  further 
changes  constituting  assimilation  or  the  passage  from  mere  crude  material 
as  taken  into  the  stomach  to  the  constituents  of  blood,  and  still  further, 
that  these  changes  take  place  largely  in  the  liver,  many  experiments  have 
been  performed  on  animals  with  a  view  of  determining  with  some  deo-ree 
of  certainty  the  function  of  the  liver,  so  far  as  it  relates  to  the  conversion 
of  the  materials  derived  from  the  digestive  organs  into  sugar.  And  al- 
though those  performed  by  Bernard  and  by  A.  Flint,  Jr.,  and  a  number  of 


856  DIABETES    MELLITUS. 

others,  seem  to  show  conclusively,  or  with  a  reasonable  degree  of  cer- 
tainty, that  sugar  was  a  product  of  the  changes  which  take  place  in  the 
liver,  still  Pavy  and  others  have  claimed  with  almost  an  equal  degree  of 
plausibility  that  the  production  of  the  sugar  found  in  the  liver  was  the  re- 
sult of  the  post  mortem  changes  taking  place  speedily  after  the  cessation 
of  life,  and  not  a  natural  product  from  the  processes  that  had  taken  place 
in  the  healthy  living  organization  from  day  to  day.  Without  attempting, 
however,  to  decide  this  controversy,  I  think  I  am  justified  in  assuming 
that  a  large  proportion  of  the  carbonaceous  and  especially  the  starchy 
constituents  of  food  are  naturally  converted  into  sugar  during  the  processes 
of  digestion  and  assimilation.  Whether  this  change  is  confined  alto- 
gether to  that  part  of  the  material  that  passes  through  the  liver,  and 
the  transformation  which  takes  place  in  the  texture  of  that  organ  is  part 
of  its  natural  function,  or  whether  the  same  general  change  is  taking 
place  more  or  less  in  all  the  glandular  structures  through  which  crude 
material  passes  from  the  stomach  and  duodenum  on  its  way  to  reach  the 
blood,  is  perhaps  not  clearly  determined.  But  that  such  a  change  does 
take  place  there  is,  at  least,  reasonably  satisfactory  evidence,  derived  alike 
from  experiments,  clinical  observations,  and  the  chemical  analysis  of  vari- 
ous secretions.  It  is  highly  probable  that  the  first  link  in  the  chain  of  mor- 
bid action,  or  the  essential  pathology  of  diabetes,  consists  in  the  arrest  of 
the  assimilative  process  at  the  stage  when  sugar  is  developed;  the  natural, 
complete  process  consisting  in  a  further  change  by  which  the  sugar  is 
converted  into  lactic  acid  and  other  constituents.  But  in  the  diabetic 
patient  this  further  change  does  not  result,  and  the  product,  as  sugar,  passes 
into  the  blood,  filling  that  fluid  with  an  excess  of  this  material,  the  pres- 
ence of  which  stimulates  the  kidneys  to  increased  activity,  by  which  it  is 
ebminated  with  a  greatly  increased  quantity  of  urine.  The  enormous 
flow  of  urine,  carrying  with  it  the  watery  element  of  the  blood,  drains  the 
tissues  and  creates  the  thirst.  The  gratification  of  this  thirst  for  replet- 
ing  the  watery  element  of  the  blood,  keeps  up  the  material  from  that 
source,  and  perpetuates  the  ability  of  the  patient  to  pass  large  quantities 
of  urine.  This  view  of  the  pathology  of  the  disease  is  corroborated  by  the 
elfects  of  regulating  the  diet.  For,  though  the  disease  is  not  cured  by 
such  regulation  of  diet,  yet  whenever  all  those  articles  of  food  are  excluded 
from  use  which  are  capable  of  being  converted  by  the  assimilative  proc- 
esses into  sugar,  the  quantity  of  urine  and  the  amount  of  sugar  excreted 
are  both  greatly  reduced;  so  much  so  indeed  as  to  show  conclusively  that 
there  is  a  direct  and  persistent  connection  between  the  quantity  of  sugar 
evolved  in  the  system  and  the  amount  of  food  the  patient  takes  capable  of 
undergoing  such  evolution. 


LECTURE    XCI. 


Diabetes  Mellitus  Continued— Diagnosis,  Prognosis  and  Treatment— Enuresis. 

GENTLEMEN:  Diagnosis. — Diabetes  is  not  likely,  after  it  is  fairly 
established,  to  be  confounded  with  any  other  disease  except  diabetes 
insipidus.  From  this  it  is  distinguished  by  the  chemical  tests  which  de- 
termine the  presence  or  absence  of  sugar  in  the  urine,  and  as   these  tests 


TREATMENT.  857 

have  already  been  spoken  of,  anil  the  characteristic  symptoms  fully  pointed 
out  while  giving  the  clinical  history  of  the  disease,  they  need  not  be  re- 
peated under  this  head. 

I-'i'or/nosis. — It  must  be  said  that  the  prognosis  in  well  formed  diabetes 
meliitus  is  unfavorable;  for  though  some  cases  have  recovered  under  per- 
sistent hygienic  and  medical  treatment,  very  much  the  larger  number  have 
pi>rsisted  until  a  fatal  termination  has  been  reached. 

Treatment. — As  you  might  infer  from  the  suggestions  concerning  the 
essential  pathology  of  the  disease,  the  important  part  of  the  treatment  in 
all  cases  of  diabetes  consists  in  the  hygienic  regulations  to  which  the  pa- 
tient must  be  subjected.  It  is  of  great  importance  that  the  patients  be 
supplied  with  pure  air,  rooms  of  comfortable  temperature,  clothing  of  such 
quality  as  will  best  secure  the  surface  against  sudden  and  severe  atmos- 
pheric changes,  of  which  flainel  next  to  the  surface  is  perhaps  the  best; 
daily,  moderate  out-door  exercise  so  long  as  the  strength  will  permit,  but 
without  excess  either  of  mental  or  physical  exertion;  a  warm  bath  at  least 
twice  a  week,  followed  by  frictions  of  flannel  to  increase  the  activity  of 
the  circulation  in  the  surface  as  much  as  possible,  and  to  keep  up  the  cuta- 
neous eliminations  which  are  liable  to  become  very  limited  and  the  skin 
very  dry.  The  diet  should  be  so  regulated  as  to  allow  the  least  amount 
of  carbonaceous,  and  especially  starchy  products  of  food  that  will  be  con- 
sistent with  the  continuance  of  digestion  and  assimilation.  It  is  desirable 
to  exclude  totally  the  use  of  potatoes,  turnips,  beets,  carrots  and  corn 
bread,  and  to  some  extent  also  the  ordinary  wheat  and  rye  flour  breads. 
Patients  should  be  limited  to  the  coarser  brown  breads,  or  still  better  to 
bread  made  of  bran;  to  the  free  use  of  meat  of  any  variety  that  they  may 
choose,  but  especially  good  fresh  lean  meats,  and  for  vegetables  the  celerv, 
cabbage,  onions,  lettuce  and  spinach  may  be  used  with  freedom.  The 
patient  may  drink  freely  of  milk  whey,  skimmed  milk,  and  of  buttermilk, 
but  should  use  rather  sparingly  sweet  milk  containing  the  caseine  nat- 
urally belonging  to  it.  He  can  drink  freely  of  certain  mineral  waters, 
of  which  the  Bethesda  spring  water  of  Waukesha,  Wisconsin,  is  a  good 
representation.  Eggs  and  butter,  as  well  as  some  kinds  of  fruit,  especially 
those  containing  but  little  saccharine  matter,  may  be  allowed  moderately. 
The  moderate  use  of  tea  and  coffee  may  also  be  allowed.  Whenever  the 
disease  is  taken  under  care  early,  and  the  diet  is  rigidly  regulated  on  the 
principles  I  have  just  indicated,  eliminating  or  excluding  all  those  articles 
that  contain  any  considerable  proportion  of  starch,  gum  or  sugar, 
or  other  ingredients  capable  of  being  converted  into  sugar,  but  al- 
lowing a  sufficient  variety  of  the  nitrogenous  and  other  ingredients 
I  have  enumerated  to  maintain  healthy  nutrition,  such  a  course  will 
greatly  ameliorate  the  condition  of  the  patient  and  retard  the  progress 
of  the  disease,  without  any  medication  whatever;  particularly,  if  it  be 
acconjpanied  by  thorough  warm  bathing  and  frictions  upon  the  sur- 
face two  or  three  times  a  week.  But  there  are  some  medicines  in  which 
I  have  acquired  considerable  confidence  as  calculated  to  add  much  to  the 
efficiency  of  the  proper  regu'ation  of  the  diet  and  habits  of  the  patient. 
After  trying  almost  every  remedy  and  combination  of  remedies  that  has 
been  proposed  in  the  last  forty  years  I  am  sure  that  none  of  them  can 
be  relied  upon  as  specifics  for  the  cure  of  this  disease.  I  have  derived  the 
greatest  amount  of  benefit  and  in  some  instances  have  seen  the  disease 
entirely  arrested,  at  least  for  a  time,  by  giving  careful  attention  to  the  reg- 
ulation of  the  bowels,  obviating  constipation,  keeping  the  secretory  func- 
tions, especially  those  concerned  in  excretion,  as  regular  and  healthful  as 
possible,  using  such  means  as  the  condition  of  each  individual  patient  may 


858  DIABETES    MELLITUS. 

indicate.  Whenever  the  tongue  is  coated,  the  patient  feverish,  and  tlio 
bowels  inclined  to  be  costive,  I  have  uniformly  found  advantage  from 
giving  three  or  four  alterative  doses  of  the  mild  chloride  of  mercury  and 
following  them  by  a  laxative  sufficient  to  procure  a  moderately  free  move- 
ment of  the  bowels.  After  paying  due  attention  to  the  regulation  of  the 
secretory  functions,  and  the  removal  of  coincident  functional  disturbances 
as  far  as  they  may  belong  to  individual  cases,  the  medicines  which  have 
seemed  to  have  most  direct  influence  in  controlling  the  disease  have  been 
moderately  large  doses  of  glycerine,  acidulated  with  citric  acid,  taken  in  a 
very  dilute  form,  usually  about  an  hour  after  each  meal,  and  a  full  dose  of 
ergotine  with  codeine  at  bed  time.  I  usually  direct  patients  to  commence 
the  use  of  glycerine  acidulated  with  citric  acid  in  doses  of  two  cubic  cen- 
timeters (fl.  3ss)  in  an  ordinary  tumbler  one  third  full  of  water,  gradually 
increasing  the  doses  of  glycerine  until,  in  the  course  of  two  weeks,  they 
reach  four  cubic  centimeters  or  an  ordinary  teaspoonful.  You  must  be  sure 
that  the  glycerine  is  taken  well  diluted  with  water.  In  many  instances  I 
have  directed,  at  the  same  time,  a  pill  of  two  decigrams  (gr.  iii)  of  ergotine 
after  breakfast  and  at  bed  time,  adding  to  the  dose  at  bed  time  from 
one  to  two  centigrammes  (gr.  ^  to  ^)  of  codeine.  Before  I  com- 
menced the  use  of  ergotine  and  codeine  I  had  given  a  considerable 
number  of  diabetic  patients  every  night  a  pill  containing  from  six  tc 
nine  centigrammes  (gr.  i  to  iss)  of  opium  with  the  one  centigramme 
(gr.  1-6)  of  sulphate  of  copper  in  addition  to  the  medicine  they  were  tak- 
ing during  the  day,  and  with  a  decided  beneficial  influence.  In  a  very 
strongly  marked  case  of  diabetes,  in  a  man  aged  about  thirty  years,  who 
was  employed  in  one  of  the  railroad  depots  of  the  city,  after  taking 
glycerine  acidulated  with  citric  acid  as  I  have  indicated,  apparently  with 
a  moderate  degree  of  benefit  during  the  first  two  weeks  of  treatment, 
and  when  he  had  reached  the  dose  of  four  cubic  centimeters  three  times 
a  day,  the  remedies  seemed  to  induce  an  attack  of  vomiting  and  diarrhoea 
almost  as  severe  as  an  ordinary  attack  of  cholera  morbus.  The  discharges 
were  at  first  thin  and  copious,  but  in  the  course  of  twenty-four  or  thirty- 
six  hours,  became  more  painful,  small  in  quantity,  and  mingled  with  mucus 
and  a  little  blood,  much  resembling  dysenteric  evacuations.  The  glycerine 
was  immediately  discontinued,  but  it  required  eight  or  ten  days  for  the 
patient  to  recover  from  the  severe  irritation  that  had  supervened  in  the 
mucous  membrane  of  the  alimentarv  canal.  During  all  this  severe  irrita- 
tion in  the  alimentary  cannl,  the  excretion  of  urine  was  but  little  more 
than  natural  in  amount,  and  afforded  very  little  evidence  of  the  presence 
of  sugar.  As  the  patient  recovered  from  his  intestinal  difficulty,  he  found 
that  the  quantity  of  urine  began  again  to  increase,  with  a  correspondingly 
increased  proportion  of  sugar.  He  was  again  put  upon  the  use  of  the 
glycerine,  being  more  cautious  to  have  it  largely  diluted  when  taken  and 
the  dose  a  little  smaller  than  had  been  the  case  before.  Irritation  of  the 
bowels  was  also  repressed  by  a  moderate  opiate  at  night.  The  disease 
was  again  checked  without  any  untoward  symptoms,  and  in  about  three 
months  he  apparently  recovered  good  health,  and  returned  to  his  ordinary 
occupation.  Twice  after  that  there  were  symptoms  of  relapse,  and  the 
same  treatment  resorted  to  again  restored  him,  after  which  be  remained 
apparently  free  from  the  disease  and  pursued  his  occupation  almost  unin- 
terruptedly for  a  period  of  nearly  ten  years.  During  the  greater  part  of  that 
time  he  used  but  little  of  the  more  starchy  vegetables.  He  adopted  as 
his  permanent  diet  what  might  be  called  a  meat  diet,  with  very  little  use 
of  the  tuberous  roots,  such  as  beets,  turnips  and  potatoes,  but  otherwise  in- 
dulged in  nearly  the  ordinary  diet  provided   upon   the   family  table.     I 


TREATMENT.  859 

have  obtained  the  same  result,  without  the  intercurrent  period  of  irritation 
of  the  bowels,  in  at  least  six  or  eight  cases  of  well  marked  diabetes 
meilitus.  But  this  is  a  small  number  compared  to  the  whole  number  of 
cases  that  have  come  under  my  observation,  and  consequently  demon- 
strates but  a  small  ratio  of  cures.  I  have  also  treated  a  number  of  pa- 
tients on  the  principle  of  aiding  in  the  assimilative  processes  more  es- 
pecially, and  consequently  have  made  diligent  and  protracted  use  of  the 
various  preparations  of  pepsin,  lactic  acid  and  the  lactates,  peroxide  of 
hydrogen,  antacids  and  carminatives,  but  in  very  few  instances  with  any 
perceptible  influence  over  the  progress  of  the  disease.  The  only  prepara- 
tion of  pepsin,  or  the  class  of  agents  addressed  directly  to  the  supposed 
improvement  of  digestion  and  assimilation,  which  has  been  in  a  marked  de- 
gree beneficial  in  my  hands  is  a  preparation  of  rennet,  made  by  macerat- 
ing a  good  specimen  of  rennet,  preferably  from  the  pig,  in  dilute  acetic 
acid  or  vinegar,  thereby  making  a  dilute  acetated  tincture  of  the  rennet. 
It  mav  be  prepared  extempore  by  cutting  up  fresh  rennet  and  putting  it 
into  the  vinegar,  allowing  it  to  stand  two  or  three  days,  occasionally  shak- 
ino- or  stirring  it  up.  The  patient  can  take  of  this  preparation  doses  of 
four  cubic  centimeters  (fl.  3i)  j'Jst  after  each  meal,  gradually  increasing 
it  till  from  eight  to  twelve  cubic  centimeters  (fl.  3ii  to  3iii)  are  taken  at  a 
dose.  This  mode  of  treatment  was  first  proposed,  so  far  as  my  knowledge 
extends,  by  Dr.  Joseph  Jones,  now  of  New  Orleans,  who  at  the  time  of  pro- 
posing this  trea'ment  was  practicing  in  Georgia,  and  in  connection  with  a 
medical  school  in  that  State.  He  reported  the  successful  treatment  of 
several  cases  of  the  disease  with  the  rennet  prepared  in  extempore  as  I 
have  already  suggested.  I  found  it  to  diminish  the  amount  of  urine 
secreted  and  to  palliate  some  of  the  more  distressing  symptoms  of  the  pa- 
tient in  the  advanced  stages  of  the  disease,  but  its  influence  appeared  to  be 
purely  palliative  or  temporary,  having  no  curative  efi"ect.  Another  remedy 
which  has  been  recommended,  and  which,  in  the  early  stage  of  the 
disease,  may  be  resorted  to  once  or  twice  a  week  perhaps  with  ad- 
vantage, is  the  pilocarpine  or  the  fluid  extract  of  jaborandi.  What- 
ever preparation  is  used  should  be  in  such  doses  as  to  produce  the 
specific  efi'ect  of  the  drug  in  a  moderate  degree  without  carrying  it 
far  enough  to  produce  too  great  a  degree  of  depression.  Creating  a 
moderate  flow  of  saliva  and  sufficient  diaphoresis  to  moisten  the  skin  for 
a  time  and  repeat  this  in  connection  with  other  treatment  once  or  twice 
a  week  has  been  found  to  exert  a  favorable  modifying  influence  over  the 
progress  of  the  disease.  As  the  patient's  strength  fails,  and  he  becomes 
tormented  day  and  night  with  inordinate  thirst,  and  yet  so  weak  and  tired 
as  to  make  life  a  burden,  and  it  has  become  apparent  that  the  disease  has 
passed  beyond  any  reasonable  expectation  of  control,  remedies  should  be 
given  more  with  a  view  of  palliating  the  patient's  symptoms,  and  ameli- 
orating his  suft'ering  than  for  any  other  purpose.  He  should  then  be  al- 
lowed a  liberal  quantity  of  drink,  persuading  him  to  use,  apart  of  the  time 
at  least,  milk  whey  and  buttermilk  rather  than  exclusively  water,  and  giv- 
ing him  some  one  of  the  preparations  of  opium,  of  which  perhaps  codeine 
is  the  best  so  long  as  it  can  be  made  to  answer  the  purpose.  For  the  pur- 
pose of  allaying  restlessness,  lessening  consciousness  of  suff'ering,  and  es- 
pecially to  procure  some  degree  of  sleep  at  night,  opiates  in  some  form 
become  indispensable  in  the  advanced  stage  of  the  disease.  This  form  of 
diabetes,  as  well  as  that  of  diabetes  insipidus,  has  been  treated  with  elec- 
tricity, galvanism  and  electro-magnetism,  in  almost  all  modes  of  application 


860  ENURESIS. 

and  degrees  of  perseverance,  but  with  very  little  apparent  influence  over 
the  progress  of  the  disease.* 

Enuresis. — By     enuresis   I   mean    incontinence   of     urine,     which,   al- 
though having  no  connection  with  or  analogy  to  diabetes  in  any  form,  is, 
nevertheless,  a  very  troublesome  affection,  particularly  apt  to  be  met  with 
in  cliildren  under  ten  years  of  age.     Some  cases  are  met  with    at  a    later 
period  of  youth,  or  up  even  to  adult  life.     The  affection  to  which  I  more 
particularly  allude  is  not  absolute  incontinence,  or  constant  dribbling    of 
urine,  for  most  of  the  patients  during  the  day  will  be  able,  by  passing  their 
urine    frequently,    to  avoid    actual  dribbling,    or  wetting   their  clorhes. 
Many  of  them,  however,  especially  when  under  ten  years  of  age,  are   not 
sufficiently  vigilant,  and  often  while  at  play,  either  in  doors  or  out,  will  al- 
low more  or  less  urine  to  escape,  and  cause  some  soiling  of  their  clothing 
almost  every  day.     But  the  chief  trouble  with  this  class  of  patients  comes 
at  night.     A    majority  of  them,  after  the  utmost  pains  are  taken  to  have 
themfully  empty  the  bladder  ongoing  to  bed,  will   soon    fall  asleep    and 
remain    so    from    one    to  four  hours,  when  the  urine  passes  involuntarily 
while  they  are  profoundly  asleep,  thereby  wetting  the  bed  and  everything 
around  them.     This  will  be  renewed  in  many  cases  two  or  three  times  in 
the  course  of  every  night,  rendering  themselves  and  the  bed  very  untidy, 
and  giving  a  great  annoyance  to  mothers    and  nurses.     Of  course    there 
are  different  degrees  of  frequency  of  urination  in  this  class    of  cases   dur- 
ing the  night  as  well  as  day.     In    some   ins;:ances  it  will  occur  but  once, 
an^  occasionally  one  or  two  nights  will  escape.     In  others,  as  already  re- 
marked, the  bed  will  be  saturated   three    or    four  times  between  the  ordi- 
nary  hours    of  retiring  at  night  and  rising  in   the  morning.     It  is  a  very 
common  occurrence  for  parents  to  be  annoyed  with  this  circumstance,  and  to 
treat  the  child  as  though  it  was  a  matter  the  child  could  control.    And  not 
infreqaent'y  chastisements  have  been  inflicted  upon  the  unfortunate   chil 
dren,  with  a  view  of  teaching  them  better  manners  than  to  be  wetting  the 
bed  every  night.     But  I  have  never  known  an  instance  in  which   chastise- 
ments succeeded  in  effecting  a  cure,  but  many  in  which  they  aggravated  the 
difficu'ty.     The  more  timid  patients  become,  and  the  more  their  minds  are 
subject  to  dread  or  fear  the  less  control  the  nerves  have  over  the    sphinc- 
ter muscles  of  the  bladder.     Consequently  all  such  harsh  and  cruel  treat- 
ment of  these  children  should  be  avoided.     It  is  the  duty  of  tlie  physician 
to  give  heed  to  these  cases  whenever  parents  call  their  attention  to  them; 
and  instead  of  treating  it  as  a  matter  of  course,  or  a  habit,  careful  inquiry 
should  ba  made  into  the  circumstances  that  operate  upon  the  patients,  their 
mode  of  eating  and  drinking,  the  condition  of  their  digestive  organs,  and 
especially  the  condition  of  the  nervous  system,  for  the  purpose  of  ascer- 
taining the  causes  on  which  the  difficulty  depends.     With  many  of  them 
it  will  be  found  that  it  is  mainly   associated  with    imperfect  digestion   of 
food  and  habit  of  drinking  water  indiscriminately  a  dozen    times    in    the 
day,  and  frequently  up  to  the  time  of  retiring  to  bed.     The  blood  is  thus 
supplied  with  an  undue  proportion  of  its  watery  element,  and   the   urin- 
ary secretion  increased.     In  other  instances,  and  perhaps  in  the  greater 

*Atthe  recentmeetingofthe  American  Medical  Association  in  Washington,  aninterestingraperon 
"The  MillcTre  itmentolDisease"  was  read  in  the  Section  on  Practice  ofMedicine  and  Materia  Medica, 
by  Dr  James  Tyson,  of  Phila  lelphia,  in  which  he  uses  the  following  language  :  "  As  to.diabetes 
mellitus,  it  is  now  generally  conce  led  that  no  measnr.^s  ;ire  so  etiicient  in  removing  the  sugar  from 
the  urine,  and  relievini<  other  symptoms,  as  the  dietetic;  and  ot  the  dietetic  treatment  none  has 
b"en  so  promptly  efficiimt  in  ray  hanils  as  an  exclusive  milk  diet."  He  prefers  skimmed  milk,  and 
requires  .idult  patients  to  take  from  130  to  390  cubic  centinn'ters  (fl.  oz.  iv  to  oz.  xli)  every  two  or 
three  hours.  Very  recently  several  cases  of  diabetes  mellitus  have  been  reported  in  the  medical 
periodicals  as  successfully  treated  with  bromide  of  arsenic.  In  a  paper  on  this  disease  read  in  the 
Medical  Section  of  the  American  Medical  Association  lit  its  recent  meeting,  by  Dr.  Aiistin  Flint, 
Jr  ,  the  bromide  of  arsenic  is  relerrcd  to  ns  beneficial  in  many  cases.  He  gives  the  remedy  in 
doses  of  three  to  five  minims  three  or  four  times  a  day,  largely  diluted  with  water. 


TREATMEXT.  8G1 

number,  the  difficulty  will  be  found  to  consist  in  a  morbid  condition  of 
the  nervous  system,  more  espacially  wicli  the  excito-motor  or  reflex  sys- 
tem, which  governs  the  sphincters  of  the  body.  It  will  be  found  that, 
while  most  of  these  patients  are  of  a  nervous  temperament,  excitable  and 
easily  frightened,  there  is  less  than  the  natural  amount  of  involuntary 
action  in  the  sphincter  muscles,  and  there  is  also  more  or  less  of  imperfect 
digestion  of  food,  causing  i.he  gascric  secretion  to  be  unduly  acid  and  the 
urine  more  stimulating  to  the  coats  of  the  bladder,  and  disturbing  to  the 
whole  nervous  system. 

Very  many  of  this  class  of  patients,  especially  those  in  early  childhood, 
are  paler  than  natural,  showing  a  decided  predominance  of  the  watery 
element  of  the  blood,  and  deficiency  of  the  red  corpuscles,  together  with 
a  markedly  excitable  nervous  temperament.  Nearly  all  of  these  cases 
can  be  cured  if  the  ,physician  will  go  earnestly  about  ascertaining  the 
temperament,  habits  and  influences  which  may  be  operative  in  produc- 
ing and  perpetuating  the  malady,  and  adjusting  the  rational  remedies  for 
their  correction.  It  is  desirable  to  select  such  remedies  for  steady,  regu- 
lar use  from  day  to  day  as  are  calculated  to  diminish  the  morbid  excita- 
bility of  the  coats  of  the  bladder,  and  to  improve  directly  the  tone  and 
efficiency  of  the  excito-motory  nervous  system.  In  other  words,  the  rem- 
edies should  embrace  a  nerve  tonic  in  connection  with  something  i^hao  will 
diminish  the  sensitiveness  of  the  mucous  membrane  lining  the  bladder  and 
urinary  passages.  In  some  of  the  slighter  cases  accompanied  by  de- 
rangement of  the  digestive  organs,  nothing  more  is  required  than  to  have 
a  watchfulness  kept  over  the  amount  of  drink  that  the  patient  takes  in 
the  latter  part  of  the  day  and  evening,  the  avoidance  of  indigestible  food, 
and  the  regular  administration  of  some  one  of  the  alkaline  carbonates  suf- 
ficient to  neutralize  any  excess  of  acid  in  the  stomach  and  the  secretions, 
thereby  rendering  the  urine  more  free  from  irritating  qualities.  Where 
the  habit  is  more  fixed  and  the  child  has  become  more  pale,  or  anaemic,  I 
have  derived  much  benefit  from  the  use  of  preparations  of  iron  as  tonics, 
and  moderate  doses,  in  some  instances,  of  ergotine,  and  in  others,  of 
strychnia  or  nux  vomica,  as  remedies  designed  to  directly  increase  tne 
tone  of  the  nervous  system.  I  have  frequently  prescribed  a  mixture  of 
glycerine  and  syrup  of  the  iodide  of  iron  in  the  proportion  of  three  parts 
of  the  first  to  one  of  the  last;  of  which  mixture  from  ten  to  twenty  minims 
may  be  given  three  times  a  day,  largely  diluted  with  water,  to  children 
from  five  to  seven  years  of  age.  With  the  evening  dose  I  have  often 
added  five  minims  of  a  good  fluid  extract  of  ergot  with  advantage.  But 
whatever  may  be  the  remedies  adopted,  if  they  are  adjusted  in  suitable 
doses  and  are  calculated  to  lessen  the  sensitiveness  of  the  urinary  organs, 
and  the  irritating  quality  of  the  urine,  whenever  it  may  contain  an  excess 
of  uric  acid  or  uric  acid  salts,  and  at  the  same  time  to  exert  a  tonic  and 
invigorating  influence  upon  the  general  tone  of  the  org-anic  nervous  sys- 
tem, there  will  seldom  be  a  failure  to  remove  this  annoying  difficulty  with- 
in a  few  weeks.  Recently  the  following  formula  has  been  used  in  a  con- 
siderable number  of  cases  with  unusual  success: 

Extract!  Rhus  Aromat.  Fluidi 
Extracti  Ergot  Fluidi 
Tincturae  Nucis  Vomicae 
Simple  Elixir 

Mix.  Give  to  a  child  five  years  of  age  from  ten  to  fifteen  minims 
three  times  a  day,  in  a  little  sweetened  water.  In  all  cases  due  attention 
should  be  given  to  the  supply  of  good  food,  pure  air,  proper  clothino-  and 
out-door  exercise. 


45 

CO. 

fiss. 

30 

0.  c. 

fi- 

15 

c.c. 

3iv. 

60 

c.  c. 

?ii- 

862  THERAPEUTICS    OF   ALCOHOL. 


LECTURE  XCII. 

Alcoholic  Liquirls  as  Therapeutic  Agents:  What  indications  are  they  actually  capable  of  ful- 
filling in  the  treatment  of  disease  ?  And  what  substitutes,  if  any,  can  be  employed  by  tue  pljysiciau 
with  advantage  to  his  patients  ? 

GENTLEMEN:  I  take  pleasure  in  complying  with  your  request  to  oc- 
cupy the  hour  that  remains  for  completing  the  present  course  of 
lectures,  in  the  presentation  of  my  views  concerning  the  therapeutic 
value  of  alcoholic  liquids  in  the  practice  of  medicine.* 

Alcoholic  liquids,  as  derived  from  the  fermentation  of  various  fruits 
and  vegetable  substances,  have  been  known  and  used  from  an  early  period 
in  the  history  of  our  race.  Being  derived  from  the  grape  or  fruit  of  the 
vine  chiefly,  the  name  vinum,  or  wine,  was  naturally  applied  to  all  these 
liquids,  until  some  time  in  the  seventh  century,  when  a  liquid  obtained 
from  the  fermentation  of  corn  began  to  be  called  beer  by  the  Saxons. 

During  the  prevalence  of  the  Alchemists'  or  Arabian  school  of  chem- 
istry, in  the  eleventh  century,  the  vinous  liquids  in  use  began  to  be  sub- 
jected to  distillation,  by  which  the  active  intoxicating  constituent  was 
obtained  in  a  concentrated  form,  to  which  was  applied  the  name '' spirit 
of  wine,"  and  afterward  the  word  "alcohol."  This  last  word  appears  to 
have  been  first  used  by  the  Arabians  to  designate  an  impalpable  cosmetic 
powder  used  by  the  women  of  that  day.  It  was  afterward  applied  to 
various  subtle  powders,  and  finally  to  spirit  of  wine.  The  first  really 
scientific  use  of  the  term  "alcohol"  with  which  we  are  acquainted  was 
by  Lemert  in  his  chemistry,  published  in  1698.  For  a  long  period  after 
the  discovery  of  spirit  of  wine  or  alcohol,  it  was  used  only  as  a  solvent  or 
menstruum  in  the  preparation  and  preservation  of  other  substances,  while 
the  fermented  liquids  continued  to  be  used  as  drinks.  The  impure  and 
diluted  alcohols  derived  from  distillation  of  fermented  liquids,  known  as 
brandy,  gin,  rum  and  whisky,  are  of  modern  origin,  having  been  intro- 
duced into  use  within  the  last  two  or  three  centuries.  Although  we  have 
a  large  variety  of  beverages  derived  from  fermentation  and  distillation, 
known  as  wines,  beers  and  distilled  spirits,  yet  ethylic,  or  absolute  ether, 
universally  known  under  the  name  of  alcohol,  constitutes  the  active,  con- 
trolling ingredient  in  them  all.  The  amount  of  this  alcohol  in  the  fer- 
mented drinks,  called  wines,  beers,  ales,  etc.,  varies  from  four  to  twenty 
per  cent.,  while  in  the  distilled  spirits,  called  brandy,  whisky,  rum  and 
gin,  it  constitutes  from  fifty  to  seventj^-five  per  cent.  Separate  the  alco- 
hol from  all  these  liquids,  and  the  remainder  would  be  capable  of  produc- 
ing very  little  more  effect  on  the  human  system  than  pure  water.  The 
juniper  in  gin,  the  hop  in  beer,  and  the  vegetable  acids  and  fecula  in 
wines,  are  in  quantities  too  small  to  exert  any  important  influence,  and 
hence  may  be  omitted  from  our  further  consideration. 

When  we  speak  of  alcohol,  therefore,  or  of  the  effects  of  alcohol, 
throughout  the  remainder  of  this  paper,  we  mean  to  include  all  alcoholic 
liquids,  whether  fermented  or  distilled.  Until  analytical  and  organic 
chemistry  had  made  sufficient  progress  to  show  the  composition,  of  the 
more  common  articles  of  food  and  drink,  no  eftorts  were  made  to  explain 
the  special  or  physiological  action  of  alcohol  on  the  human  system.  All 
liquids  containing  it  were  simply  regarded  as  cordial  or  stimulant,  and 
capable  of  supporting  strength  and  life.     When    the   chemico-physiolog- 

*This  was  the  closing  lecture  in  the  Practitioners'  Course  for  1884,  and  was  given  in  compliance 
with  a  special  request  of  the  class  in  attendance. 


THERAPEUTICS    OF    ALCOHOL.  863 

iVal  school  of  investigators,  -with  Baron  Liebig  at  its  head,  developed  the 
face  tliat  all  alimentary  substances  were  capable  of  being  arranged  into 
two  classes,  the  nitrogenous  and  carbonaceous,  they  very  naturally  adopt- 
e  I  the  theoretical  idea  that  the  former,  when  taken  into  the  system,  were 
appropriaced  to  the  nourishment  of  the  tissues,  wl.ile  the  latter  united 
with  oxygen  by  a  species  of  combustion,  resulting  in  the  development  of 
animal  heat  and  carbonic  acid  gas,  and  hence  were  familiarly  styled 
"  respiratory  food." 

Alcohol,  being  one  of  the  purest  of  the  carbonaceous  class,  and  espe- 
cially rich  in  carbon  and  hydrogen,  was  at  once  assigned  a  place  at  the 
head  of  the  list  of  respiratory  foods,  and  of  supporters  of  animal  heat. 
AVhen  taken  into  the  living  system  it  was  supposed  to  unite  rapidly  with 
the  oxygen  received  through  the  lungs,  evolving  heat,  and  leaving  as  re- 
sultants carbonic  acid  gas  and  water;  in  this  way  its  supposed  heating  and 
stimulating  effects  were  explained. 

The  simplicity  of  the  explanation,  coupled  with  the  high  authority  of 
Liebig,  caused  it  to  be  almost  universally  accepted,  although  resting  on 
a  purely  theoretical  basis,  without  a  single  experimental  fact  for  its  sup- 
port. It  was  not  lonor,  however,  before  Dr.  Prout,  of  London,  ascertained, 
by  direct  experiment,  that  the  presence  of  alcohol  in  the  human  system 
directly  diminished  the  amount  of  carbonic  acid  gas  exhaled  from  the 
lungs,  and  consequently  there  could  be  no  combustion  or  oxydation  of  the 
alcohol  by  which  it  was  converted  into  carbonic  acid  and  water.  Dr.  Percy* 
and  others,  by  examination,  found  that  alcohol  taken  in  a  dilute  form  into 
the  stomach,  was  taken  up  without  change  of  composition,  and  carried 
with  the  blood  into  all  the  organs  and  structures  of  the  body,  and  that 
its  presence  could  be  easily  detected  by  the  proper  chemical  tests.  The 
chemico-physiologists,  however,  still  assuming  that  alcohol,  being  a  hydro- 
carbon, must  necessarily  be  used  for  maintaining  temperature  and  respira- 
tion, suggested  that  the  union  of  its  elements  with  oxygen  might  be 
such  as  to  result  in  forming  acetic  acid  or  aldehyde  instead  of  carbonic 
acid  gas.  Hence  they  still  sustained  the  popular  belief  that  alcoholic 
drinks  were  capable  of  increasing  both  the  temperature  and  strength  of 
the  human  body.  In  the  mean  time,  the  process  of  experimentation 
went  on.  Dr.  Bficker,f  of  Germany,  by  a  well-devised  and  carefully 
executed  series  of  experiments,  proved  that  the  presence  of  alcohol  in  the 
living  system,  actually  diminished  the  sum  total  of  eliminations  of  effete 
matter  daily;  and  consequently,  that  its  presence  must  retard  those  molec- 
ular changes  by  which  nutrition,  secretion  and  elimination  are  effected. 
In  1850,  the  writer  of  this  paper  prosecuted  an  extensive  series  of  experi- 
ments to  determine  the  effects  of  different  articles  of  food  and  drink  on 
the  temperature  of  the  body,  and  on  the  amount  of  carbonic  acid  excreted 
from  the  lungs.  These  experiments  proved  conclusively  that,  during  the 
active  period  of  digestion  after  taking  any  ordinary  food,  whether  nitrog- 
enous or  carbonaceous,  the  temperature  of  the  body  is  always  increased; 
but  after  taking  alcohol  in  the  form  of  either  fermented  or  distilled  drinks, 
the  temperature  begins  to  fall  within  half  an  hour,  and  continues  to  de- 
crease for  from  two  to  three  hours.  The  extent  and  duration  of  the  re- 
duction of  temperature  was  in  direct  proportion  to  the  amount  of  alcohol 
taken,  provided  the  effect  was  not  complicated  by  the  coincident  ingestion 
of  digestible  food.  The  results  of  this  series  of  experiments  were  embodied 
in  a  paper  read  to  the  American  Medical  Association  in  May,  1851. J    A  few 

*  An  Experimental  Inquiry  Concerning  the  Presence  of  Alcohol  in  the  Ventricles  of  the  Brain, 
etc.;  London,  1839. 
t  Jieitrage  zur  Heilkunde.  Crefeld,  1849. 
j  see  Northwestern  Medical  aud  Surgical  Journal  for  1851. 


864  THERAPEUTICS    OF    ALCOHOL, 

years  later,  the  experimental  researches  of  Lallemand,  Perrin  and  Duroy,* 
proved  conclusively  that  alcohol,  when  taken  into  the  stomach,  was  not 
only  absorbed  and  carried  with  the  blood  into  all  the  organs  and  tissues  of 
the  body,  but  also  that  it  was  eliminated  as  alcohol,  unchansjed  chemically, 
from  the  lungs,  skin  and  kidneys.  The  experiments  of  Prout  were  re- 
peated, and  his  results  coMfirmed  by  Sandras  and  Bouchardet,  of  France, 
W.  A,  Hammond,f  myself  and  others  of  this  country.  Those  of  BScker 
were  carefully  repeated  and  varied  by  Anstie,  of  England,  and  Hammond, 
of  this  country.  My  own  in  reference  to  the  eflFects  of  alcohol  on  animal 
heat  have  been  repeated,  and  the  results  confirmed  by  a  large  number  of 
observers,  among  whom  are  Drs.  Richardson,J  Anstie  and  Hammond. 
Those  of  Lallemand,  in  reference  to  the  elimination  of  alcohol,  have  been 
equally  confirmed,  except  the  claim  that  the  amount  eliminated  is  not 
equal  to  the  whole  quantity  taken. 

It  is  conceded  by  all  investigators  that  when  alcoholic  liquids  are  taken 
into  the  stomach  or  in  any  other  way  administered,  the  alcohol  is  rapidly 
absorbed  into  the  blood,  circulates  with  it  throughout  all  the  tissues  of  the 
body,  and  may  be  detected  in  the  form  of  alcohol,  both  in  the  blood  and 
in  the  structures  of  the  various  organs.  All  agree,  also,  that  it  is  elimi- 
nated through  the  various  eliminating  structures,  as  the  skin,  lungs,  kid- 
neys, etc.  These  simple  facts,  when  observed  in  regard  to  the  behavior 
of  any  other  substance,  are  regarded  as  amply  sufficient  to  prove  that 
the  substance  so  acting  is  not  alimentary  in  its  nature,  but  foreign  to  the 
system. 

But  so  strong  is  the  predisposition  to  find  some  important  use  for  alco- 
hol in  the  human  system,  caused  by  customs  and  habits  of  thought 
through  many  generations,  that  the  most  vigorous  tests  and  calculations 
have  been  made  to  ascertain  whether  some  part,  at  least,  of  the  alcohol 
taken  might  not  be  retained,  and  if  not  used  directly  for  nutrition  of  the 
tissues,  certainly  converted  into  some  kind  of  force  or  energy.  The  late 
Dr.  Anstie,  who  followed  up  the  investigation  of  this  question  with  the 
most  commendable  perseverance,  came  to  the  conclusion  that  an  average 
sized  adult  in  ordinary  health  was  capable  of  retaining  about  45  grammes 
(fl.  §iss)  of  pure  alcohol  in  the  twenty-four  hours,  admitting  that  when- 
ever more  than  this  was  taken  in  the  time  specified,  it  re- appeared  in  the 
evacuations  or  was  eliminated  unchanged.  From  this  it  has  been  very 
generally  assumed,  not  only  that  the  amount  named  may  be  retained,  but 
that  it  must  of  necessity  be  so  used  or  re-combined  as  to  evolve  some 
kind  of  sustaining  force.  For  a  long  time  it  was  claimed  the  retained 
alcohol  underwent  oxydation,  and  evolved  heat.  When  this  was  fully 
demonstrated  to  be  erroneous  by  the  direct  application  of  the  clinical 
thermometer,  by  all  experimenters  from  my  own  in  1850  to  the  present 
time,  §  it  was  then  assumed  that  its  consumption  resulted  either  directly 
or  indirectly  in  the  evolution  of  nerve  force.  But  here  again  the  crucial 
test  of  direct  experimental  observation  soon  showed,  that  so  far  as  the 
motor  and  sensory  nerve  and  muscular  functions  are  concerned,  both 
were  diminished  in  direct  ratio  to  the  quantity  of  alcohol  taken. 

While  the  presence  of  alcohol  in  the  blood  slightly  increases  the  fre- 
quency of  the  action  of  the  heart,  it  renders  its  systole  shorter  and  quick- 
er, while  it  simultaneously  so  modifies  the  vaso-motor  nerve  influence 
over  the  whole  system  of  smaller  vessels  and  capillaries  as  to  retard  the 

*  Du  Role  de  1' A.lcool  et  des  Anestheslques  dans  I'Organism,  Paris,  1860. 
tPhvsiological  Memoirs,  pp.  43  to  5U. 

t  Diseases  of  Modern  Life,  pp  220  an  1  230,  New  York,  18S3. 

>/  Even  the  extended  observations  of  Dr.  Parkes  and  Count  Wallowicz,  led  only  to  negative  re- 
sults in  tills  regard. 


THERAPEUTICS    OF    ALCOHOL.  865 

current  of  blood  in  them  and  to  cause  their  manifest  dilatation.  Conse- 
quently, the  sphygmrgraphic  line  is  made  to  rise  more  abruptly  with  the 
cardiac  systole  and  fall  still  more  quickly  in  the  diastole,  with  a  slight 
wavy  or  unsteady  character  of  the  line  before  the  next  systole,  giving  to 
the  tracing  characters  closely  resembling  the  pulse  line  of  typhoid 
fever.* 

The  increased  frequency  of  the  pulse  led  Dr.  Parkes  and  Count  Wal- 
lowicz  to  make  an  interesting  mathematical  calculation  of  the  supposed 
increased  amount  of  work  done  by  the  heart  under  the  influence  of  alcohol 
as  compared  with  the  normal  standard. 

Their  results  under  eight  days  daily  use  of  alcohol,  gave  an  average  of 
over  34,000  beats  per  day  more  than  without  the  alcohol,  from  which  they 
estimated  that  the  heart  did  an  amount  more  of  work  per  day  equal  to 
the  lifting  of  from  fifteen  to  twenty  tons  one  foot.  The  language  used  by 
these  observers  in  stating  the  foregoing  results,  has  created  the  manifest- 
ly erroneous  impression,  that  the  heart,  under  the  influence  of  alcohol, 
is  made  to  do  so  much  more  actual  efficient  work  in  the  circulation 
of  the  blood;  whereas  the  increased  frequency  of  the  beats  is  more  than 
counterbalanced  by  the  diminished  influence  of  the  vaso-motor  nerves  on 
the  coats  of  the  smaller  vessels,  causing  them  to  become  unnaturally  full 
from  the  retardation  of  the  blood  currents  in  them.f  The  truth  is  that 
under  the  influence  of  alcohol  in  the  blood,  the  systolic  action  of  the  heart 
loses  in  sustained  force  in  direct  proportion  to  its  increase  in  frequency, 
until  by  simply  increasing  the  proportion  of  alcohol,  the  heart  stops  in  dias- 
tole, as  perfectly  paralyzed  as  are  the  coats  of  the  smaller  vessels  throughout 
the  system.  This  was  admirably  demonstrated  by  the  recent  experimental 
investigation  of  Professor  Martin,  of  the  Johns  Hopkins  University,  Mary- 
land, on  the  effects  of  different  proportions  of  alcohol  on  the  action  of  the 
heart  of  the  dog,|  and  of  Drs.  Sidney  Ringer  and  Harrington  Sainsbury, 
to  determine  the  relative  strength  of  the  different  alcohols,  as  indicated  by 
their  influence  on  the  action  of  the  heart  of  the  frog.§  These  latter  emi- 
nent experimenters  say  in  closing  their  report  on  the  action  of  the  alcohols, 
"  that  by  their  direct  action  on  the  cardiac  tissue,  these  drugs  are  clearly 
jKiralyzant.  and  that  this  appears  to  be  the  case  from  the  outset,  no  stage 
of  increased  force  of  contraction  preceding."  Professor  Martin  states  the 
results  obtained  by  him  as  follows:  "  Blood  containing  one  eighth  per  cent, 
by  volume  of  absolute  alcohol  has  no  immediate  action  on  the  isolated 
heart.  Blood  containing  one  fourth  per  cent,  by  volume,  that  is  two  and 
a  half  parts  per  thousand  of  absolute  alcohol,  almost  invariably  remarka- 
bly diminishes,  within  a  minute,  the  work  done  by  the  heart;  blood  con- 
taining one  half  per  cent,  always  diminishes  it,  and  may  even  bring  the 
amount  pumped  out  by  the  left  ventricle  to  so  small  a  quantity,  that  it  is 
not  sufficient  to  supply  the  coronary  arteries."  Professor  Martin  estimates 
one  fourth  per  cent.,  or  two  and  a  half  parts  per  thousand,  of  the  blood  of 
an  adult  man,  weighing  150  pounds,  to  be  only  fifteen  cubic  centimeters 
(fl.  3iv),  an  amount  only  equal  to  that  contained  in  an  ordinary  glass  of 
brandy  or  whisky.]]  These  investigations  of  Professor  Martin,  directly 
corroborated  by  those  of  Drs.  Ringer  and  Sainsbury,  complete  the  series 
of  demonstrations  needed  to  show  the  actual  effects  of  alcohol  on  the  car- 
diac, as  well  as  the  vaso-motor  nerves,  and  also  on  the  direct  contractibil- 
ity  of  the  muscular  structure,   when   supplied    with  blood    containing  all 

*  See  Chicago  Medical  Examiner,  Vol.  VIII,  p.  522, 1867. 
t  Diseases  of  Modern  Life  by  B.  W.  Richardson,  p.  ?16. 
t  See  Journal  nf  the  American  Medical  Association,  Vol.  1,  page  307. 

f  See  The  Practitioner,  London.  May,  lt83,  and  Journal  of  American  Medical  Association,  Vol.  1, 
p  ge272. 
li  Maryland  Medical  Journal  for  September,  1883. 

55 


866  THERAPEUTICS    OF    ALCOHOL. 

gradations  in  the  relative  proportion  of  alcohol,  leaving  no  longer  a  refuge 
for  the  idea,  popular  both  in  and  out  of  the  profession,  that  alcohol  in  any 
dose  is  capable  of  increasing,  even  temporarily,  the  force  or  efficiency  of  the 
heart's  action.  It  is  certain,  therefore,  that  if  a  small  proportion  of  the 
alcohol  taken  in  the  various  fermented  and  distilled  liquids  is  retained  in 
the  living  bodv,  or  can  not  be  actually  reproduced  in  the  eliminations 
within  a  limited  time,  such  retained  portion  is  neither  used  for  the  evo- 
lution of  heat,  the  increase  of  nerve  force,  the  efficiency  of  muscular 
contraction,  nor  yet  for  quickening  molecular  movements  in  the  processes 
of  nutrition,  disintegration  and  secretion.  Consequently,  the  assump- 
tion that  if  any  part  of  the  alcohol  taken  is  retained  for  a  time,  at  least, 
it  must  from  necessity  be  converted  into  some  kind  of  force  or  energy,  is 
not  sustained  by  any  known  facts,  either  of  scientific  experiment  or  of 
clinical  experience.  On  the  contrary,  it  acts  in  the  same  direction  as 
chloroform,  ether,  and  all  the  other  members  of  the  same  chemical  group 
of  substances,  laaraely,  as  an  anassthetic  to  nerve  sensibility,  a  relax- 
ant of  muscular  tone  or  contractibility,  and  a  retarder  of  molecular 
movements  in  the  tissues:  these  eifects  being  produced  in  direct  ratio  to 
the  amov;nt  taken,  relatively  to  the  whole  weight  of  the  individual  taking 
it.  That  the  action  of  alcohol  in  the  human  system  is  in  all  respects  sim- 
ilar, except  m  being  slower,  to  that  of  chloroform  and  ether,  was  fully  dem- 
onstrated by  the  direct  investigations  of  Dr.  Anstie,  who  concludes  this 
part  of  the  subject  with  the  following  important  declaration:  "A  general 
review  of  the  phenomena  of  alcohol-narcosis  enables  me  to  come  to  one 
distinct  conclusion,  the  importance  of  which  appears  to  be  very  great, 
namely,  that  (as  in  the  case  of  chloroform  and  ether)  the  symptoms  which 
are  so  commonly  described  as  evidences  of  excitement,  depending  on  a 
stimulation  of  the  nervous  system  preliminary  to  the  occurrence  of  narco- 
sis, are  in  reality  an  essential  part  of  the  narcotic,  that  is,  the  paralytic 
phenomena."*  So  far  from  being  justified  in  the  common  assumption  that 
all  the  alcohol,  not  capal-jle  of  being  detected  in  the  eliminations  during 
twenty-four  or  forty-eight  hours  after  it  is  taken,  is  converted  into  some 
kind  of  force,  there  is  positive  proof  that  it  remains  unchanged,  and  can 
be  detected  in  the  living  tissues  long  after  it  ceases  to  be  detected  in 
either  the  breath,  perspiration  or  urine.  Thus  the  same  author  just 
quoted,  says  on  page  368:  "  Nothing  is  more  plainly  proved  by  M.  M. 
Lallemand,  Duroy  and  Perrin,  than  the  fact  that  long  after  the  latest 
periods  at  which  any  of  the  alcohol  absorbed  can  be  recognized  in  the 
'breath,  the  urine,  or  the  sweat,  unchanged  alcohol  in  notable  quantities 
can  be  recognized  in  the  blood  and  tissues  of  the  alcoholized  animal.  M. 
Baudot  justly  observes  that  ther^  is  no  necessity  to  suppose  that  this  sub- 
stance must  be  transformed  immediately^  if  transformed  at  all,  in  the  or- 
ganism." And  T  may  add,  in  view  of  the  fact  that  the  most  varied  and  scru- 
tinizing researches  of  different  investigators  have  entirely  failed  to  find 
any  products  of  such  transformation,  either  in  the  form  of  matter  or  force, 
there  is  no  probability  that  such  transformation  ever  does  take  place; 
but  that  the  retained  alcohol  is  held  simply  by  a  strong  affinity  for  the 
albuminoid  constituents  of  the  blood  and  tissues,  retarding  by  its  pres- 
ence the  natural  affinities  and  movements  of  such  constituents,  and  being 
detached  and  eliminated  by  the  slow  process  of  disintegration,  and  disap- 
pearance of  the  atoms  by  which  it  is  held.  It  is  exactly  this  retained 
alcohol  that  causes  in  the  habitual  moderate  drinker,  those  slow,  but  cer- 
tain deteriorations  of  structure  in  the  liver,  kidneys,  cardiac  and  vascular 

«  See  Stimnlants  and  Narcotics,  Their  Mutu  ,1  Relations,  etc.,  by  Francis  E.  Anstie,  M.  D.,  M.  R. 
■C.  P.,  page  357. 


THERAPEUTICS    OF    ALCOHOL.  867 

walls  and  structures,  generally  described  by  pathologists  under  the 
head  of  fatty  and  atheromatous  degenerations.  That  part  of  the  alcohol 
taken  which  finds  ready  elimination,  contrit)utes  to  the  direct  anaesthetic 
effect,  and  more  prominent  temporary  functional  disturbances,  but  leaves 
little  permanent  impression  on  the  living  structures. 

From  all  the  foregoing  considerations  we  may  formulate  the  following 
propositions: 

First.  That  alcohol,  when  taken  diluted  in  the  form  of  fermented  or 
distilled  spirits,  is  rapidly  absorbed  without  change,  carried  into  the  blood, 
and  with  that  fluid  brought  in  contact  with  every  structure  and  part  of 
the  human  body. 

Second.  That  while  circulating  in  the  blood,  its  presence  retards  those 
molecular  or  atomic  changes  which  constitute  nutrition,  disintegration  and 
secretion,  and  on  which  the  phenomena  of  life  depend. 

Third.  That  its  presence  in  the  living  system  retards  the  elimination 
of  waste  matter,  impairs  nerve  sensibility,  lessens  muscular  excitability 
and  contractibility,  and  lowers  the  temperature  of  the  body. 

Fourth.  That  a  large  part  of  the  amount  taken  is  rapidly  eliminated 
with  the  various  excretions,  and  there  is  no  evidence  whatever  that  such 
part  as  may  be  retained  a  longer  period,  is  either  assimilated  or  converted 
into  any  form  of  force. 

These  propositions  are  as  well  established  as  any  facts  in  the  domain  of 
physiology,  or  in  the  whole  field  of  natural  science,  and  they  point  with 
all  the  clearness  and  force  of  a  mathematical  demonstration  to  the  con- 
clusion that  alcohol  is  in  no  sense  food;  neither  furnishing  material  for 
the  tissues,  nor  fuel  for  combustion,  nor  yet  generating  either  nervous  or 
muscular  force.  Having  thus  determined,  experimentally,  that  alcohol  is 
neither  food  nor  a  generator  of  fdrce  in  the  living  body,  the  question  re- 
curs, what  are  its  positive  effects  when  taken  in  the  ordinary  manner? 
I  answer,  simply  those  of  an  anaesthetic  and  organic  sedative.  Like  ether 
and  chloroform,  its  presence  diminishes  the  sensibility  of  the  nervous  sys- 
tem and  brain,  thereby  rendering  the  individual  less  conscious  of  all  out- 
ward and  exterior  impressions.  This  diminution  of  sensibility,  or  anes- 
thesia, is  developed  in  direct  ratio  to  the  quantity  of  alcohol  taken,  and 
may  be  seen  in  all  stages,  from  simple  exemption  from  all  feeling  of 
fatigue,  pain,  and  idea  of  weight,  exhibited  by  ease,  buoyancy,  hilarity, 
etc.,  to  that  of  complete  unconsciousness,  and  loss  of  muscular  power.  It 
is  this  anaesthetic  effect  of  alcohol  that  has  led  to  all  the  popular  errors  and 
contradictory  uses  which  have  proved  so  destructive  to  human  health  and 
happiness.  It  has  long  been  one  of  the  noted  paradoxes  of  human  action, 
that  the  same  individual  would  resort  to  the  same  alcoholic  drink  to  warm 
him  in  winter,  protect  him  from  the  heat  in  summer,  to  strengthen  when 
weak  or  weary,  and  to  soothe  and  cheer  when  afflicted  in  body  or  mind. 
With  the  facts  now  before  us,  the  explanation  of  all  this  is  apparent.  The 
alcohol  does  not  relieve  the  individual  from  cold  by  increasing  his  tem- 
perature, nor  from  heat  by  cooling  him,  nor  from  weakness  and  exhaustion 
by  nourishing  his  tissues,  nor  yet  from  affliction  by  increasing  nerve 
power,  but  simply  by  diminishing  the  sensibility  of  his  nerve  structures, 
and  thereby  lessening  his  consciousness  of  impressions,  whether  from  cold 
or  heat,  or  weariness  or  pain.  In  other  words,  the  presence  of  the  alcohol 
has  not  in  any  degree  lessened  the  effects  of  the  evils  to  which  he  is  ex- 
posed, but  has  diminished  his  consciousness  of  their  existence,  and  there- 
by impaired  his  judgment  concerning  the  degree  of  their  action  upon  him. 

It  is  this  property  of  alcohol  to  produce  that  sense  of  ease,  buoyancy 
and  exhilaration,  arising  from  a  moderate  diminution  of  nerve  sensibility, 


868  THERAPEUTICS    OF    ALCOHOL. 

that  gives  it  the  fascinating  and  delusive  power  over  the  human  race 
which  it  has  wielded  so  ruinously  for  centuries  gone  by.  But  while  the 
presence  of  alcohol  diminishes  the  sensibility  of  the  nervous  structure,  it 
also  retards  all  the  molecular  changes,  thereby  diminishing  the  activity  of 
nutrition,  secretion,  elimination  and  the  evolution  of  heat,  constituting  a 
true  organic  sedative.  When  taken  in  small  quantities,  repeated  df>i!y, 
the  individual  usually  slowly  increases  in  weight,  not  from  increased  nutri- 
tion, but  from  retarding  the  waste  and  retaining  the  old  atoms  longer  in 
the  tissues.  By  some  investigators  this  power  to  retard  atomic  changes 
and  consequently  to  retain  the  old  atoms  has  been  regarded  as  equivalent 
to  nutrition,  or  the  actual  assimilation  and  addition  of  new  atoms.  It  is 
on  this  basis  that  Dr.  Hammond  and  a  few  others  persist  in  representing 
alcohol  as  indirect  food.*  The  fallacy  of  such  claim,  and  its  mischievous 
tendency,  will  be  fully  apparent  by  reference  to  one  of  the  plainest  laws 
governing  living  animal  matter.  The  law  is,  that  all  the  phenomena  of 
animal  life  are  associated  with  and  dependent  on  atomic  changes,  and 
that  each  individual  cell  or  aggregation  of  bioplasm  constituting  an  or- 
ganic atom,  has  its  determinate  period  of  growth,  maturity  and  dissolution. 
Hence,  to  introduce  into  the  living  system  any  agent  that  will  retard 
atomic  change,  is  equivalent  to  retarding  the  phenomena  of  life.  And  if 
by  retarding  the  atomic  changes,  cells  or  atoms  are  retained  in  the  tissues 
longer  than  the  natural  duration  of  their  activity,  such  retention  may  in- 
crease the  bulk  and  weight,  but  in  the  same  ratio  it  embarrasses  the  tis- 
sues with  the  presence  of  material  which  is  constantly  becoming  inert  and 
tending  to  degeneration.  Consequently,  the  individual  who  thus  increases 
his  bulk  and  weight  by  taking  just  enough  of  the  weaker  alcoholic  drinks 
daily  to  retard  the  processes  of  secretion  and  waste,  in  the  same  propor- 
tion diminishes  his  activity,  his  power  of  endurance,  and  his  ability  to 
resist  the  effects  of  morbid  agents  of  every  kind.  This  is  abundantly 
illustrated  by  the  thousands  of  beer  and  wine  drinkers,  who  from  twenty 
to  twenty-five  years  of  age  were  muscular,  active,  capable  of  any  reason- 
able endurance,  with  a  weight  of  150  pounds,  but  who,  after  moderately 
retarding  atomic  changes  and  retaining:  old  atoms  by  the  daily  use  of  wine 
or  beer,  have  acquired  a  weight  of  20lJ  pounds  or  more,  and  have  lost  their 
muscular  activity  and  endurance  to  such  an  extent  that  an  active  exercise 
of  twenty  minutes  would  make  them  entirely  out  of  breath.  It  is  this 
sedative  effect  of  alcohol  on  the  organic  or  molecular  changes  in  the 
tissues,  retaining  waste  and  effete  matter,  that  ought  to  have  been  prompt- 
ly disintegrated  and  thrown  out,  which  impairs  the  vital  properties,  and 
predisposes  or  prepares  the  system  to  yield  to  morbid  influences  of  any 
kind  to  which  it  may  be  exposed.  And  especially  does  this  sedative  effect 
of  alcohol  on  the  organic  changes,  when  maintained  by  a  moderate  and 
continued  use  of  the  article,  fiivor  those  degenerative  changes  which  re- 
sult in  tubercular,  caseous,  and  fatty  deposits  in  the  lungs,  liver,  kidneys, 
heart  and  arteries  of  the  brain,  and  in  materially  shortening  the  duration 
of  life.  It  is  the  same  interference  with  the  processes  of  nutrition  an  1 
waste,  only  exerted  more  actively,  that  causes  gastritis  and  delirium  tre- 
mens in  the  excessive  drinker  of  distilled  spirits.  If  you  ask  for  the  special 
modus  operandi  of  alcohol,  how  it  produces  its  anassthetic  and  sedative 
effect  when  taken  into  the  human  system,  I  answer,  chiefly  by  its  strong 
affinity  for  water  and  albumen.  The  two  last  named  substances  exist  in 
the  blood  and  all  the  tissues  of  the  body,  and  for  them  alcohol  has  a  strong 
chemical  affinity.     Hence,  when  it  is  present  in  the  blood,  it  attracts  the 

*  A  Treatise  on  Hygiene,  with  Special  Reference  to  Military  Service,  1863,  p.  35. 


THERAPEUTICS    OF    ALCOHOL.  86d 

water  from  the  blood  corpuscles,  causing  them  to  become  more  or  less 
corrugated,  and  inclined  to  adhere  to  one  anotlier  as  described  bv  Dr. 
Ricliardson,  of  London,  and  diminishing  the  capacity  of  the  blood  to  ab- 
sorb oxygen  or  other  gases  from  the  air  in  the  lungs;  and  by  its  strono- 
affinity  lor  the  albumen  of  the  tissues,  it  retards  the  play  of  vital  affinity 
between  that  substance  and  the  other  materials  with  which  it  is  in  contact, 
thereby  retarding  the  molecular  changes  as  already  described.  The 
paralyzing  effect  exerted  on  the  vaso-motor  as  well  as  cerebro-spinal  nerv- 
ous structures  by  which  sensibility  is  impaired,  is  owning  partly  to  the 
direct  anajsthetic  properties  of  the  alcohol,  and  partly  to  the  diminished 
interchange  of  oxygen  for  carbonic  acid  gas  in  the  process  of  respiration. 
That  a  part  of  the  alcohol  should  be  retained  for  a  considerable  length  of 
time  in  the  system  by  the  affinities  just  mentioned,  is  very  probable. 
Hence  the  late  Dr.  Anstie  may  have  been  correct  in  claiming  that  it  was 
not  all  eliminated  from  the  system  within  any  limited  period  of  time,  and 
yet  its  retention  would  afford  no  proof  that  it  was  either  appropriated  as 
food  or  for  the  generation  of  force. 

On  the  contrary,  the  catalytic  influence  of  its  presence  retards  both. 
If  we  scan  the  whole  domain  of  physiology  and  pathology  in  connection 
with  the  logical  deductions  from  the  experimental  researches  by  parties 
widely  separated  by  time,  space,  nationality  and  language,  we  shall  be 
forced  to  the  conclusion  that  alcohol,  as  found  in  any  or  all  of  the  fer- 
mented and  distilled  drinks,  is  neither  stimulating,  strengthening,  nor 
nourishing  to  the  human  system,  but  simply  aniesthetic  and  sedative. 

What  then  are  the  therapeutic  indications  they  are  capable  of  fulfilling 
in  the  treatment  of  disease?  First.  By  the  anaesthetic  properties  of  the 
alcohol  they  contain,  they  are  capable  of  diminishing  nerve  sensibility 
and  muscular  force,  in  the  same  manner  as  other  well-known  ana3S- 
thetics. 

But  from  the  slower  development  of  the  effects  of  the  alcohol,  and  the 
still  slower  disappearance  of  those  effects,  the  liquids  containing  it  are 
far  inferior  for  all  practical  anesthetic  purposes,  to  chloro.orm,  ether  or 
nitrous  oxide,  and  are  consequently  seldom  used  in  that  cap  icity,  except 
to  relieve  pain  and  promote  sleep  in  certain  conditions  of  nervous  unrest. 
And  here,  again,  they  are  far  less  efficient  and  more  liable  to  secondary 
bad  consequences  than  the  bromides,  chloral,  and  the  numerous  class  of 
milder  anodynes  and  antispasmodics  familiar  to  every  intelligent  phy- 
sician. 

Second.  By  the  power  of  alcohol  to  retard  the  evolution  of  heat  in 
retarding  molecular  changes  in  the  tissues,  the  liquids  containing  it  may 
be  used  as  antipyretics  when  the  temperature  is  too  high,  and  to  retard 
the  processes  of  waste  when  these  ai'e  too  rapid.  But  tlie  antipyretic  in- 
flur^nce  of  alcohol  is  so  feeble  in  comparison  with  the  proper  application 
of  water  to  the  surface,  or  with  the  internal  administration  of  sulphate  of 
quinia,  salicylic  acid,  digitalis,  etc.,  that  no  one  thinks  of  using  it  for  an- 
tipyretic purposes- 

The  power  of  alcoholic  liquids  to  retard  the  molecular  changes  in  the 
blood  and  tissues,  and  thereby  lessen  the  rapidity  of  tissue  change,  really 
constitutes  the  basis  on  which  rests  the  use  of  a  large  part  of  what  is 
prescribed  by  the  profession  at  the  present  day  in  the  treatment  of  the 
sick.  In  this,  however,  there  are  involved  two  fallacies  of  much  im- 
portance. The  first  arises  from  the  failure  to  discriminate  between  the 
loss  of  flesh  and  strength  from  a  failure  or  diminution  of  the  processes  of 
assimilation  and  nutrition  by  which  the  natural  tissue  waste  is  replaced 
by  new  matter,  and  the  loss  of  flesh   and   streno'th  from  simple   excess  of 


870  THERAPEUTICS    OF    ALCOHOL. 

rapidity  in  the  processes  of  disintegration  or  tissue  wasto  while  the  repara- 
tive processes  remain   natural. 

The  second  consists  in  the  assumption,  that  retarding  molecular  move- 
ments in  such  manner  as. to  lessen  the  rapidity  of  natural  change  or  dis- 
integration of  tissue  is  equivalent  to  the  maintenance  of  tissue  integrity 
by  the  assimilation  and  addition  of  new  matter;  the  falsity  of  which  I 
have  already  pointed  out. 

There  is,  indeed,  no  more  mischievous  error  existing  either  in  or  out 
of  the  profession,  at  this  time,  than  that  of  regarding  the  loss  of  flesh, 
whether  from  disease  or  overwork,  as  generally  due  to  increased  disin- 
tegration instead  of  diminished  nutrition.  The  first  existing  alone  as  a 
primary  morbid  condition  is  exceedingly  rare,  while  the  latter  is  present, 
to  some  extent,  in  nearly  all  the  morbid  conditions  met  with.  And  yet 
alcohol  is,  even  theoretically,  applicable  only  to  cases  of  the  first,  while 
practically,  as  shown  by  clinical  experience,  it  is  not  adapted  to  the  suc- 
cessful treatment  of  either  of  the  conditions  named.  For  while  its 
presence  in  the  blood  retards  tissue  change,  it  does  it  by  equally  retard- 
ing the  molecular  movements  concerned  in  the  processes  of  assimilation, 
nutrition  and  secretion.  Consequently  while  its  first  impression  is  often 
delusively  beneficial,  its  continuance  for  one,  two  or  three  weeks  almost 
invariably  develops  a  diminution  of  appetite  for  food,  an  impairment  of 
the  digestive  function,  or  manifest  derangements  in  the  excretory  func- 
tions. 

An  infinitely  better  method  of  promoting  nutrition  and  maintaining 
the  healthy  balance  between  it  and  waste,  consists  in  a  full  supply  of  pure 
air,  a  sufficient  supply  of  plain  digestible  food,  and  the  judicious  regula- 
tion of  the  hours  of  exercise  and  rest,  both  mental  and  physical.  To 
supplement  these  with  any  form  or  quantity  of  alcohol,  is  entirely  super- 
fluous; and  to  attempt  to  substitute  the  latter  in  the  place  of  any  one  of 
the  former,  only  leads  more  speedily  and  certainly  to  disastrous  failure. 
In  cases  requiring  any  other  aid  to  the  nutritive  processes  and  the  main- 
tenance of  general  tonicity,  besides  pure  air,  good  food,  and  a  proper  reg- 
ulation of  exercise  and  rest,  the  hypophosphites  of  calcium,  sodium  and 
iron,  the  lactophosphates  of  calcium  and  iron,  the  ordin^sry  preparations 
of  iron,  and  the  bitter  infusions  may  be  resorted  to  with  advantage. 

The  two  therapeutic  indications  I  have  now  passed  in  review  are  the 
only  ones  that  can  be  founded  on  the  known  and  demonstrated  effects  of 
alcohol  on  the  functions  and  structures  of  the  human  body.  But  there 
are  two  others  supposed  to  exist  by  a  large  portion  of  the  profession  and 
of  the  community.  One  of  these  is  founded  on  the  supposed  ability  of  the 
alcohol  to  strengthen  the  action  of  the  heart  and  sustain  the  circulation 
generally.  It  is  to  fulfill  this,  that  the  alcoholic  liquors  are  so  extensively 
used  in  the  ty2:(lioid  and  many  other  low  forms  of  febrile  disease.  And  yet 
you  have  already  seen  that  the  entire  series  of  facts  derived  from  the  whole 
field  of  experimental  investigation,  proves  that  the  presence  of  alcohol  ex- 
erts a  paralyzing  influence  over  the  whole  vaso-motor  system  of  nerves  and 
finally  paralyses  the  heart  itself,  and  wherever  the  proper  tests  have  been 
applied,  the  results  of  experimental  research  have  been  corroborated  by 
clinical  experience.  It  is  now  thirty-five  years  since  I  commenced  the 
direct  clinical  study  of  the  effects  of  alcohol  as  a  remedial  agent.  I 
have  used  the  spygmograph  and  all  other  means  of  testing  the  strength  of 
the  heart  and  the  efficiency  of  the  circulation,  in  every  variety  of  the  low 
forms  of  febrile  disease  coming  under  my  observation,  and  I  have  never 
yet  found  an  instance  in  which  it  increased  the  cardiac  force  or  the 
efficiency   of   the    general    circulation.     But  I  have  seen   many  cases  in 


THEEAPEUTICS    OF    ALCOHOL.  871 

which  it  so  impaired  the  vaso-inotor  influence  as  to  greatly  increase 
passive  congestion  in  the  lungs  and  other  vascular  structures,  and  that,  loo, 
while  its  anaesthetic  inlluence  in  quieting  restlessness,  caused  the  patients 
to  appear  comfortable,  and  to  say  they  were  better,  even  up  to  the  time  of- 
relaxation  of  the  sphincters  and  the  occurrence  of  involuntary  discharges. 
I  have  repeatedly,  under  such  circumstances,  stopped  entirely  the  admin- 
istration of  alcoholic  remedies  and  in  their  place  given  strychnine  and  the 
mitieral  acids,  alternated  with  suitable  doses  of  digitalis,  caffeine,  or  in-- 
fusion  of  coffee  with  milk,  and  wheat-flour  and  milk  gruel  for  nourishment^ 
with  the  most  satisfactory  results.  Strychnia,  digitalis,  convallaria, 
cactus  grandiflora,  caffeine  and  theine,  are  true  vaso-motor  and  cardiac 
tonics,  with  none  of  the  paralyzing  influences  of  alcoiiol,  and  none  of  the 
secondary  tissue  degenerative  tendencies  possessed  by  the  latter. 

They  are  consequently  admirably  adapted  to  fulfill  the  indications  pre- 
sented in  the  lower  types  of  acute  general  diseases,  for  which  alcoholic 
preparations  have  so  long  been  prescribed  injuriously  on  a  false  basis. 
The  second  popular  therapeutic  indication  is  founded  on  the  equally  false 
idea,  that  alcohol  is  capable  of  acting,  at  least  as  a  temporary  stimulant, 
in  arousing  nerve  sensibility  and  sustaining  cardiac  action  in  cases  of  threat- 
ened syncope,  shock,  and  other  forms  of  sudden  and  severe  depression  or 
exhaustion.  But  the  same  fatal  objection  lies  against  its  use  for  fulfilling 
this  indication  as  in  the  immediately  preceding  one;  namely  that  the 
alcohol  acts  as  a  paralyzant  and  anaesthetic  from  the  first  drop  to  the  last, 
and  in  no  sense  as  a  stimulant.  If  you  ask  me  how  it  happens  that  a 
remedy  that  does,  not  only  no  good,  but  is  directly  calculated  to  do  harm, 
can  so  long  and  universally  nviintain  its  reputation,  both  in  and  out  of  the 
profession,  in  such  cases,  1  answer,  that  it  does  so  solely  by  reason  of 
two  facts:  First,  that  ninety  and  nine  of  every  hundred  cases  of  threat- 
ened or  actual  syncope,  shock,  nervous  prostration  and  sinking,  for  which 
alcoholic  liquids  are  so  hurriedly  used,  would  and  do  recover  just  as  quick- 
ly and  more  certainly,  if  simply  placed  at  rest  in  fresh  air  without  a  drop 
of  alcohol  in  any  form.  But  as  such  cases  are  sometimes  severe  enough 
to  require  some  prompt  and  judicious  treatment,  we  have  in  the  corbonate 
and  aromatic  spirits  of  ammonia,  and  the  preparations  of  camphor,  far 
more  speedy  and  efficient  remedies  for  immediately  arousing  sensibility, 
especially  when  aided  by  a  few  sudden  dashes  of  cold  water  upon  the  face 
and  chest,  and  in  the  caffeine,  digitaline,  convallaria,  etc.,  the  proper 
cardiac  tonics  for  restoring  permanent  steadiness  and  force  to  the  circula- 
tion. I  speak  the  more  positively  on  this  subject,  gentlemen,  because, 
for  more  than  thirty  years  past  I  have  faithfully  tested  the  correctness  of 
the  sentiments  I  have  given  you  in  relation  to  the  therapeutic  effects  and 
uses  of  alcoholic  liquids  in  an  ample  clinical  experience  both  in  hospital  and 
private  practice;  and  during  ail  that  time  I  have  found  no  case  of  disease 
and  no  emergency  arising  from  accident,  that  I  could  not  treat  more  success- 
fully without  any  form  of  fermented  or  distilled  liquors  than  with.  It  is  easy 
to  see  that  the  anesthetic  properties  of  alcohol  can  be  made  available  by 
an  intelligent  and  skillful  physican  to  meet  a  very  limited  number  of  in- 
dications in  the  treatment  of  some  cases  that  will  come  before  him.  But 
the  same  intelligence  and  skill  will  enable  him  to  select  other  remedies 
capable  of  meeting  the  same  indications  more  perfectly,  and,  with  less 
tendency  to  secondary  bad  effects.  I  have  no  hesitation,  therefore,  in 
stating  that  for  the  attainment  of  the  highest  degree  of  success  in  the 
management  of  all  forms  of  disease,  whether  acute  or  chronic,  we  need  no 
form  of  fermented  or  distilled  alcoholic  drinks.  Pure  alcohol  for  chemical, 
pharmaceutical  and  manufacturing  purposes,  is  all  that  is  necessary  or  vaJu- 


872  THERAPEUTICS   OF    ALCOHOL. 

able  to  be  derived  from  this  class  of  agents.  And  whoever  will  boldly  make 
the  trial,  will  find  that  his  patients,  of  every  kind,  will  make  better  prog- 
ress, on  good  air  and  simple  nourishment,  without  any  admixture  of 
alcoholic  liquids,  than  they  will  with  such  addition.  In  other  words  he  will 
find  that  the  supposed  benefits  of  this  class  of  agents  in  medicine,  are  as 
illusory  as  they  are  in  general  society,  and  that  the  words  of  the  wise 
man  are  worthy  of  careful  consideration  when  he  says:  "  Wine  is  a  mocker 
and  strong  drink  is  raging,  and  whosoever  is  deceived  thereby  is  not 
wise." 


INDEX. 


4  BERNETHY.  JOHN. 
i\.     on  mental  derangements,  798 
Acidum  Benzoicum. 

diphtheria,  173 

scarlet  fever,  283 

scrofulous  periostitis,  267 
Acidum  Carbohcum. 

bronchitis,  4  i6,  409,  415 

carcinoma,  282,  285. 

cerebro-spinal  meningitis,  352 

cholera,  epidemic,  674 

cholera  morbus,  656,  658 

diphtheria,  173,  175 

dysentery,  565,  570 

dyspepsia,  837,  841 

enteritis,  540 

fever,  yellow,  150 

fever,  relapsing,  137,  138 

hydrophobia,  782 

inflammation  of  mucous  membrane 
nose,  379,  380 

parasites  of  intestines,  848 

periostitis,  scrofulous,  267 

phthisis  pulmonalis,  466 

pneumonia,  437 

stomatitis  mercurial,  496 

stomatitis  scorbutic,  502 

syphilis,  288 

trichinosis,  849 

ulcer,  givstric,  521 

variola,  217.  218 
Acidum  Citricum. 

diabetes,  858 
Acidum  Galicum. 

diabetes,  852 

dysentery,  565 

hemorrhages,  693 

nephritis,  626 

fever,  typhoid,  119 

ulcer,  gastric,  525 
4  Acidum  Hydrobromicum, 

cholera  morbus,  656 
Acidum  Hydrochloricum. 

diphtheria,  174 

fever,  typhoid,  101,  116 

glossitis,  506 

heart,  fatty  degeneration  of,  833. 

scarlatina,  234 
Acidum  Hydrocyanicum. 

dyspepsia,  837, 


of 


Acidum  Lacticum. 

diabetes  mellitus,  859 

diphtheria,  176. 

laryngo-tracheitis,  389 
Acidum  Nitricum. 

dysentery,  567 

roseola,  246 

syphilis,  2^8 

variola,  218 
Acidum  Salicylicum. 

dengue,  77. 

diphtheria,  173 

fever,  relapsing,    137 

parasites,  intestinal,  348 

rheumatism,  298,  299 
Acidum  Suiphuricum  Aromaticum. 

cholera  morbus,  656 

cholera,  epidemic,  673 

dysentery,  564,  566 

enteritis,  540 

fever,  typhoid,  118 

iniiaenza,  73. 
Acidum  Sulphurosum. 

diphtheria,  172,  173 

erysipelas,  161 
Acidum  Tannicum. 

diabetes,  852 

hemorrhages,  694 

nephritis,  626 
Aconitum. 

aneurism,  834 

apoplexy,  709 

endocarditis,  486 

fevers,  eruptive,  212 

fever,  intermittent,  191 

fever,  relapsing,  191 

myocarditis,  48^ 

pleuritis.  444 

pneumonia,  428 

scarlatina,  234 

spinal  meningitis,  358 

tonsilitis,  509 
Addison's  Disease,  276 
Addison,  Thomas 

on  Addison's  disease,  275 

on  anseniia,  pernicious,  276 
Adenitis,  258 

pathological  anatomy,  261 

scrofulous  inflammation   of   mucous 
membranes,  262 


(873) 


^74 


INDEX. 


Adenitis,  treatment  of,  266 

symptoms,  258 

treatment,  261 
^theris  Nitrosi,  Spiritus. 

cholera  morbus,  658 

diphtheria,  173 

dysentery,  565 

dropsies,  683 

enteritis,  538,  539 

erysipelas,  160 

levers,  eruptive,  212 

lever,  typhoid,  105,  116 

hsematuria  malarial,  203 

hepatitis,  601 

nephritis,  616 

peritonitis,  579 

pleuritis,  444,  445,  446 

pneumonia,  430 

scarlatina,  237 

thrush,  493 
jEther  Sulphuricus. 

ulcer,  gastric,  523 
Air 

Compressed. 

bronchitis,  409 
Rarefied. 

bronchitis,  409 
Aitkens,  William 

on  fever,  35 

on  fever,  yellow,  146 

on  rubeola,  237 
Alcohol. 

acute  general  diseases,  871 

apoplexy,  712 

cerebro-spinal  meningitis,  350 

cholera,  epidemic,  675 

diphtheria,  172 

fevers,  870 

fever,  pernicious,  199 

fever,  typhoid,  106 

fluxes,  641 

gout,  309 

insomnia,  764 

physiological  action,  863,  867 

spinal  meningitis,  366 

tetanus,  774 

therapeutic  agent,  86-! 

therapeutic  indications, 869 
Alkalies. 

diabetes,  851 

diabetes  mellitus,  861 

dyspepsia,  838 
Allen,  J.  A. 

on  ei'ysipelas,  154 

on  meningitis,  342,  351 
Aloe. 

apoplexy,  711 

bronchitis,  408 

exophthalmic  goitre,  831  , 

fever,  intermittent,  195 

fever,  relapsing,  195 

fever,  typhoid,  120 

fluxes,  643 

inflammation    of  mucous  membrane 
of  nose,  380 

phthisis,  466 


Aloe. 

rheumatism,  301 

ulcer,  gastric,  523 
Alteratives, 

fever,  typhus,  127 

leucocythemia,  272 
Alumen. 

diabetes,  852 

dysentery,  565 

hemorrhages,  693 

laryngo-tracheitis,  390 

stomatitis  follicular,  495 

thrush,  493 
Ames,  S., 

cerebro-spinal  meningitis,  epidemic, 
349,  349  _ 
Ammonise  Spiritus  Aromatic. 

cholera  morbus,  659 

syncope,  871 
Ammonii  Acetatis,  Liquor. 
-      bronchitis,  405,  407 

diphtheria,  173 

dysentery,  565 

enteritis,  538,  539    ' 

fever,  eruptive,  21'2 

fever,  typhoid,  105,  116 

hepatitis,  601 

nephritis,  616  ' 

peritonitis,  579 

pleuritis,  444,  445,  446 

pneumonia,  480 

scarlatina,  234  ' 

Ammonii  Bromidum.  ' 

apoplexy,  711 

epilepsy,  736 

hysteria,  760 

insomnia,  764 

meningitis,  338 

mental  derangements,  806 

roseola,  246 
Ammonii  Carbonas. 

bronchitis,  407 

cerebro-spinal  meningitis,  351 

diphtheria,  172,  175 

peritonitis,  581 

pneumonia,  431 

scarlatina,  234  ' 

syncope,  871 

variola,  217,  218 
Ammonii  Chloridum. 

diphtheria,  174 

fever,  intermittent,  195 

fever,  relapsing,  195 
Ammonii  lodidum. 

scrofulous  periostitis,  266 
Ammonii  Murias 

broncliitis,  406 

hepatitis,  601,  602 

laryngo-tracheitis,  389 

phthisis,  469 

pneumonia,  429,  436. 

scarlatina,  234 
Ammonii  Nitras. 

asthma,  413 
Ammonii  Phosphas. 

gout,  307 


INDEX. 


875 


Ammonii  Valen'anas. 

epileps3',  744 

hysteria,  760 
Amyl  Nitrite. 

asthma,  415 

asthma,  spasmodic,  818 

hydrophobia,  7S0 

roseola,  '246 
Ansemia,  pernicious,  274 
Anderson. 

scarlet  lever,  233 
Andral,  Gabriel. 

anasmia,  pernicious,  275 

fever,  typhoid,  97 
Andrews,  Edmund 

chr^jnic  general  diseases,  257 

pneumonia,  4-J2 
Aneurism,  834 
Angina  pectoris,  824 

causes,  826 

pathology,  825 

prognosis,  826 

symptoms,  824 

treatment,  826 
Anise  seed. 

dyspepsia,  842 

miguet,  492 
Anodynes. 

angina  pectoris,  Hoffman's,  8! 

perityphli  is,  546 
Anstie,  Francis  E. 

alcohol,  866,  869 
Antacids. 

diabetes  mellitus,  859 
Antimonii  et  potassii  tartras. 

asthma,  413 

bronchitis,  406 

laryngo-tracheitis,  390 

phthisis,  469 

pneumonia.  429 
Antimonii  Vinum. 

bronchitis,  405 
Antipyretics. 

fever,  relapsing,  138 

fever,  typhoid,  114 
Antiseptics. 

fever,  relapsing,  137 

fever,  typhoid,  127 

hydrophobia,  780 
Aphonia. 

symptoms,  820 

treatment,  822 
Apomorphia. 

hydrophobia,  780 

laryngo-tracheitis,  390,  392 
Apoplexy. 

diagnosis,  706 

symptoms,  703 

treatment,  708 
Ai'genti  Nitras. 

apoplexy.  732 

diphtheria,  173 

dysentery,  565,  570,  571 

enteritis.  540,  541 

erysipela.s,  162,  163 

fever,  typhoid,  112,  117,  121 


Argenti  Nitras. 

laryngo-tracheitis,  390,  892 

meningitis,  338 

stomatitis  follicular,  494 

ulcer,  gastric,  522,  524,  525 
Arsenici  Bromidum. 

diabetes  mellitus,  860 
Arsenicum. 

leucocythemia 
Arthritis  deformans,  310 

symptoms,  310 

treatment,  311 
Ascepias  tuberosa. 

bronchitis,  408 

influenza,  73 
Aspiration. 

dropsies,  683;  pericarditis,  478 

peritonitis,  581,  589 

pleuritis,  446 
Asafoetida. 

catalepsy,  749 

hysteria,  760 
Asthma,  410. 

germs  in,  415 
Asthma,  spasmodic,  815. 
Astringents 

cholera,  epidemic,  675. 

fever,  typhoid,  112,  119 
Atropia. 

cholera,  epidemic,  674 

delirium,  tremens,  795 

fever,  pernicious,  202 

neuralgia,  768 


BACTERIA.  38,  71,  79,  80 
erysipelas,  160,  166 

fever,  relapsing,  133 
Badham. 

bronchitis,  393 
Bailey,  N.  B. 

erysipelas,  166 
Baudot,  M. 

alcohol,  866 
Bard,  John. 

fever,  yellow,  149 

meningitis,  341 
Bard,  Samuel. 

erysipelas,  163 
Barii  Chloridum. 

meningitis,  338 
Barker. 

fever,  relapsing,  132 
Barnes. 

fever,  pernicious,  202 
Bartlett,  E. 

fever,  typhus,  122 

simple  continued  fever,  165 
Bartholow  Roberts. 

carcinoma,  285 

fever,  simple  continued,  65 

heat  exhaustion,  785 

pneumonia,  434 
Barthez,  M. 

pneumonia,  427 


876 


INDEX. 


BartleW,  J. 

fever,  periodical,  181 . 
Bastian. 

1  neuiuonia,  4B4 
Baths. 

endocarditis,  486 

epilepsji-,  734 

inflammation  of  mucous  membrane 
of  nose,  380 

myocarditis,  486 

nephritis,  619,  626,  628 

pleuritis,  466 

rheumatism,  301 
Beale,  L.  15 
Beardslej^  Z.  N. 

erysipelas,  163,  1G4 
Beaugency. 

vaccinia,  223 
Beismer. 

antBmia,  pernicious,  275 
Bell,  John. 

erysipelas,  163 
Belladonna. 

apoplexy,  711 

cere bro- spinal  meningitis,  352,  358 

colic,  bilious,  551 

diaphoresis,  644 

diphtheria,  174 

fever,  typhoid,  110,  119 

glossitis,  506,  509 

hydrophobia,  782 

laryngo-tracheitis,  392 

mumps,  248 

peritonitis,  588 

scarlatina,  234,  235 

stomatitis,  496 

tetanus,  774;  typhlitis,  543 
Bennett  Hughes. 

anaemia,  pernicious,  273 

inflammation,  819 

leucocythemia,  2t:8 
Benzoin. 

bronchitis,  408 

hysteria,  572 
Bernard,  Claude. 

action  of  potassii  chloras,  101 

diaphoresis,  640 

fibrin,  13 
Biermer. 

bronchitis,  398 
Bigelow,  Jacob. 

action  of  medicines,  45 
Bilious  colic,  547 
Bismuthi  Subnitras. 

diaphoresis,  644 

duodeno-hepatitis,  534 

dysentery,   571 

enteritis,  541 

fever,  typhoid,  122 

rheumatism,  299 

ulcer,  gastric,  523 
Bitters. 

fever,  intermittent,  195 

fever,  remittent,  195 
Bleeding. 

c«rebro-spinal  meningitis,  350 


Bleeding. 

fever,  intermittent,  191 

fever,  remittent,  191 

fever,  yellow,  149 

laryngo-tracheitis,  389 

spinal-meningitis,  358 
Blisters. 

bronchitis,  406 

duodeno-hepatitis,  583 

erysipelas,  162 

laryngo-tracheitis,  390 

peritonitis,  580 

pleuritis,  445,  446 

pneumonia,  429 

rheumatism,  299 

ulcer,  gastric,  523 
Bocker. 

alcohol,  863 
Bontius. 

cholera  epidemic,  661 
Bouchardet,  M. 

alcohol,  864 
Brain. 

inflammation  of,  321 
Brainard,  Daniel. 

carcinoma,  282 
Brayera. 

parasites,  intestinal,  848 
Bretonneau,  M. 

erysipelas,  163 
Bi'ight,  Richard. 

nephritis,  621,  624 
Bromides. 

apoplexy,  710 

cerebro-spinal  meningitis,  351 

epilepsy,  788 

insomnia,  764 

terrors,  night,  765 
Brjuiine. 

diphtheria,  172,  174 

dysentery,  5  1 

enteritis,  542 

epilepsy,  737 

fever,  typhoid,  122 
Brown,  John. 

theory  of  disease,  23 
Bronchitis,  393 

acute,  395 
Broussais,  F.  J.  V. 

bronchitis,  898 

theory  of  disease,  23 
Brown- Sequard,  M. 

epilepsy,  78l 
Buchu. 

fever,  pernicious,  203 
Buchwaki. 

fever,  relapsing.  133 
Buck,  Gurdon. 

laryngo-tracheitis,  392 
Budd. 

fever,  typhoid,  82,  93 

laryngo-tracheitis,  392 
Buhl. 

erysipelas,  166 
Byford,  W.  H. 

erysipelas,  157 


INDEX. 


877 


Blood. 

constituents  of,  12 


n  ACTUS. 

V     cardiac  irritability,  824 
endocarditis,  486 
fatty  degeneration,  883 
insomnia,  765 
myocarditis,  486 
Caffeine,  dysentery,  567 
peritonitis,  581 
syncope,  871 
Calcii  Hypopliosphis. 
bronchitis,  408 
diphtheria,  178 
fever,  intermittent,  195. 
fever,  remittent,  195 
Calcii  Hyposulphis. 

fevers,  eruptive,  210 
scarlatina,  238 
variola,  217 
Calcii  lodidum. 

arthritis  deformans,  311 
chronic  general  diseases,  256 
phthisis,  436,  465,  466,  469 
rubeola,  240 
Calcii  Lactophosphas. 
bronchitis,  4  08 

cerebro-spinal  meningitis,  354 
chorea,  745 

chronic  general  diseases,  256 
diphtheria,  178 
fever,  periodical,  193,  195 
fever,  typhoid,  120 
phthisis,  486,  465,  466,  469 
rubeola,  240 
spinal  meningitis,  367 
stomatitis  scorbutic,  502 
Calcii  Oxidum. 

arthritis  deformans,  311 
Calcii  Sulphis. 

diphtheria,  172 
erysipelas,  167 
fever,  eruptive,  210 
fever,  pernicious,  193 
Calorification,  25,  28 
Campbell,  H.  F. 
dengue,  74 
Camphor. 

catalepsy,  749 

cerebro-spinal  meningitis,  353,  354 
diphtheria,  172,  175,  176 
fever,  relapsing,  137 
fever,  typhoid,  119 
nephritis,  615 
peritonitis,  581 
roseola,  246 
syncope,  871 
teiTors,  night,  766 
variola,  217,  218 
Camphor,  monobromated. 

paraplegia,  723 
Cancrum  Oris,  503 
Cannabis  Indica, 

hyflrophobia,  780 


Cannabis  Indica. 

rheumatism,  301 

paraplegia,  723 

tetanus,  774 
Cautharides. 

cerebro-spinal  meningitis,  353 
Carbonates. 

endocarditis,  485 

myocarditis,  485 
Carcinoma,  278 

anatomical  structure,  279 

causes,  278 

diagnosis,  280 

historj',  278 

pvoiinosis,  281 

treatment,  281 

varieties,  279     . 
Cardamom  seeds. 

indigestion,  842 
Cardiac  n-ritability,  822 

symptoms,  822 

treatment,  8-3 
Carditis,  Endo  and  Myo,  478 

diagnosis,  483 

prognosis,  483 

symptoms,  479 

treatment,  484 
Carey.  , 

anaemia,  pernicious,  276 
Carminatives. 

diabetes  mellitus,  859 

indigestion,  838 
Carpenter,  W.  B. 

fibrin,  12 
Catalepsy,  746 

diagnosis,  748 

pathology,  748 

prognosis,  748 

symptoms,  746 

treatment,  749 
Cathartics,  86 

apoplexy,  709 

hepatitis,  562 

nephritis,  628 

recto- colitis,  561 

scarlatina,  234 
Catlin,  B.  H.  _ 

cerebro-spinal  meningitis,  350 

cerebritis,  380 
Cerii  Oxalas. 

giistritis,  523 

ulcer,  gastric,  523 
Charcoal. 

indigestion,  888 
Charcot,  J.  M. 

epilepsy,  731 

hystero-epilepsy,  762 

leucocythemia,  268 

pneumonia,  484 

spinal  meningitis,  364 
Cheviot,  M, 

spinal  meningitis, 
Chloral. 

bronchitis,  413 

cerebro-spinal  meningitis,  351 

chorea,  744 


878 


INDEX. 


Chloral. 

delirium  tremens,  794 

epilepsy,  783 

hydrophobia,  780 

hysteria,  760 

insomnia,  764 

meningitis,  338 

mental  derangements,  806 

nephritis,  615 

roseola,  '246 

sunstroke,  789 

terrors,  night,  766 

tetanus,  774 
Chlorine. 

diphtheria,  172 
Chloroform. 

bronchitis,  415 

convulsions,  758 

diphtheria,  174 

fevers,  periodical,  191 

fever,  typhoid.  118 

hydrophobia,  780 

inflammation   mucous   membrane  of 
nose,  380 

laryngismus  stridulus,  818 

neuralgia,  768 

sunstroke,  789 

tetanus,  774 
Cholera,  epidemic,  661 

anatomical  changes,  667 

causes,  662 

complications  and  sequelae,  675 

diagnosis,  669  --  — 

history,  661 

prognosis,  670 

prophylaxis,  676 

symptoms,  655 

treatment,  671 
Cholera  morbus,  644 

anatomical  changes,  653 

etiology,  645 

pathology,  654 

prognosis.  653 

prophylaxis,  645 

symptoms,  650 

treatment,  655 
Chorea,  738 

causes,  738 

clinical  history,  738 

diagnosis,  742 

pathology,  741 

prognosis,  742 

treatment,  742 
Christison. 

fever,  relapsing,  132 
Chronic  general  diseases,  249 

etiology,  251 

names,  249 

pathology,  general,  249 

pathological  inferences,  254 

treatment,  254 
Cimicifuga  Racemosa. 

bronchitis,  458 

chorea,  745 

rheumatism,  299 

spinal  meningitis,  367 


Cinchona. 

adenitis,  262 

cerebro  spinal  meningitis,  350 
cholera,  ep;demic,  671 
chorea,  745 

leucocythemia,  272 

nephritis,  627 

periostitis,  scrofulous,  266 

stomatitis,  493,  496 

syphilis,  289 
C.nchonidia,  761 

sunstroke,  790 
Clark,  Alonzo. 

fever,  yellow,  147 
Clark  N.  Hayes. 

scarlatina,  233 
Classification,  48 
Climate. 

bronchitis.  410 

phthisis,  436 
Cline. 

vaccina,  221 
Clymer,  Meredith. 

fever,  relapsing,  132 
Cochineal. 

roseola,  246 
Codia. 

bronchitis,  405,  406,  408,  413 

diabetes  mellitus,  858 

fluxes,  644 
Cotfee. 

dysentery,  431 

pneumoniii,  567 
Cohn,  B. 

erysipelas,  166 

fever,  relapsing,  133 
Colchicum. 

apoplexy,  713 

bronchitis,  407,  413 

chorea,  745 

gout,  307,  308,  309 

rheumatism,  300,  301 
Cold. 

apoplexy,  709,  710 

convulsions,  753 

spinal  meningitis,  358 

sunstroke,  788 

tetanus,  775 
Colic. 

bilious,  547 

symptoms,  547 

treatment,  548 
Colocynth. 

fluxes,  643 

gout,  308 
Condie,  D.  Francis. 

cholera,  epidemic,  671 
Conheim,  Julius. 

inflammation,  319 
Conium. 

adenitis,  262 

epilepsy,  736 

hepatitis,  601,  602 

laryngo-tracheitis,  392 

meningitis.  337 

nephritis,  626. 


INDEX. 


879 


Ton  in  m. 

paraplegia,  722 

peritonitis,  588 

spinal  meningitis,  367 

syphilis,  289 

tetanus,  774 
Connolly,  J. 

mental  derangements,  798 
Constipation,  88-") 
Contagion  or  contagium,  63 
Convallaria. 

aneurisms,  834 

cardiac  irritability,  824 

endocarditis,  486 

fatty  degeneration,  833 

insomnia,  765 

myocarditis. 

syncope,  871 
Convulsions,  750 

treatment,  753 

varieties,  750 
Copaiba. 

roseola,  242 
Copeland,  James,  88 

fever,  53,  57 

miasms,  38 
Coptis. 

stomatitis,  490,  493,  500 
Cormack. 

fever,  relapsing,  132 
Com  us  Florida. 

fever,  pernicious,  192,  194 
Corrigan. 

pneumonia,  434 
Corson,  H. 

scarlatina,  233 
Counter  Irritation 

duodeno-hepatitis,  534 

laryngo-tracheitis,  392 

peritonitis,  588 

spinal  meningitis,  358,  C67 
Craigie. 

fever,  relapsing,  132 
Crudeli,  1. 

fever,  periodical,  181 
Cullen. 

theory  of  disease,  28 

fever,  53 
Cupping. 

cholera,  epidemic,  671 

nephritis,  614,  615,  617 

spinal  meningitis,  367 

sunstroke,  788 

tetanus,  775 
Cupri  Sulphas. 

diphtheria,  173 

diabetes  mellitus,  858 

gastritis,  524 

laryngo-tracheitis,  390,  392 

stomatitis,  494 

ulcer,  gastric,  524 
Curare.       • 

hydrophobia,  780 
Currie,  James. 

antipyretics,  103 

scarlatma,  233 


DA.NA,  C.  L. 
pachymeningitis,  323 
Davidson,  J.  P. 

fever,  pernicious,  201,  202 
Davis,  F.  H. 

bronchitis,  397 

fevers,  eruptive,  206 

variola,  218 
DeClat. 

carcinoma,  282 
Delirium  Tr^nens,  790 

anatomical  changes,  "(92 

diagnosis,  793 

prognosis,  793 

symptoms,  790 

treatment,  794 
Degner. 

cholera,  epidemic,  661 
Dengue,  74 

diagnosis,  76 

etiology,  76 

history,  74 

prognosis,  75 

progress,  75 

symptoms,   75 

trea,tment,  76 
Depletion. 

inflammation,  320 
Dexter,  G.  J. 

erysipelas,  155 
Diabetes  Insipidus,  850 

anatomical  changes,  851 

prognosis,  851 

symptoms,  850 

treatment,  851 
Diabetes  Mellitus,  852 

diagnosis,  856 

patholoary,  855 

prognosis,  857 

symptoms,  852 

treatment,  857 
Diaphoretics,  36 

inflammation,  320 
Diarrhoea,  serous,  644 
Dickson,  S.  H. 

dengue,  44 
Diet. 

gout,  309 
Diuretics,  36 

inflammation,  320 
Digitaline. 

apoplexy,  710 

syncope,  871 
Digitalis. 

aneurisms,  834 

angina  pectoris,  828 

aphonia,  822 

apoplexy,  709,  710,  713. 

bronchitis,  406 

cardiac  irritability,  824 

cholera  morbus,  658 

delirium  tremens,  794 

dropsies,  683 

dysentery,  565 

endocarditis,  484,  486 

epilepsy,  733,  736 


830 


INDEX. 


Digitalis. 

exophthalmic  goitre,  881 

fatty  degeneration  of  heart,  833 

fever,  relapsing,  188 

fever,  typhoid,  106,  118, 119,  120 

hemorrhages,  692 

hepatitis,  601 

insomnia,  764 

meningitis,  386 

mental  derangements,  806 

myocarditis,  484,  486 

nephritis,  615,  616,  617,  618,  619,  626 

pericarditis,  477 

peritonitis,  581,  588 

pleuritis,  445,  446 

pneumonia,  430,  431 

rheumatism,  299 

scarlatina,  234 

sunstroke,  789 

terrors,  ni  ht,  766 
Diphtheria,  163 

causes,  164 

convalescense,  177 

diagnosis,  171 

history,  168 

pathology,  172 

prognosis,  172 
prophylaxis,  177 

sequelse,  177 

symptoms,  167 
treatment,  172 
Disease,  definition  of,  19 
Disintegration,  25,  26 

conditions  of,  26 
D'Orta. 

cholera,  epidemic,  661 
Douglass,  William. 
erysipelas.  163 
Dover's  Powder, 
bronchitis,  407 
cerebro-spinal    meningitis,   epidemic 

352 
diphtheria,  176 
duodeno-hepatitis,  533,  534 
enteritis,  539 
erysipelas,  160 
fever,  relapsing,  137 
inflammation  of  mucous  membrane  of 

nose,  378 
meningitis,  338 
nephritis,  615 
pleuritis,  445 
pneumonia,  429 
rheumatism,  298,800 
lubeola,  240 
spinal  meningitis,  358 
tonsillitis,  o09 
variola,  217 
Drake,  Daniel. 

ce.-ebro-spinal  meningitis,  epidemic, 

346 
chronic  general  diseases,  253 
fever,  54 

fever,  intermittent,  188 
fever,  pernicious,  196,  200 
fever,  typhoid.  81.  90 


Drake,  Daniel. 

inflammation  of  mucous  membrane  of 
air  passages,  372,  374 

pneumonia,  416 
Dropsies,  678 

causes,  678 

prognosis,  681 

treatment,  682 

varieties,  678 
Dubois,  A. 

fever,  relapsing,  182 
Dummler. 

fever,  relapsing,  18J 
Dunglison,  Robley. 

on  febrine,  12 
Duodeno- Hepatitis. 

anatomical  changes,  529 

diagnosis,  580 

prognosis,  531 

symptoms,  527 

treatment,  532 
Duroy,  M. 

alcohol,  864,  866 
Dysentery,  551 

anatomical  changes,  553 

causes,  551 

diagnosis,  560 

prognosis,  560 

symptoms,  553 

treatment,  561 
Dysentery,  chronic,  568 

prognosis,  569 

treatment,  570 
Dyspepsia,  835 


EARLE,  C.  W. 
rotheln,  241 
Eberle,  John. 

fever,  53 

fever,  intermittent,  195 

fever,  remittent,  195 

fever,  simple,  continued,  68 
Eberth. 

fever,  typhoid,  83 
Edwards  Milne. 

fever,  pernicious,  200 
Ehrenberg. 

fever,  relapsing,  133 
Elaterium. 

dropsies,  683 

nephritis,  628 
Electricity. 

arthritis  deformans,  311 

catalepsy,  749 

diabetes  mellitus,  859 

diphtheria,  178 

epilepsy,  749 

epilepsy,  hystero,  762 

exophthalmic  goitre,  832 

hemorrhages,  694 

leucocythemia,  723  * 

spinal  meningitis,  358,  868. 
Emetics,  86 

bronchitis,  407 

cholera,  epidemic,  675 


INDEX. 


881 


Emetics. 

scarlatina,  224 
Enemas. 

colic,  bilious,  564 

entei'itis,  539 

trysipelas,  162 

meaimgitis,  336 

peritonitis,  579 

perityplilitis,  546 

pneumonia,  428 

recto- colitis,  564 

typhlitis 
Engel. 

fever,  relapsing,  132 
Enteritis,  534 

anatomical  changes,  537 

causes,  534 

diagnosis,  538 

symptoms,  534 

treatment,  538 

varieties,  534 
Enuresis,  860 

symptoms,  860 

treatment,  861 
I'pilepsy,  724 

anatomical  changes,  731 

causes,  729 

symptoms,  725 

treatment,  732 

varieties,  724 
Erb,  W.  H. 

spinal  meningitis,  362 
Ergot. 

cerebro-spinal  meningitis,  352 

diabetes  insipidus,  852 

enteritis,  867 

exophthalmic  goitre,  831 

hemorrhages,  692 

meningitis,  338. 

nephritis,  626 

spinal  meningitis,  658 
Ergotine. 

apoplexy,  710,  712 

diabetes  mellitus,  858 

enuresis,  861 

lever,  typhoid,  119 

fluxes,  643,  644 

hydrophobia, 

nephritis,  615,  619 

phthisis  pulmonalis,  469 

pneumonia,  430 

tetanus,  774 

ulcer,  gastric,  525 
Erigeron  Canadensis. 

diarrhoea  serous,  659 
Erysipelas,  154 

causes.  155 

diagnosis,  159 

history,  154 

pathological  anatomy,  159. 

prognosis,  159 

prophylaxis,  162 

special  anatomy,  160 

symptoms,  156 

treatment,   160 
Etiology,  37 

56 


Eucalyptus. 

bronchitis,  408,  414,  415 

inflammation  mucous   membrane  of 
nose,  360 

laryngismus  stridulus,  818 
Evacuents. 

abuse  of,  27 

cholera,  epidemic,  675 
Examination  of  the  sick,  40 
Expectorants,  36 

■PACHS,  F.  C- 

J?     fever,  pernicious,  203 

Eearn. 

fever,  pernicious,  201 
Felix,  Mas. 

parasites,  intestinal,  848 
Fenner,  E.  D.  _ 

cerebro-spinal  meningitis,  346 

cholera,  epidemic,  665 

dengue,  74,  76 

fever,  yellowr,  145 
Ferri  chloridum. 

cerebro-spinal  meningitis,  353 

diphtheria,  173,  175 

erysipelas,  161,  163 

fever,  yellov?,  151 

hemorrhages,  693 

lai-ynaio-tracheitis,  390 

nephritis,  616,  626 

scarlatina,  234,  237 

variola,  217 
Ferri  citras. 

diphtheria,  178 

fevers,  periodical,  193 

gout,  309 

hysteria,  761 
Fern  et  Quiniae  Citras. 

syphilis,  290 
Ferri  Hypophosphas. 

fever,  periodical,  195 
Fern  lodidum. 

enuresis,  861 

fluxes,  643 
Ferri  Lactas. 

carcinoma,  282 

diphtheria,  176  _ 

laryngo-tracheitis,  389 
Ferri  Lactophosphas. 

leucocythemia,  273 
Ferri  "^Titras. 

cholera  morbus,  659 
Ferri  Fersulphas. 

fever,  typhoid,  119 

hemorrhages,  692 

ulcer,  gastric,  524 

variola,  218 
Ferri  Phosphas. 

bronchitis,  408 
Ferri  Pyrophosphas. 

leucocythemia,  273 
Ferri  Subcarbonas. 

dysentery,  571 

enteritis,  541 

fever,  typhoid,  122 


882 


INDEX. 


Ferri  Subcarbonas. 

fluxes,  644 
Ferri  Sulphas, 
apoplexy,  711 
bronchitis,  408 
constipation,  840 
erysipelas,  162 
exophthalmic  goitre,  831 
fever,  periodical,  194 
fever,  typhoid,  120 
gastritis,  523 
gout,  308 
inflammation  of  mucous  membrane  of 

nose,  380 
phthisis  pulmonalis,  466 
rheumatism,  301 
stomatitis  follicular,  495 
Ferrum. 

convulsions,  755 
diabetes  insipidus,  8b'S 
diphtheria^  172 
hysteria,  761 
leucocythemia,  26S 
Fever. 

blood,  59 
definitions,  53 
beat,  58 
self-limited.  60 
varieties,  57 
Fevers — coutinsued,  61 
kinds,  62 
causes,  62 
Fever,  eruptive,  204 

anatomical  changes,  209 
causes,  205 
history,  204 
names,  204 
pathology,  207 
treatment,  210 
Fever,  irritative,  64 
Fever,  intermittent,  .186 
Fevers,  periodical,  178 
causes,  180 

general  pathology,  182 
history,  178 
varieties,  182 
Fever,  pernicious,  196 
Fever,  relapsing,  131 
causes,  133 
diaarnosis,  135 
histoiy,  131 
pathology,  136 
prognosis,  135 
prophylaxis,  138 
Bymptoms,  134 
treatment,  137 
Fever,  remittent,  188 
Fever,  simple — continued,  64 
etiology,  66 
history,  64 

pathological  anatomy,  66 
symptoms,  65 
treatment,  67 
Fever,  typhoid,  77 
complications,  119 
diagnosis,  91 


Fever,  Typhoid, 
etiology,  78 

pathological  anatomy,  95 
prognosis,  92 
symptoms,  86   ^ 
treatment,  102 
Fever,  typho-malarial,  203 
Fever,  typhus,  122 
causes,  123 
diagnosis,  126 
history,  122 
pathology,  127    • 
prognosis,  126 
prophylaxis,  128 
symptoms,  125 
treatment,  127 
Fever,  yellow,  139 
causes,  140 
diagnosis,  145 
hi-tory,  139 
pathology,  147 
prognosis,  1-.6 
prophylaxis,  151 
symptoms,  144 
treatment,  148 
Fibrin. 

function,  12 
Fischel. 

fever,  typhoid,  83 
Flaxseed. 

nephritis,  614 
Flint,  Austin,  Jr. 

diabetes  mellitus,  860 
Flint,  Austin.  Sr. 

anaemia,  pernicious,  275 
cholera  morbus,  645 
dengue,  74 
dysentery,  555 
fever,  55,  59 

fever,  relapsing,  182,  133 
fever,  typhoid,  72,  80 
.  meningitis,  338 
pneumonia,  416 
varicella,  226 
Fluxes,  51,  638 
definition,  638 
treatment,  641 
Fomentations. 

duodeno-hepatitis,  533 
peritonitis,  579,  580 
perityphlitis,  546 
Food. 

cholera  morbus  660 
definition,  33 
fever,  typhoid,  113 
indirect,  34 
Forbes,  John. 

action  of  medicine,  45 
Ford,  W.  H. 

fever,  yellow,  140 
Forrey,  Samuel. 

chronic  general  diseases,  253 
inflammation  of  mucous  membrane  of 

air  passages,  372 
pneumonia,  416,  417,  418 


INDEX. 


883 


Forbes,  Murray. 

gout,  306 
Fothergill,  John. 

erysipelas,  1(53 
Fox,  Wilson. 

pneumonia,  484 
Frank. 

bronchitis,  393 
Fraser. 

tetanus,  775 
Frierich. 

fever,  60 
Fungus. 

fever,  relapsing,  133 


GALEN, 
fevers,  53 
Galium. 

dropsies,  683 

epilepsy,  736 
Gallup,  Joseph  A. 

cerebro- spinal  meningitis,  349,  350 

meningitis,  342 

pneumonia,  416 
Galvanism. 

diabetes  mellitus,  859 
Garrod. 

gout,  306 
Gastritis. 

acute  and  chronic,  512 

anatomijdl  changes,  518 

diagnosis,  519 

follicular  inflammation,  514 

prognosis,  520 

symptoms,  512 

treatment,  520 

ulcer,  516 
Gastrodinia,  842 
Gaultheria. 

cholera  morbus.  658 

fever,  typhoid,  116 
Gavarett,  M. 

fever,  typhoid,  97 
Gelseminum. 

aneurism,  8,34 

carcinoma,  285 

cerebro-spinal  meningitis,  352 

cholera,  epidemic,  674 

chorea,  745 

endocarditis,  486 

epilepsy,  733 

fever,  yellow,  150 

gasti'itis,  521 

meningitis,  352 

myocarditis,  486 

pleuritig,  444 
Genei-ai  Diseases. 

definition,  49 
Geranium  Maculatum. 

gastritis,  525 
Gerhard. 

fever,  typhus,  122 
Gevms, 

astthma,  415 

diphtheria,  166 


Germs. 

erysipelas,  154,  160 

fevers,  eruptive,  205 

fever,  periodical,  181 

fever,  relapsing,  133 

fever,  yellow,  143 

pertussis,  243 

rubeola,  237 
Ghent. 

fever,  pernicious,  202 
Gill,H.  Z. 

laryngo-tracheitis,  391 
Glasgow,  W.  C 

bronchitis,  399,  402 
Glossitis,  505 
Glycerina. 

diabetes  mellitus,  858 

enuresis,  861 

eiysipelas,  162 

gastritis,  521 

stomatitis,  502 
Glycyrrhiza. 

bronchitis,  406 

duodeno- hepatitis,  533 

phthisis  pulmonalis,  469 

pneumonia,  428,  429 
Goitre,  Exophthalmic,  829 

causes,  830 

pathology,  830 

symptoms,  829 

treatment,  829 
Good,  John  Mason. 

nosology,  48 
Goumoeus. 

bronchitis,  399 
Gout,  302;  causes,  302 

diagnosis,  307 

history,  302 

morbid  anatomy,  306 

prognosis,  307 

symptoms,  303. 

symptoms  of  chronic,  304 

treatment,  307 
Graves. 

fever,  relapsing,  132 
Greenhow. 

Addison's  Disease,  276,  277 
Griesinger. 

fever,  relapsing,  132 

leucocythemia. 
Grin  del  ia  Robusta. 

asthma,  413,  415 

bronchitis,  408 

laryngismus  stridulus,  819 
Guaicum. 

exophthalmic  goitre,  831 
Gum  Arabic. 

nephritis,  614 


HEMATOMA, 
pachymeningitis,  325 
Hahnemann. 

theory  of  disease,  24 
Hale,  Enoch. 

fever,  typhus,  12f 


884 


INDEX. 


Hall,  Charles. 

eiTsipelas,  154,  155 
Hall,  Marshall, 731 
Haller,  14 
Hamilton,  F.  H. 

fever,  remittent,  189 
Hammond,  W.  A. 

alcohol,  864,  868 

epilepsy,  787 

meningitis,  338 

rubeola,  238 
Hartshorne,  Henry. 

fever,  yellovr,  139 

varicella,  2'2S 
Helmholtz. 

asthma.  415 
Hemiplegia,  715 

anatomical  changes,  718 

diagnosis,  719 

prognosis,  719 

symptoms,  715 

treatment,  720 
Hemorrhages.  685 

causes,  685 

consequences.  688 

pathology,  692 

treatment,  692 

varieties,  685 
Hepatitis,  58^ 

anatominal  changes,  599 

diagnosis,  600 

prognosis,  600 

symptoms,  590 

treatment,  601 
Hepatitis,  Duodeno,  526 
Hertz. 

fever,  pernicious,  197, 199 
Hippocrates. 

fever,  55 
Hirsch . 

erysipelas,  154 

fever,  typhus,  123 
Hodgkin, 

pseud  o-leucoeythemia,  173 
Hodgkin's  Disease,  273 
Hofl'man. 

fever,  53 

fever,  typhoid,  96 

theory  of  disease,  23 
Holland,  J.  W. 

spinal  meningitis,  chronic,  366 
Holmes,  O.W.,  32 

action  of  medicines,  45 
Hoag,  Martin. 

cholera,  epidemic,  661 
Hosack,  David. 

fever,  yellow,  149 
Hubbard. 

laiyngo-tracheitis,  391 
Hueter. 

diphtheria,  166 
Huguenin. 

pachymeningitis,  323,  325 
Humulus  lyupulus. 

cerebro-spinal  meningitis,  epidemic, 
354 


Humulus  Lupulu'. 

chronic  general  diseases,  256 

diphtheria,  176 

laryngo- tracheitis,  389 

phthisis,  466 

rubeola,  240 
Hunt,  Sand  ford  B. 

erysipelas,  154 
Hunter,  John. 

vaccinia,  220 
Huntington. 

cerebro-spinal  meningitis,    epidemic, 
350 
Heister,  J.  P. 

scarlatina,  233 
Huxley,  Thomas,  15 
Hydrargyi'i  Chloridum  Corrosivum. 

carcmoma,  283 

duodeno-iiepatitis,  533 

fever,  typhoid,  103 

hepatitis,  601,  602 

hydrophobia,  780,  782 

leucocythemia,  272 

laryngo;tracheitis,  388,  3S9 

meningitis.  337 

nephritis,  627 

scrofulous  inflammation  of  mucous 
membranes,  262 

scrofulous  periostitis,  266,  267 

spinal  meningitis,  chronic,  367 

syphilis,  289  _ 
Hydrargyri  Chloridum  Mite. 

apoplexy,  709 

bronchitis,  405,  407 

cerebro-spinal  meningitis,  epidemic, 
350, ;  52 

cholera,  epidemic,  670,  676 

cholera  morbus,  657 

colic,  bilious,  549 

dengue,  77 

diabetes  mellitus,  858 

diphtheria,  173  174,  176 

duodeno-hppatitis,  533 

dysentery,  563,  566 

enteritis,  538 

erysipelas,  160 

fever,  intermittent,  192 

fever,  pernicious,  200 

fever,  remittent,  192 

fever,  simple,  continued,  68 

fever,  typhoid,  103,  116 

fever,  yellow,  150 

gastritis,  520,  522 

gout,  308 

influenza,  73 

meningitis.  336 

parasites,  intestinal,  846 

peritonitis, 

pertussis,  246 

pleuritis,  444,  447 

pneumonia,  429 

rheumatism.  299,  300 

scarlatina,  233 

spinal  meningitis,  358 

syphilis,  289 

variola,  217,  218 


INDEX, 


885 


Hydi-argyruni  Cum  Creta. 

cholera  morbus,  659 
Hydraryyri  lodidum  Rubrum. 

periostitis,  scrofulous,  266 
Hydrar^yri  lodidum  Viride. 

•periostitis,  scrofulous,  266 
Hydrargfyri  Oleas. 

peritonitis,  588 
Hydrarj^yrl  Oxidura  Rubrum. 

periostitis,  scrofulous,  267 
Hydrargyri  Pilula, 

apoplexy,  711 

asthma,  408 

cholera,  epidemic,  673 

constipation,  840,  841 

exophthalmic  goitre,  831 

fever,  remittent,  191 

gastritis,  522,  523 

gout,  308 

hepatitis,  602. 

inflammation  of  mucous  membrane  of 
nose,  380 

phthisis,  466 

spinal  meningitis,  358 
Hydrargyri  Subsulphas  Flavus. 

diphtheria,  176 

laryngo-tracheitis,  389 
Hydrargyri  Unguentum. 

syphilis,  290 
Hydrogen  Peroxide. 

diabetes  mellitus,  859 
Hydrophobia,  776 

anatomic-al  changes,  779 

causes,  776 

prognosis,  779 

prophylaxis,  780 

sympioms,  778 

treatment,  779 
Hyoscyamus. 

apoplexy,  711 

bronchitis,  408 

constipation,  837 

dysentery,  65,  570 

endocarditis,  485 

fever,  intermittent,  194 

fever,  remittent,  194 

fever,  typhoid,  117,  119,  121 

gastritis,  322,  323,  324,  325 

gout,  308,  309 

indigestion,  840,  841, 

inflammation,  mucous  membrane  of 
nose,  380' 

meningitis,  336 

mental  derangements,  806 

myocarditis,  485 

nephritis,  626 

paraplegia,  722 

peritonitis,  588 

phthisis,  466 

spinal  meningitis,  chronic,  367 

tetanus,  774 

terrors,  night,  766 
Hysteria,  755 

causes,  756 

diagnosis,  757 

paihology,  757 


Hysteria. 

prognosis,  758 

symptoms,  756 

treatment,  759 

varieties,  755 
Hystero-epilepsy,  762 
Hypophosphites. 

adenitis,  262 

cerebro-spinal   meningitis,  epidemic, 

chorea,  745 

convulsions,  755 

leucocythemia,  273 

rubeola,  240 

spinal  meningitis,  358 

spinal  meningitis,  chronic,  367,    369 

stomatitis,  scorbutic,  502 


TCE. 

JL    cerebro-spinal  meningitis,  352 
cholera,  epidemic,  675 
enteritis,  539 
gastritis,  520 
hemorrhages,  694 
peritonitis. 
Incisions. 

perityphlitis,  547 
Ind.gestion,  835 
Infection,  definition,  63 
Inflammation,  313 

essential  pathology,  313 
gangrene,  318 
results,  316 
treatment,  319 
aorta,  487 

genito-urinary  organs,  608 
oesophagus,  510 
raucous  membranes, 
scrofulous,  262 
pancreas,  607 

respiratory  organs,  369,  371 
age,  371 

c.imatic  conditions,  372 
etiology,  371 
exciting  causes,  374 
habits,  personal,  372 
occupation,  371 
symptomatology,  374 
nasal  passages, 
a3u':e,  374 
chronic,  376 
diagnosis,  378 
prognosis,  378 
treatment,  378 
Influenza,  69 
diagnosis,  72 
etiology,  7l 
history,  69 
pathology,  71 
prognosis,  71 
symptoms,  70 
treatment,  72 
Insomnia,  762 

treatment,  763 
varieties,  762 


886 


INDEX. 


Instruments,  ''^S 
Iodides. 

cerebro-spinal  meningitis,  352 
lodinum. 

adenitis,  262 

diphtheria,  172,  173,  174 

duodeno-hepatitis,  534 

erysipelas.  162 

fever,  typhoid,  103,  118 

fever,  typho-iualarial,  204 

gastritis,  523 

inflammation     mucous     membrane, 
nose,  380 

laryngo-tracheitis,  390 

nephritis,  601 

periostitis,  scrofulous,  266,  267 

peritonitis,  588 

plague,  131 

scarlatina,  233 

syphilis,  290 
lodoformum. 

laryngo-tracheitis,  802 

syphilis,  288 
Ipecacuanha . 

dysentery,  561,  568,  570,  571 

enteritis,  538,  540 

gastrodinia,  843 

laryngismus  stridulus,  819 

laryngo-tracheitis,  390 
Ipecacuanhse  Pulv.  Comp. 

influenza,  73 


TABORANDI. 

eJ     diabetes  mellitus,  859 

fluxes,  642 

gout,  307 

nephritis,  616,  628 
Jaccoud.  ' 

leucocythemia,  268 
Jackson,  James. 

carcinoma,  283 

epilepsy,   734 

fever,  typhoid,  92 
Jackson,  Samuel. 

elementary  properties,  15 
Jalapa. 

colic,  bilious,  549 

meningitis,  .336 

nephritis,  628 
Jenner,  Edward. 

vaccinia,  220,  221,  224 
Jenner,  Sir  William. 

fever,  35 

fever,  eruptive,  205 

fever,  relapsing,  132 

fever,  typhoid,  122,  126 
Jewell,  J.  S.    _ 

cerebro-spinal  meningitis,  347 
Jones,  Bence. 

fever,  typhoid,  98 
Jones,  Joseph. 

diabetes  mellitus,  859 

fever,  typhoid,  98 


KAMEELA.. 
parasites,  intestinal,  848 
Kane,  W.  M. 

tetanus,  775 
Klebs. 

fever,  periodical,  181 

fever,  typhoid,  83 
Klein. 

fever,  typhoid,  83 
Koosso. 

parasites,  intestinal,  848 

T  ACTOPHOSPHATES. 
Li    convulsions,  755 
Laennec. 

bronchitis,  393 
Lallemand. 

alc9hol,  864,  866^ 
Laryngismus  stridulus,  817 
Laiyngo-tracheitis,  acute,  381 

causes,  382 

pathological  anatomy,  382 

symptoms,  383 

varieties,  382 
Laryngo-tracheitis,  chronic,  386 

diagnosis,  387 

pathological  anatomy,  387 

prognosis,  387 

symptoms,  386 

treatment,  388 
Laxatives. 

apoplexy,  709 

bronchitis,  405,  407 

diphtheria,  174 

dysentery,  561,  562 

erysipelas,  160 

fever,  typhus,  127 

hepatitis,  601,  602 

inflammation,  320 

inflammation  of  mucous  membrane  of 
nose,  378 

laryngo-tracheitis,  388 

pleuritis,  446 

rheumatism,  298,  300 

rubeola,  240 

stomatitis,  490 

variola,  217 
Lebert. 

ansemia,  pernicious,  275 

fever,  relapsing,  133,  137 

fever,  typhus,  126 
Leeches. 

apoplexy,  709 

bronchitis,  404,  406 

gastritis,  520 

glossitis,  509 

nephritis,  615 

peritonitis,  579 

perityphhtis.  546 

sunstroke,  788 
Letulle. 

Addison's  disease,  276 
Lemert. 

alcohol,  862 


INDEX. 


887 


LeRoche,  E. 

fever,  yellow,  143,  145 
Leucocythemia,  267 

causes,  268 

diagnosis,  270 

history,  267 

morbid  anatomy,  269 

prognosis,  272 

special  pathology,  270 

symptoms,  268 

treatment,  272 
Liebig. 

alcohol,  863 

bodily  heat,  58 

foods,  29 
Liebermeister. 

fever,  typhoid,  82,  90,  92 

plague,  128 
Lime,  Quick. 

diphtheria,  176 
Linimentum  Saponis  Camph. 

aden  tis,  262 

mumps,  248 

peritonitis,  588 

scarlatma,  234 

spinal  meningitis,  367 

syphilis,  290 
Lithii  Bromidum. 

apoplexy,  713 

asthma,  413 

epilepsy,  736 

gout,  307,  308,  309 

laryngo- tracheitis,  390 

meningitis,  338 
Lithii  Cabonas. 

gou%  307 
Lithii  Citras. 

gout,  307,  308 
Lisfranc,  M. 

laryngo-tracheifcis,  392 
Littlefield. 

cerebro-spinal  meningitis,  350 
Lobelia. 

laryngismus  stridulus,  318 

roseola,  246 
Local  Diseases,  49 
Locke,  John. 

mental  derangements,  798 
Louis.  M. 

fever,  typhoid,  77,  85,  90 

fever,  typhus,  122,  126 
Lupulin. 

bronchitis,  408 

gastritis,  523 


MACKENZIE, 
fever,  relapsing,  132 
Macrobius. 

diphtheria,  168 
Magnesii  Carbonas. 

constipation,  842 
Magnesii  Citras. 

cerebro-spinal  meningitis,  352 

duodeno-hepatitis,  532 

erysipelas,  615 


!  Magnesii  Hyposulphis. 

fever,  er.^ptive,  210 
Magnesii  Sulphas. 

cholera,  epidemic,  673 

duodeno-hepatitis,  532 

dysentery,  564,  566 

enteritis,  539,  540 

erysipelas,  615 

fever,  typhoid,  117,  118 

meningitis,  336 

spinal  meningitis,  358 
Magnesii  Sulphis. 

fevers,  eruptive,  210 

fever,  intermittent,  193 

fever,  remittent,  193 
Magnetism-Electro. 

diabetes  mellitus,  859 
Malone,  G.  B. 

fever,  pernicious,  203 
Malt.  Extract. 

adenitis,  262,  369 

spinal  meningitis,  chronic, 
Manassein. 

fever,  relapsing,    138 
Manna. 

stomatitis,  492 
Martin,  H.  A. 

vaccinia,  228 
Martin. 

alcohol,  865 
Massage. 

epilepsy,  755 

spinal  meningitis,  358 
Mcintosh. 

fever,  periodical,  191 
McNaugbtjn,  James. 

fever,  typhoid,  92 
Measles,  237 

nephritis,  610 
Medical  Theories,  23 
Medicines. 

classification,  34 

definition,  33 

method  of  introduction,  34 
Meeker,  D. 

erysipelas,  154 
Meigs,  J.  F. 

fever,  60 
Melasma  Suprarenalis,  276 
Meningitis,  325 

causes,  325 

diagnosis,  333 

pathology,  331 

prognosis,  334 

scrofulous,  327 

symptoms,  325 

treatment,  334 

tuberculous,  327 
Meningitis,  cerebro-spinal,  359 

diagnosis,  340 

prognosis,  340 

symptoms,  339 

treatment,  340 
Meningitis,  cerebro-spinal,  epidemic,  841 

causes,  342 

diagnosis,  348 


888 


INDEX. 


Meningitis,  cerebro-spinal,  epidemic. 

history,  341 

morbid  anatomy,  347 

prognosis,  348 

symptoms,  345 

treatment,  350 
Meningitis,  spinal,  355 

diagnosis,  357 

etiology,  355 

morbid  anatomy,  357 

prognosis,  357 

symptoms,  356 

treatment,  357 
Meningitis,  spinal,  chronic,  361 

diagnosis,  365 

morbid  anatomy,  364 

prognosis,  365 

symptoms,  361 

treatment,  366 
Miasms,  38 

definition,  64 
Michel,  R.  F. 

fever,  pernicious,  202 
Miguet,  491 
Miner. 

cerebro-spinal  meningitis,   epidemic, 
350 
Mint,  indigestion,  842 
Miscellaneous  diseases,  810 

varieties,  810 
Mitchell,  J.  K. 

arthritis  deformans,  311 

fever,  periodical,  181 

influenza,  71 

miasms,  38 
Myelitis,  359 

diagnosis,  359 

pathological  anatomy,  360 

prognosis,  360 

symptoms,  359 

treatment,  360 
Marcy,  H.  0. 

hydrophobia,  780 
Morgagni. 

cholera,  epidemic,  661 
Morphise  Acetas. 

cholera,  epidemic,  674 

cholera  morbus,  658 

dysentery,  566,  567 
Morphife  Sulphas. 

angina  pectoris,  827 

asthma,  413 

bronchitis,  406 

cholera,  epidemic,  673,  674 

cholera  morbus,  657,  659 

colic,  bilious,  548 

delirmm  tremens,  795 

dysentery,  568 

fever,  intermittent,  191 

fever,  pernicious,  201 

fever,  remittent,  191 

fever,  typhoid,  122 

fluxes,  644 

heat  exhaustion,  789 

meningitis,  cerebro-spinal,  epidemic, 
351 


Morphitie  Sulphas, 
neuralgia,  768 
peritonitis,  578,  579,  580 
phthisis  pulmonalis,  469 
pleuritis,  444,  447,  469 
pneumonia,  429 
tetanus,  775 
Morton. 

cholera,  epidemic,  661 
Mott,  Valentine. 

action  of  hydrargyri  chlondum  cor- 
rossivum,  103 
Miiller. 

on  fibrine,  12 
Mumps,  247 

diagnosis,  248 
prognosis,  248 
symptoms,  247 
treatment,  248 
Murchison. 
fever,  59 

fever,  typhoid,  92 
fever,  typhus,  126 
Musk. 

roseola,  246 
Mustard. 

cholera,  epidemic,  675 


YTAECOTICS,  35 

ii     convulsions,  755 
Nasse. 

fibrine,  12 
Nature. 

definition,  31 
Nauman. 

pseudo-leucocythemia,  273 
Neil,  John. 

cholera,  epidemic,  668 
Nephritis,  608 

anatomical  changes,  613 

causes,  608 

diagnosis,  609,  613 

prognosis,  614 

symptoms,  610 

treatment,  614 
Nephritis,  chronic,  619 

anatomical  changes,  623 

causes,  619 

diagnosis,  624 

prognosis,  625 

symptoms,  620 

treatment,  625 
Nephritis,  Suppurative,  630 

anatomical  changes,  635 

causes,  630 

diagnosis,  635 

prognosis,  636 

symptoms,  631 

treatment,  637 
Neuralgia,  766 

diagnosis,  767 

pathology,  768 

treatment,  768 

varieties,  766 


INDEX, 


889 


Neuroses,  694 

patholog'y,  694 

physiology,  694 
Nux  Vomica. 

apoplexy,  711 

cholera  epidemic,  673 

constipation,  840 

enuresis,  861 

fever,  periodical,  194 

phthisis  pulmonalis,  466 
Nulntion,  25 

conditions,  26 


A'BRIEN. 

\j     lever,  relapsing,  132 

Oenothera  Biennis. 

bronchitis,  408 
Oleum  Morrhuae,  103 

adenitis,  262 

bronchitis,  408 

diphtheria,  175 

phthisis  pulmonalis,  465,  466,  469 

pneumonia,  436 

rubeola,  240 

scarlptina,  284 

syphilis,  290 
Oleum  Ohvse. 

diphtheria,  174. 
Oleum  Tigiii. 

duodeno-hepatitis,  534 

gastritis,  523 

hepatitis,  601 

laryngo-tracheitis,  392 
Opiates. 

convulsions.  755 

insomnia,  764 

paraplegia,  222 
Opium. 

angina  pectoris,  828 

bronchitis,  406,  407,  409 

carcinoma,  285 

cerebro- spinal  meningitis,  250,  354 

cholera,  epidemic,  678,  674 

cholera  morbus,  656,  657,  658,  659 

constipation,  841 

dengue,  77 

diabetes  mellitus,  858,  859 

diphtheria,  176 

dysentery,  562,  563,  564,  565,   566, 
567,  570,  571 

enteritis,  538,  539,  540,  541 

erysipelas,  161 

fever,  typhoid,  116,  118 

fever,  relapsing,  137,  138 

fever,  simple  continued,  73 

fever,  yellow,  150,  151 

gastritis,  521,  522 

gout,  807,  308 

inflammation  mucous  membrane  of 
nose,  381 

laryngismus  stridulus,  818 

laryngo-tracheitis,  388 

peritonitis,  578,  579 

pleuritis,  444,  445,  446,  448 

pneumonia,  401,  437 


Opium. 

roseola,  246 

rubeola,  240 

stomatitis  scorbutic,  502 

tetanus,  774 

trichinae,  849 

variola,  218 
Organized  matter,  properties  of,  14 

structures,  varieties  of,  14 

functions,  15,  17 

primary  morbid  conditions,  19,  22 

functions,   morbid  conditions  of,  22 
Oertel. 

diphtheria,  166,  173 
Osborne. 

fever,  pernicious,  202 
Oberraeir. 

fever,  relapsing,  133 
Ozena,  377 


PACHYMENINGITIS,  322 
JL      diagnosis,  324 

pathological  changes,  324 

prognosis,  325 

treatment,  325 
Paget. 

fibrine,  12 
Paine,  Martyn. 

elementary  properties,  15 

theory  of  disease,  23 
Palmer,  A.  B. 

pneumonia,  434 
Palpitation,  42 
Paralysis,  714 

varieties,  714 
Paraplegia,  720 

prognosis,  722 

treatment,  722 

varieties,  720 
Park,  Roswell. 

rotheln,  241 
Parker,   WiUard. 

carcinoma,  283 

nephritis,  627 

perityphlitis,  547 
Parkes. 

alcohol,  865 

fever,  53,  59 
Peacock,  T.  B. 

bronchitis,  398. 
Pepper,  Wm. 

Addison's  disease,  277 

anseraia,  pernicious,  275 
Pepper,  Cayenne. 

scarlatina,  2-^ 
Pepsina. 

constipation,  838 

diabetes  mellitus,  859 
Percy. 

alcohol,  863,  864 
Pericarditis,  471 

diagnosis,  476 

pathological  changes,  474 

prognosis,  476 

svmptoms,  472 


890 


INDEX. 


Pericard'tis. 

treatment,  476 
Periodical  fever,  173 
Peritonitis,  572 
acute,  573 

anatomical  changes,  575 
diagnosis,  576 
prognosis,  577 
symptoms,  5  3 
treatment,  578 
chronic,  581 

prognosis,  586 
symptoms,  582 
treatment,  588 
nephritis,  629 
Perityphlitis,  548 
symptoms,  543 
treatment,  545 
Pernicious  fever,  182,  196 
Perrin,  M. 

alcohol,  864,  866 
Peter. 

diphtheria,  166 
Peters,  J.  C 

cholera,  epidemic,  665 
Phlegmasia,  50 
Phloridzin. 

cholera  morbus,  659 
Phosphorus. 

meningitis,  838 
Phthisis. 

fibroid,  484 
pulmonalis,  450 

anatomical  changes,  459 
diagnosis,  461 
prognosis,  463 
symptoms,  452 
treatment,  46  i 
Physic,  Philip  Syug. 
varieties,  450 
fever,  yellow,  149 
Physostigma. 

cerebro-spinal  meningitis,  epidemic, 

352,  854 
epilepsy,  783 
hydrophobia,  780 
spinal  meningitis,  353 
tetanus,  774 
Phytolaccse  Decandra. 
bronchitis,  407 
meningitis,  838 
rheumatism,  299 
spinal  meningitis,  chronic,  867 
Pilocarpin. 

br.nchitis,  407 
diabetes  mellitus,  852,  859l 
fluxes,  642 
influenza,  74 
nephritis,  616,  617,  623 
Pine,  Oil  of  Scotch, 
bronchitis,  409 
inflammation,  mucous  membrane  of 

nose.  881 
pneumonia,  487 
Plague,  128 
causes,  128 


Plague. 

diagnosis,  129 

history,  128 

pathology,  180 

prognosis,  130 

prophylaxis,  131 

symptoms,  129 

treatment,  180 
Pleuritis,  437 

diagnosis,  443 

history,  437 

nephritis,  629 

pathological  anatomy,  442 

prognosis,  442 

symptoms,  acute,  438 

symptoms,  chronic,  441 

treatment,  443 
Plumbi  Acetas. 

cholera,  epidemic,  674 

cholera  morbus,  657,  653 

dysentery,  565,  566,  567 

erysipelas,  162 

fever,  ty,  hoid,  119 

gastritis,  525 

hemorrhages,  693 
Pneumonia,  acute,  416 

age,  419 

catarrhal,  423 

diagnosis,  424 

disseminated,  423 

etiology,  416 

exciting  causes,  419 

history,  416 

interstitial,  416 

lobar,  416 

lobular,  416,  423 

malarial  influences,  421 

occupation,  418 

pathological  anatomy,  424 

previous  condition,  419 

prognosis,  424 

rheumatic  influences,  422 

seasons,  418 

sex,  419 

symptoms,  420 

typhoid  influences,  422 

treatment,  426 
Pneumonia,  chronic,  432 

prognosis,  435 

symptoms,  435 

treatment,  436 
Podagra. 

arthritis  deformans,  302 
Podophyllum. 

hepatitis,  602 
Pomegranate. 

parasites,  intestinal,  848 
Potassii  Acetas. 

cholera  morbus,  658 

dropsies,  683 

fevei",  relapsing,  138 

fever,  typhoid,  118 

rheumatism,  299 
Potassii  Arsenias. 

carcinoma,  285 

chorea,  744 


INDEX. 


891 


Potassii  Arsenias. 

fever,  periodical,  192 
Potassii  Bicarbonas. 

arthritis  det'ormans,  307 

bronchitis,  407 

rheumatism,  298 
Potassii  Bitartras. 

dropsies,  683 

inflammation  mucous   membrane  of 
nose,  378 

nephritis,   614,   616,   618,   626,  627, 
628 

pericarditis,  477 

roseola,  243 

varicella,  226 
Potassii  Bromidum. 

apoplexy,  711 

asthma,  413,  415 

bronchitis,  405 

constipation,  837 

delirium  tremens,  794 

dysentery,  571 

enteritis,  542 

epilepsy,  737 

fever,  periodical,  122 

influenza,  73 

insomnia,  764 

meningitis,  338 

mental  derangements,  806 

mumps,  248 

roseola,  240 

rubeola,  240 
Potassii  Carbonas. 

rheumatism,  298 
Potas-ii  Chloras. 

aneurisms,  854 

diphtheria,  172  _ 

fatty  degeneration  of  heart,  833 

fever,  typhoid,  101,  102,  116 

glossitis,  506 

laryn  go- tracheitis,  890 

pneumonia,  431 

scarlatina,  233,  234,  235 

stomatitis,  496,  500 

tonsilitis,  509 
Potassii  Chloridum. 

diphtheria,  174 
Potassii  lodidura. 

adenitis,  262 

aneurisms,  854 

apoplexy,  709 

asthma,  413 

bronchitis,  408 

cerebro-spinal  meningitis,  epidemic, 
355 

diabetes,  851 

dropsies,  683 

endocarditis,  484 

fever,  typhoid,  106,  118 

glossitis,  506 

laryngo-tracheitis,  389 

meningitis,  336 

myocarditis,  484 

paraplegia,  722 

periostitis,  scrofulous,  266 

peritonitis,  581,  588 


Potassii  todidum. 

plague,  131 

pleuritis,  446 

pneumonia,  chronic,  436 

rheumatism,  299 

roseola,  242 

spinal  meningitis,  358 

stomatitis,  510 
Potassii  Nitras. 

asthma,  415 

cholera,  epidemic,  676 

diabetes,  851 

dropsies,  683 

duodeno-hepatitis,  533 

dysentery,  563 

erysipelas,  160 

fever,  simple  continued,  68 

fever,  typhoid,  116. 

influenza,  73 

laryngo-tracheitis,  389,  390 

nephritis,  616,  617,  618,  626 

pleurilis,  448 
Potassii  Permanganas. 

diphtheria,  172,  176 

inflammation,  mucous  membrane  of 
nose,  381 

periostitis,  scrofulous,  266 

scarlatina,  233 

stomatitis  495,  496,  502 
Potassii  Salicylas. 

gout,  308 
Poultice. 

phthisis  pulmonalis,  468 

pneumonia,  428 

syphilis,  289 
Prout. 

alcohol,  863,  864 
Prunus  Virginiana. 

bronchitis,  406 
Pseudo-leucocythemia,  273 
Pumpiiin  Seeds. 

parasites,  intestinal,  848 
Purgatives. 

apoplexy,  709 

cerebro-spinal  meningitis,  epidemic, 
350 
Purtussis,  213 

causes,  243 

diagnosis,  243 

prognosis,  245 

sequelge,  247 

special  pathology,  245 

symptoms,  244 

treatment,  246 


QUINTS  CITRAS. 
fever,  relapsing,  138 
Quinise  Sulphas, 
asthma,  413 

bronchitis,  405,  406,  407,  408 
cerebro-spinal  meningitis,  epidemic, 

350,  351,  353,  354 
cholera,  epidemic,  673 
dengue,  76 


892 


INDEX, 


Quinise  Sulphas. 

diphtheria,  175,  177 

dysentery,  506 

erysipelas,  161 

fever,  pernicious,  193,  202 

fever,  periodical,  192,  193,  194 

fever,  relapsing-,  187 

fever,  typhoid,  115 

fever,  typho-malarial,  204. 

fever,  yellow,  149,  151 

gout,  309 

hysteria,  761 

inflammation  mucous  membrane  of 

nose,  379 
influenza,  73,  74 
laryngo-tracheitis,  389,  390 
leucocythemia,  272 
neuralgia,  669 
phthisis,  469 

pneumonia,  429,  430,  431 
rheumatism,  299 
roseola,  243,  246 
scarlatina,  237 
spinal  meningitis,  358 
stomatitis,  502 
sunstroke,  790 
tonsilitis,  509,  510 
variola,  217 
QuinijB  Tannas. 

cholera  morbus,  659 


KOTHELN,  241 
causes,  241 

diagnosis,  242 

history,  241 

prognosis,  242 

symptoms,  241 

treatment,  242 
Rattlera. 

parasites,  intestinal,  848 
Recklinghausen. 

inflammation,  819 

typhoid,  83 
Recto-colitis,  551 
Remedial  Agents. 

definition,  83 
Rennet. 

diabetes  mellitus,  859 
Reynolds. 

'  rubeola,  237 
Rhatany. 

gastritis,  525 
Rheumatism,  291. 

acute  articular,  292 

chronic,  295 

clinical  history,  292 

diagnosis,  296 

etiology,  291 

pathology  297 

prognosis,  296 

sub-acute,  294 

treatment,  297 

varieties,  291 
Rhubarb. 

intestinal  parasites,  846 


Rhus  Aromatica. 
enuresis,  861 
Richardson,  B.  W". 

alcohol,  864 
Richardson,  J.  G. 

fever,  yellow,  149 
Ringer,  Sidney, 
alcohol,  865 
Robin,  M. 

fibrin,  13 
Rochelle  Salts. 

cerebro-spinal  meningitis,  352 

duodeno-hepatitis,  532 

enteritis,  539 

gout,  308 

nephritis,  615 
Roseola,  242 

clinical  history,  242 

treatment,  243 
Rubeola,  237 

causes,  237 

diagnosis,  239 

history,  237 

pathological  anatomy,  239, 

prognosis,  239 

sequelae,  240 

symptoms,  238 

treatment,  239 
Rush,  Benjamin. 

dengue,  74 

fever,  yellow,  143,  149 

gout,  303 

theory  of  disease,  23 


QAGE. 

O  _  thrush,  493 

Sainsbury,  Harrington. 

alcohol,  865 
Salisbury,  J.  H. 

influenza,  71 

fever,  periodical,  181 

rubeola,  238 
Salix  Alba. 

fever,  periodical,  192, 194 
Sanderson,  Burdon. 

diphtheria,  166 
Sandras,  M. 

alcohol,  864 
Sanguinaria. 

bronchitis,  405 

laryngo-tracheitis,  389 

laryngismus  stridulus,  819 

pneumonia,  428 

roseola,  246 

rubeola,  240 
Santonin 

intestinal  parasites,  846 
Sarsaparilla. 

nephritis,  626 
Satterthwaite. 

diphtheria,  156 
Scarification. 

laryngo-trache.tis,  391 
Scarlatina,  227 

complications,  232 


INDEX. 


893 


Scarlat-'na. 

diagnosis,  230 
history,  227 
pathology,  231^ 
prophyhxxis,  235 
prognosis,  230 
sequelae,  235 
symptoms,  228 
treatment,  232 
Schmidt,  C. 

fever,  yellow,  147 
cholera,  epidemic,  668 
Scilla. 

bronchitis,  405,  407 
diphtheria,  176 
iniiuenza,  73 

laryngismus  stridulus,  818 
laryngo-tracheitis,  388 
roseola,  246 
rubeola,  240 
Sclerosis,  Cerebral,  330 
Scrofula,  258 
Scutellaria. 

aphonia,  822 
endocarditis,  486 
exophthalmic  goitre,  831 
cardiac  irritability,  828 
fluxes,  643 
gastritis,  522 
hysteria,  760 
myocarditis,  486 
Secretions. 

classification,  12 
Sedatives. 

cerebro  spinal  meningitis,  353 
general,  35 
pneumonia,  428 
meningitis,  335,  336 
nervous,  36 
vascular,  36 
Seguin,  E. 

meningitis,  362 
Senecio  Aureus. 

rheumatism,  299 
meningitis,  367 
Senega. 

bronchitis,  405 
influenza,  73 
Senna. 

parasites,  intestinal,  845,  846 
Setzerich. 

pertussis,  243 
Shonbein. 

influenza,  71 
Simmers,  D.  B. 
rubeola,  237 
Simon,  M. 

fibrine,  13 
Simons,  T.  G. 

bronchitis,  399 
Sinapism. 

angina  pectoris,  828 
apoplexy,  710 

cerebro-spinal  meningitis,  350 
convulsions,  753 
fever,  relapsing,  138 


Sinapism. 

tever,  yellow.  150 
hvstena,  760 
tetanus,  775 
variola,  217 
Smith,  J.  L. 

riitheln,  241 
Smith,  J.  M. 

diphtheria,  164 

fevei,  typhus,  124 
Smith,  R.  K. 

scarlatina,  283 
Smith,  Southwood. 

fever,  54 
Snow. 

cholera,  epidemic,  669 
Sodii  Arsenias. 

carcinoma,  284 
Sodii  Bicarbonas. 

bronchitis,  407 

cerebro-spinal  meningitis,  352 

cholera  morbus,  657 

dengue,  77 

duodeno-hepatitis.  534 

diphtheria,  173,  176 

fever,  periodical,  192 

fever,  yellow,  150 

gastritis.  521,  522 

indigestion,  842 

laryngo-tracheitis,  389 

pericarditis,  447 

pleuritis,  444,  447 

rheumatism,  298,  299 

spinal  meningitis,  358 

thrush,  492 
Sodii  Benzoas. 

asthma,  415 

diphtheria,  172,  175 

laryngo-tracheitis,  390 

scarlatina,  233 
Sodii  Boras. 

stomatitis,  490,  493 
Sodii  Bromidum. 

mental  derangements,  806 
Sodii  Carbonas. 

rheumatism,  298,  301 
Sodii  Chloras. 

diphtheria,  172 
Sodii  Chloridum. 

cholera,  epidemic,  675 

inflammation  mucous  membrane  of 
nose,  381 

fever,  typhoid,  102 

parasites,  intestinal,  845 
Sodii  Hypophosphis. 

bronchitis,  408 

diphtheria,  178 

fever,  periodical,  195 

hydrophobia,  782 
Sodii  Hyposulphis. 

fever,  eruptive,  211 

fever,  pernicious,  203 

fever,  relapsing,  138 

scarlatina,  233 
Sodii  lodidum. 

bronchitis,  407,  408 


894 


INDEX. 


Sodii  lodidum, 

periOf^titis   "icrofalous,  266 

meningitis.  6^11,  o36 

svph'iis,  289 
Sodi"  Saiicyias. 

bronchitis,  407 

chorea,  745 

enuresis,  861 

fever,  relapsing,  137 

glossitis,  507 

gout,  808,  309 

memrigitis,  338 

rheumatism,  298 

spinal  meningitis,  358 

tonsiiitis,  509 
Sodii  Sulphis. 

diphtheria,  172 

erysipelas,  161,  163 

fever,  eruptive,  210 

fever,  pernicious,  203 

fever,  periodical,  123 

fever,  relapsing,  1;:>8 
Sodii  Sulpho-Carbolas. 

diphtheria,  172 

scarlatina,  233 
Spigelia. 

parasites,  intestinal,  845,  846 
Splenitis,  603 

anatomical  changes,  605 

clinical  history,  603 

diagnosis,  606 

prognosis,  607 

treatment,  609 
Sponging. 

scarlatina,  233 
Stahl,  14 
Sternberg,  G-.  M._ 

fever,  periodical,  181 

hydrophobia,  780 
Stewart,  A.  P. 

fever,  typhus,  122 
Stimulants,  general,  35 
Stomatitis,  490 

folicular,  493 

materni,  497 

symptoms,  497 

treatment,  499 

mercurial,  495 

treatment,  496 

scorbutic,  501 
Stramonium. 

arthritis  deformans,  311 

asthma,  415 

chorea,  745 

epilepsy,   736 

endocarditis,  484 

meningitis,  367 

myocarditis,  484 

rheumatism,  299,  301 
Strychnia. 

bronchitis,  408 

cholera,  epidemic,  673 

constipation,  841 

diphtheria,  172,  175.  177,  178 

fever,  periodical,  194 

fever,  pernicious,  202 


Strychnia. 

fever,   typhoid.    100,   106,    115,   118, 
119,  120 

fever,  yellow,  151 

gastritis,  523 

spinal  meningitis,  358 

variola,  218 
Strychnife  Citras. 

syphilis,  290 
Sudamina,  227 
Sunstroke,  783 

anatomical  changes,  785 

diagnosis,  785 

prognosis,  788 

symptoms,  784 

treatment,  788 

varieties,  783 
Sutton,  Geo. 

erysipelas,  154 
Sutton,  W.  L. 

scarlatina,  233 
Sydenham. 

scarlatina,  227 
Syphilis,  constitutional,  286 

rpEMPERATURE,  NORMAL,  28 
X     daily  variations,  29 
Terebmthina. 

bronchitis,  408 

cholera,  epidemic,  673 

cholera  morbus,  658 

diphtheria,  174 

dysentei7,  564,  570,  571 

enteritis,  539 

erysipelas,  161 

fever,  typhoid,  116, 119,  121 

fever,  typhus,  127 

fever,  yellow,  151 

hsematuria,  malarial,  203 

peritonitis,  579 

roseola,  242 

variola,  218 
Terror,  Night,  765 
Tetanus,  770 

anatomical  changes,  771 

causes,  772 

prognosis,  773 

symptoms,  770 

treatment,  774      ; 
Theine. 

dysentery,  567 

peritonitis,  581 
Therapeutic  Methods,  44 
Thomas,  Louis. 

rubeola,  237 
Thompson,  Samuel. 

theory  of  disease,  24 
Thrush,  491 
Tobacco. 

cancrum  oris,  503 

colic,  bilious,  550 

insomnia,  763 

spinal  meningitis,  366 
Todd,  R.  B. 

gout,  306 


INDEX. 


895 


Tolutana. 

broHchitis,  408 
Tonsilitis,  507 
Tonics,  general,  35 
Tracheotomy. 

diphtheria,  176 

hi ryngo- tracheitis,  391 
Trichinte,  849 
Trouseau,  A. 

diphtheria,  166 

leucocythemia,  268 

rubeohi,  237 

spinal  meningitis,  364 
Typhlitis,  542 
Tyson,  James. 

diabetes  mellitus,  60 

TTLCER,  GASTRIC,  516 
U     anatomical  changes,  518 

diagnosis,  519 

prognosis,  520 

treatment,  520 
Ulmus  Flava. 

nephritis,  614 

stomatitis,  490,  500 
Upham,  J.  B. 

typhus,  127 
Uva  Ursa. 

dropsies,  6'^3 

nephritis,  626  ' 


YACCINA,  220 
V     Valeriana. 

aphonia,  822 

cardiac  irritability,  824 

catalepsy,  749 

heat  exhaustion,  789 

hysteria,  760 

nephritis,  615 

paraplegia,  72? 

terrors,  night,  766 
Varicella,  225 

diagnosis,  226 

symptoms,  .225 

treatment,  226 
Variola,  213 

diagnosis,  216 

malignant,  218 

prognosis,  216 

symptoms,  213 

treatment,  216 
Varioloid. 

diagnosis,  219 

prognosis,  220 

prophylaxis,  220 

symptoms,  219 

treatment,  220 
Venesection, 

apoplexy,  708,  709,  712. 

bronchitis,  405 

cholera,  epidemic,  675 

meningitis,  335 

nephritis,  615 

peritonitis,  578 


Venesection. 

pleuntis,  444,  448 

pneumonia,  428,  430 
Veratria 

spinal  meningitis,  367 
Veratrum  Viride 

aneurisms,  834 

apoplexy,  709,  713 

bronchitis,  405 

dysentery,  565 

endo-carditis,  486 

fever,  eruptive,  212 

fever,  periodical,  191 

fever,  simple  continued,  68 

fever,  yellow,  150 

influenza,  73 

meningitis,  336 

myocarditis,  486 

nephritis,  614,  616 

pleuritis,  444 

rheumatism,  299 

spinal  meningitis,  358 
Vinegar. 

diphtheria,  176 
Virchow. 

Addison's  disease,  277 

fever,  53,  59. 

inflammation,  319 

leucocythemia,  268 

pachymeningitis,  325 

pseudo-leucocythemia,  278 


WALES,  P.  S. 
cerebro-spinal  meningitis,  349 

Waller.. 

inflammation,  319 
Wallowiez. 

alcohol,  865 
Waterhouse,  Benjamin. 

vaccina,  221 
Waters. 

Bethesda. 

diabetes  mellitus,  857 
nephritis,  625 

Lime. 

gastritis,  521 

Mineral. 

diabetes  insipidus,  851 
rheumatism,  301 
Watson. 

tetanus,  775 
Webster,  Noah. 

epidemic   and    pestilential  diseases, 
69 
Weigert. 

fever,  relapsing,  133 
Welden,  Austm. 

anaemia  pernicious,  276 
Wells,  Wm.  L. 

diphtheria,  164 
Welsh. 

tever,  relapsing,  132 
Wey,  Wm.  C. 

diphtheria,  165 


896 


INDEX. 


Whitniire,  J.  S. 

eiysipelas,  162 
Willard. 

diphtheria,  164 
Wilks,  Samuel. 

Addison's  disease,  276 
Williams,  C.  J.  B. 

elementary  properties,  15 
^    fibrin,  12 
Williamson,  Hugh. 

spinal  meningitis,  341 
Wood,  Geo.  B. 

fever,  53,  54 

fever,  typhoid,  78,  92 
Wood.  H,  C._ 

diphtheria,  166 
Woodward,  J.  J. 

rubeola,  238 
Wragg,  W.  T. 

dengue,  75,  74 
Wright,  N. 

fever,  periodical,  191 
Wunderlach. 

fever,  59 
Wyman,  Morrell. 

asthma,  415 


yELLOW  DOCK. 
J.     nephritis,  627 


yiEMSSEN. 

Li    fever,  simple  continued,  65 

Zimmerman. 

fibrin,  12 
Zinci  Oxidum. 

fluxes.  643 

gastritis,  523 
Zinci  Phosphidum. 

spinal  meningitis,  367 
Zinci  Sulphas. 

diphtheria,  176 

epilepsy,  732 

inflammation  mucous  membrane  of 
nose,  379,  380_ 

laryngo-tracheitis,  390 

stomatitis,  495,  502 
Zinci  Valerianas. 

chorea,  744 

epilepsy,  636 
Zuelzer. 

erysipelas,  154 


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